A randomized controlled trial to evaluate the efficacy of an automated behavioural informatics system to increase physical activity level of family members of diabetes patients in China Dr. Lancelot Mui, MPH Post-doctoral Fellow School of Public Health and Primary Care The Chinese University of Hong Kong
Overview Introduction Methods Results Discussion 2011/10/13 2
Why telehealth in China? INTRODUCTION 2011/10/13 3
The Then and The Now 2011/10/13 4
Physical activity in China Physical activity level decreased by 32% from 1991-2006 (Ng et al., 2009) Urban-Rural disparity (Muntner et al., 2005) Urban: 78.2% inactive Rural: 21.9% inactive 80% of people living in urban China are physically inactive (Reynolds et al., 2003) 2011/10/13 5
Diabetes in China China has a heavy burden on its hands with 92.4 million adults with diabetes and 148.2 million adults with prediabetes (Yang et al., 2010) There are more people with diabetes in urban parts of China. The rural parts of China are catching up. Prevalence of prediabetes are similar in all parts of China. International Diabetes Federation estimated that there will be half billion people with diabetes in China by 2030. 2011/10/13 6
Physical activity for DM prevention The Da Qing study have shown that physical activity alone can reduce the risk of progression to diabetes for people with IGT by 41% (Pan et al., 1997). There is a need to help the urban dwellers to become physically active. 2011/10/13 7
What to do? Health care system? Public health system? Da Qing-style intervention? Social media? Internet? Telephone? 2011/10/13 8
More and more people are getting their own mobile phone Convenience Reach Low cost Why telephone? 2011/10/13 9
TLC-PA-China Telephone-Linked Care (TLC) system for increase of physical activity Provider-to-Patient system Automated Computerized Expert counselling system Theory-based Trials in English-speaking countries, e.g. USA, Australia 2011/10/13 10
A typical call Identification of user by a password PA level assessment Individualized counselling session (~8-10 minutes) based on user s profile Interactive goal-negotiation Goal-setting for coming week 2011/10/13 ("Insert", "Texts", "Slide Numbering" to insert) Your Presentation Title Here 11
Randomized controlled trial to test the efficacy of the TLC-PA-China system METHODS 2011/10/13 12
Setting Shenzhen, China 23% of adults living in Shenzhen have diabetes mellitus and 11.94% have impaired glucose tolerance (Peng et al., 2000) 4 th highest GDP in China among major cities 20 million registered mobile phone numbers in use in Shenzhen (Shenzhen Statistical Bureau, 2011) 2011/10/13 13
An international collaboration Medical Information Unit, Boston University Inventor of the TLC technology and provided technical support School of Public Health & Primary Care, The Chinese University of Hong Kong Translating and adopting the software and hardware for Shenzhen Shenzhen Centres for Chronic Disease Control and Prevention (previously Shenzhen Chronic Disease Hospital) Provided the local community network of CHCs for recruitment and follow-up Hosting of the TLC server 2011/10/13 14
Study Design Randomized controlled trial Non-blinded Study population: 1 st degree family members of diabetes patients Recruitment from eight Community Health Centres (CHC) Inclusion criteria: Age 30+, <150 min/wk moderate PA Exclusion criteria: Unfit to do moderate PA Recruitment period: July to August 2009 2011/10/13 15
Recruitment and Sample Size 2011/10/13 16
The intervention Intervention group Users were asked to call in once every week to listen to advices from the TLC system Goal of the TLC-PA-China is to get people to participate in >=150 min/wk of at least moderate-intensity PA Control group Information pamphlet about benefits of physical activity 6-month intervention Change in PA level was assessed at Month 3 and Month 6 and compared to control group 2011/10/13 17
Does telehealth for physical activity promotion work in China? RESULTS 2011/10/13 18
Sociodemographics Male: 38%; Female: 62% Mean age: 41.1 years 92.4% have senior high school education or above 71.3% have a full-time job 84.8% are married 19.3% current smoker Males are more likely to be obese (BMI>=25); 38.5% (male) vs. 18.9% (female) 2011/10/13 19
Increase in physical activity >= 150 min/wk at least moderate intensity physical activity (%) Group N Baseline 3 months 6 months Control 78 0.0 6.5 14.0 Intervention 93 0.0 50.0 48.7 RR(95% CI) = 7.75 (3.465, 17.336) RR(95% CI) = 3.49 (2.004, 6.060) ARR = 43.5% ARR = 34.7% RRR = 675% RRR = 249% NNT = 2.30 NNT = 2.88 RR: Relative Risk; ARR: Absolute Risk Reduction; RRR: Relative Risk Reduction; NNT: Number Needed to Treat 2011/10/13 20
Increase in time spent on physical activity General Estimating Equation (GEE) analysis, controlling for gender and age Intervention group spent significantly more time on physical activity at Month 3 (B=7.487, 95% CI=5.882, 9.092; p<0.001) and Month 6 (B=6.584, 95% CI=4.864, 8.304; p<0.001) No change in body mass index or waist-hip ratio (p > 0.05). 2011/10/13 21
What s next? DISCUSSION 2011/10/13 22
Discussion TLC-PA-China more effective than traditional information pamphlet to motivate sedentary people to become physically active. Uses information technology to provide personalized and interactive intervention to users. Rural residents can benefit in the future since telephone is ubiquitous. Reduces the disparity caused by low literacy by using voice to communicate the message. 2011/10/13 23
Benefits of TLC-PA-China Computerization -> high fidelity Low setup cost -> high scalability Low running cost -> high sustainability Cost-effective 2011/10/13 24
Limitations and Future Direction Long-term effect of TLC-PA-China unclear Next: Longer follow-up to compare physical activity level Duration of study is not enough to track conversion to diabetes Next: Longer follow-up to compare incidence of DM Selected group of motivated individuals, unknown effect in the general population Next: Effectiveness trial in actual practice setting, then real-world implementation in different populations Self-report bias Next: Use objective measures of physical activity to verify results Limited interactivity Next: Use results from evaluation to improve contents 2011/10/13 25
Conclusion / Summary TLC-PA-China is better than information pamphlet in motivating people to become physically active. Long-term effect of this type of behavioural informatics intervention needs to be studied. 2011/10/13 26
Acknowledgement This project is funded by the Fogarty International Research Collaboration Award (FIRCA) by the Fogarty International Center, National Institutes of Health, USA Boston: Prof Robert Friedman, Prof Abu Abdullah, Paulie Pena Hong Kong: Prof Joseph Lau, Albert Cheung Shenzhen: Dr. J Peng, Crystal Lu, CHCs 2011/10/13 27
Thank you! Email: lmui@cuhk.edu.hk Tel: +852 2252 8724 Website: www.sphpc.cuhk.edu.hk