When it comes to online public health interventions, why think small? Researchers at the Institute for International Internet Interventions for Health (i4Healthopens in new window) at Palo Alto University, founded by psychologist Ricardo F. Muñoz, PhD, are testing a growing set of online interventions aimed at improving mental and behavioral health for an unlimited number of people.
Several studies have shown that people see digital interventions as an acceptable alternative or complement to traditional therapy. A 2014 review in the Journal of Medical Internet Research opens in new window, for example, suggested that people age 14 to 25 are more likely to look for online interventions for mental illnesses than to seek professional help.
As a result, developers are thinking big, including i4Health. At the University of California, San Francisco, where he is professor emeritus, Muñoz and colleagues tested an anti-smoking Web-based programopens in new window in Spanish and English that allowed users to choose any or all of nine program components. Among them were the Guía para Dejar de Fumar — a National Cancer Institute-funded smoking cessation guide developed by Eliseo J. Pérez-Stable — a checklist to help smokers get ready to quit, a guide for using pharmacological aids such as nicotine patches and an opportunity to sign up for email messages keyed to their quit dates.
The program also included an online course that teaches smokers with depression — who are more likely to relapse — about how quitting may affect their thoughts, mood and activities, and a "virtual group" in the form of a bulletin board, which allowed participants to provide information and support to each other.
For 30 months starting in 2008, the site reached 292,978 people in 168 countries using a Google Ad Grant, at a cost of less than $1 per visitor. The study was funded by California's Tobacco-Related Disease Research Program. Of 15,170 visitors surveyed, 3,479, or 22.9 percent, reported quitting at least once over 12 months ( Clinical Psychological Science opens in new window, 2015). For comparison, the study reports, quit rates are 14 percent to 22 percent for people using a nicotine patch and 24 percent to 27 percent for in-person group interventions.
Inspired by the growing number of MOOCs — massive open online courses — Muñoz coined the term massive open online interventions, or MOOIs, to describe i4Health's global efforts. MOOIs aren't therapy, says Muñoz. They're self-help automated digital interventions, more like "self-help books on steroids" that can help people manage conditions with a high potential for recurrence, such as depression, eating disorders, alcoholism and smoking. And they're a cost-effective way to provide standardized evidence-based mental and behavioral health interventions to the millions who need them but cannot access them due to cost, stigma or logistics, or not having access to therapists or to therapists who speak their language, he says.
"We'll never train enough therapists to meet the need in the world," he says. "Our health-care system relies almost entirelyopens in new window on consumable interventions, including professional time, and that's the reason we cannot scale up to reduce health disparities."
Other like-minded MOOI efforts include the National Cancer Institute's Smokefree websitesopens in new window, Smokefree Women, Smokefree Teen, and Smokefree Español — which had 2,160,745 visitors from May 2014 to May 2015.
Psychologists are also studying a large-scale intervention to help prevent and treat depression called MoodGYMopens in new window, a website developed by the National Institute for Mental Health Research at The Australian National University. The site's diagnostic quizzes help users identify symptoms of depression or anxiety and track progress, and exercises using hypothetical characters and situations aim to teach principles of cognitive behavioral and interpersonal therapy. More than 850,000 people from 222 countries have registered to use MoodGYM. In a trial by John Powell, PhD, of the University of Oxford, and colleagues, people in the program reported significantly improved well-being when compared with a wait-listed control group ( Journal of Medical Internet Research opens in new window, 2013).
Though easy to access by design, many online interventions have high dropout rates. Nevertheless, in a 2012 article in the Journal of Medical Internet Research opens in new window, Muñoz and his colleagues estimate that 20 percent to 30 percent of participants in their online studies quit smoking.
"This is comparable to the quit rates with the nicotine patch or with smoking cessation groups. If we can ‘match the patch' with free digital interventions for smokers anywhere in the world, public health systems ought to be using them routinely," Muñoz says.
MOOIs are here to stay, he adds. "We should be thinking about how to use MOOIs to help as many people as possible."
— Stacy Lu
