Using the telephone to improve health behavior and health service delivery
Introduction
The past decade has seen widespread use of telephone and computer technologies to provide a broad array of health behavior interventions and health services. The proliferation of these telephone-delivered interventions (TDIs) has been driven in part by the growing emphasis on reducing the cost of health care and the consequent incentives for management of demand for services [1]. Other technological and theoretical innovations have further broadened the potential for TDIs. For example, telephone network and transtelephonic communication have facilitated `distance medicine', the transmittal of patients' medical information to providers across broad geographic regions. Innovations in the methods used to promote behavior change, such as the Stages of Change model [2], have facilitated telephone outreach to individuals who are not actively seeking health promotion interventions. Together, these developments have placed TDIs in the forefront of health service delivery [3].
TDIs have a number of variable components that, in combination, yield a broad continuum of applications (for a good review of individual components, see Ref. [4]). Briefly, TDIs vary in how the calls are initiated. Calls can be initiated reactively, that is through call-in services or helplines often with 800 numbers, or proactively, via outreach services that are initiated by trained interventionists. TDIs also vary in who provides the service, such as health professionals, lay staff, and whether staff are paid or volunteer. The number, length, and timing of calls varies from single contacts up to 19 calls over a 12-month time frame; the majority rely on brief calls, 10 min or less, although some services have necessitated longer calls. TDIs also have served as the main intervention or as one adjunctive component of a multi-component intervention or service. This wide array of variable components increases the potential flexibility and cost-effectiveness of providing individualized patient services.
But even as telephone-delivered health services have proliferated, a number of questions remain concerning their reach, their efficacy in improving health behaviors and whether they increase the efficiency of health service delivery. We review TDIs evaluated in the past 12 years for evidence related to each question and make recommendations for the next generation of research and evaluation.
Section snippets
Methods
The Medline and Psychinfo databases were searched for articles published in English between 1985 and 1997 using the key word, `telephone' in combination with `counseling, interventions, and information services.' The ubiquity of the telephone is evidenced by the results of our initial search that yielded over 400 articles. Review of the abstracts indicated that the majority of these studies described audits of telephone inquiries to information services in health and social service settings. A
Has the potential of TDIs been realized?
This review describes 74 TDI trials representing research in the US, Canada, Britain and Australia. The majority of studies (n=44) have been published since 1993 (see Table 1). About half (n=39) describe TDIs as the main intervention component and 58 of the studies evaluate proactively delivered services. In the following sections, the extent to which TDIs have broadened the reach of health interventions, promoted health behavior change, and increased the efficacy of health services delivery is
Motivating and sustaining health behavior change
TDIs used to promote health behavior change have been categorized into three broad topic areas: addictive behaviors, behavior change for patients with chronic diseases, and preventive behaviors. The TDIs evaluated in each of these areas is summarized below.
Increasing the efficacy of health services
Several studies have shown that TDIs can reduce system and patient burdens associated with inappropriate use of health services. For example, monthly follow-up calls from a nurse-allergist resulted in significant reductions in emergency room visits and hospital stays among asthma patients compared to usual care, with an associated reduction in costs of $87 000 [63]. The use of `telephone house calls', to monitor chronic diseases and to increase the appropriate use of health services, also has
Practice implications
We examined whether the potential of telephone interventions has been realized in three essential areas: broadening the reach of health interventions, promoting behavior change and increasing the efficacy of health services delivery. The evidence base for the effectiveness of TDIs in each of these areas is summarized below.
Reach: with few exceptions, higher educated, white women are over-represented participants in TDIs that use a reactive approach except when major efforts are made to increase
Conclusions
The telephone can be used to deliver individualized interventions for health promotion, disease management and to encourage appropriate use of health services. These interventions can be delivered at convenient times, with privacy, and can be individualized to the specific needs of the client. However, TDIs have not yet achieved their full potential. The next generation of research should answer the many practical questions we have raised here.
Acknowledgements
This work was supported in part by grants from the National Cancer Institute CA60141-03, CA72099-01, CA59734-04, CA63782-04 and the National Heart Lung and Blood Institute HL48121-05, and Cancer Information Service Contract N01 CO03874. The authors wish to acknowledge the contributions of C. Tracy Orleans, Ph.D., for her comments on an earlier draft of the manuscript and Jennifer Heisler for research assistance.
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