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Researchers Use Technology, Apps to Reach At-Risk Populations with Health Messaging

Headshot of Dr. Abby C. King
From the pale green living room with the Stanford University logo above a window, out walks a pleasant, dark-haired woman in a blue shirt and slacks.“Hola,” she says,“My name is Carmen and my job is to help seniors live healthier lifestyles.” Except Carmen isn’t real.  

“She” is a “Virtual Advisor” created to encourage seniors to exercise and lead more active lives. Carmen seeks to overcome the boundaries of health inequity by targeting at-risk populations that could most benefit from a low-cost personal health advisor, accessible by computer at their local senior centers. Carmen is also part of a research project being led by Dr. Abby C. King, professor of health research and policy and the Stanford Prevention Research Center at Stanford School of Medicine, in collaboration with Dr. Timothy Bickmore at Northeastern University, that seeks to showcase the effects of an e-Health program involving a “Virtual Advisor” on the physical activity habits of mostly Latino adults.

Dr. King and her colleagues recently received formal recognition from the Association of American Medical Colleges (AAMC) for their “outstanding” work in the health equity research field with their “Virtual Advisors for Physical Activity Promotion in Underserved Communities” study. In Spring 2014, Dr. King and colleagues’ work will be part of a new initiative, an annual Health Equity Research Snapshot, sponsored by the AAMC. She was invited to share a short video describing her research, its goals, and its potential impact on health inequities. The initiative will represent research across a broad spectrum of health outcomes and populations. The goal is to show how each stage of research contributes to closing the gaps in health care and to garner awareness for the investigators conducting health equity research.

The Research: Health equity describes an environment in which all people are able to reach their fullest health potential.  However, health inequities exist across the board in the differing lifestyles and conditions experienced by different sectors of society. These inequities affect an individual’s ability to live, thrive, work and age in his or her own community. Health inequities often lead to poorer health due to lack of money and resources needed to afford good health and a lack of education concerning how to achieve better health. Physical inactivity is one of the key risk factors linked to the development of major chronic diseases, from heart disease, diabetes, and lung disease to some types of cancer as well. These diseases are responsible for 50 percent of deaths worldwide, which makes physical activity promotion a pivotal field of study.

In Dr. King’s case, study in this field involves examining the potential benefits of using technology to help achieve health equity for all and reduce the prevalence of chronic diseases, including heart disease, stroke, diabetes, and lung disease.  

“In developing more of a public health focus to the physical inactivity problem in the U.S. and other countries, it has become clear that we need to develop evidence-based strategies and programs for everyone in the community, not just those with comparatively high levels of affluence, education, and computer and health literacy who typically constitute the major targets for research as well as programs,” said Dr. King “We are particularly interested in targeting those population segments that could benefit the most from appropriately developed health promoting strategies but who have received the least attention to date.”

According to Dr. King, the development of Carmen, the bilingual “virtual advisor” on this project, was based on prior work with relational agents by her colleague Dr. Tim Bickmore at Northeastern University. Carmen is being evaluated to assess her ability to motivate previously inactive adults to achieve sustained levels of health-enhancing physical activity. Early findings have shown that Latino midlife and older adults who used Carmen for four months at a local community center significantly increased their regular walking levels. Based on these results, Dr. King and colleagues now would like to expand upon that research and study Carmen in a larger context with more participants.

Meet Carmen, a "virtual advisor" who wants to lep seniors get active
Grant Close Up: Dr. King and colleagues initially tested Carmen’s effectiveness at a local community center in San Jose, Calif. Now, as part of an active NHLBI grant, the research team is studying Carmen’s effectiveness across a longer period of time (at least one year) and over a broader area (the San Francisco Bay region). What remains the same is the target population: midlife and older insufficiently active Latino adults. 

The new study also will evaluate Carmen’s effectiveness compared to trained lay advisors, which would be another “potentially cost-efficient and culturally relevant approach to promoting healthy lifestyles,” according to Dr. King. This comparison between virtual advisors and human advisors will provide insights into the benefits of these two types of advisors and will help the researchers better understand who benefits most from each type of motivational “touch.”

Public Health Benefits: If Carmen proves successful and cost-efficient in comparison to trained lay advisors, there is the potential to “scale up” and translate Carmen for use at many different community settings, such as community centers, pharmacies, shopping malls, clinics, and libraries. Carmen also could be offered to a wide range of different population groups and could provide insights into the development of virtual advisors for other types of health-related behaviors and regimens. Some initial pilot work has already been done with Carmen in other underserved populations: Filipino, Asian, African American. And although such technologies benefit from being tailored specifically to target audiences, Dr. King noted the researchers’ surprise and pleasure at how positively these other groups responded to “meeting” Carmen. Finally, Carmen could “go mobile” in terms of using her on mobile devices.

Once proven, the low-cost alternative of a virtual advisor could be particularly beneficial because many existing electronic programs and games that seek to promote health awareness and activity, such as Nintendo’s Wii and Microsoft’s Kinect, are not readily affordable to all.  Carmen works to bridge these gaps in health inequity.

What’s Next? Dr. King and her colleagues are not content to only evaluate Carmen.

“Among the ‘borderless health promotion’ scientific initiatives that we are conducting are the testing of easy-to-use smartphone apps, in multiple languages, aimed specifically at mid-life and older adults unfamiliar with smartphone technology who need to move more and sit less throughout the day,” she explained.

Another important development is the “citizen-scientist” model of health promotion, which, according to Dr. King, is “aimed at harnessing the power of cutting-edge communication technologies (e.g., electronic tablets) that can be used by residents from all walks of life and educational backgrounds to document the barriers to healthy living in their neighborhoods in ways that compel action at the policy level.” 

Most importantly, Dr. King asserted, “underlying all of these scientific initiatives is the goal of bringing personally, culturally, and contextually relevant health promotion solutions to all members of society, irrespective of education, language, or economic circumstances.”

Journey to Health Equity: Before Dr. King became active in health equity research, she was well on her way to a clinical psychology degree with a focus on clinical settings and populations. 

Her clinical psychology graduate program was among a few at the time that focused on health-related behaviors and their impacts on mental and physical health processes and outcomes. Dr. King’s original goal was to work in a clinical context; however, she soon began to focus more on the science part of the “scientist-practitioner” model within the realm of clinical psychology. She noted feeling frustrated with the case-by-case method of solving problems when “the scope of the chronic disease challenge requires a public health/population level ‘lens’.” Upon reading the publication describing the Stanford Three-Community Study and related articles, she became increasingly aware of the importance of “reaching into underserved populations with strategies that fit their needs and preferences.” Dr. King finished her clinical psychology residency program and moved on to a postdoctoral fellowship at the Stanford Heart Disease Prevention Program—now known as the Stanford Prevention Research Center (the very same group that conducted the pivotal Stanford Three-Community Study), which is where she continues to work today.

Dr. King, professor at Stanford, walking as a way to promote healthy living for for all, including herself

Dr. King, professor of health research and policy and the Stanford Prevention Research Center at Stanford School of Medicine, promoting healthy living for all, including herself.


Last Updated: April 11, 2014