isaacmarks:
A very forward-looking proposal that could make a substantial contribution to health improvement on a broad international scale by adding a cost-effective arrow to the quiver of interventions needed to manage major public health problems. A crucial part of this enterprise is its ability to identify elements critical for efficacy: `In the studies we have already published, the most effective additional element was individually timed educational messages (“ITEMs”), that is, email reminders to return to the Web site and read specific sections of the smoking cessation guide keyed to where they were in the quitting process.' Another of its many impressive features is the IWHRC's readiness to collaborate with business in a partnership that could be very synergistic.
Thank you for your comment.
It is important to note that the UK’s National Institute for Health and Clinical Excellence (NICE) has approved two computer-based programs for use by the UK National Health Service (NHS) — Fear Fighter for treating people who have phobias or suffer from panic attacks, and Beating the Blues for treating people with mild to moderate depression.
This decision was taken after a very thorough review of the empirical evidence for computerized therapies.
We should follow the example of the UK, and expand the use of these interventions to other health problems, other languages, and share the interventions with the world.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
This is the type of global, public health thiking necessary to truly impact health issues both nationally and internationally. Dr. Muñoz is one of the leaders in this cutting edge approach of evidence-based Web interventions. There will never be enough people to personally help everyone who needs help. However, if you operationalize interventions and deliver them using the web, the potential reach is enormous. Fantastic idea.
The issue of whether we will ever be able to train enough professionals is a key element in this proposal.
I have been training clinical psychologists and psychiatrists at San Francisco General Hospital for 30 years.
When I first became professor at the University of California in 1977, I thought that within 10 or 20 years we would be able to train at least enough Spanish-speaking psychologists to serve the Spanish-speaking patients we see at San Francisco General. Now, 30 years later, we still have trouble recruiting enough Spanish-speaking psychologists. The waiting lists for Spanish-speaking patients are longer than for English-speaking patients. And the waiting lists for English-speaking patients are also longer than we would wish. Services for people who speak other languages are even harder to provide. The best we can do is often a translator, which is not optimal, especially for psychological treatment.
We really need to think of a stepped system of care: first, providing evidence-based services for the most common behavioral health problems in as many languages as we can in an automated fashion. Then, for those who do not improve with these services, advance to face-to-face services. The big advantage of developing the Internet-based automated services is that, once developed, they could be shared with people all over the world without taking anything away from our local patients. That will never happen with face-to-face services.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
Dr. Muñoz. I´m writing you form Colombia, actually I don´t know if I need to write you in english.....I could´t enter to the page you send, constantly there is an error on the page!
But for you at least: I found the website very interesting and beneficial for a large group of users, either professionals, patients, common people. The objectives explicited are clear (The development of health interventions delivered via the Web; Internet recruitment of participants for research studies and data collection). I don´t think there is enough information for people about HOW all these objectives work, they can write and ask for, but there is a phrase in Colombia that everything should be “a prueba de bobos”. Even if it is obvious,things must be very simple, especially if people from all educational levels are using it. Well that´s my point of view. I am a psychologist, graduated from the Javeriana University of Bogotá, 7 years ago. I am a young researcher at a medicine faculty, currently attending
a master in psychology with emphasis in health psychology. I did a research about Burnout prevalence in medical surgical residents and obtaining information by email or web was disastrous, I hope delivering the results can improve and can be useful for them. I wish you the best results with your site and any information about your develpments.
Thanks for your comments.
I agree that Web-based health interventions should be as simple as possible.
In our studies focused on smoking cessation, we have been finding that additional elements beyond the basic stop smoking guide we provide do not seem to increase efficacy on the average. However, there are subsets of users who do seem to quit at higher rates if provided with additional interventions (e.g., a mood management intervention in addition to a stop smoking intervention).
The issue of reaching people at all educational levels is also very important.
We feel that the ideal evidence-based Web intervention would have primarily a graphic and audio interface, so it would be useful for people who cannot read and write, plus additional material that someone with higher levels of literacy could drill down to, if they so wished.
Our plan is to be able to make behavioral health interventions that have been shown to work in scientific studies available to all.
Thanks again for your comments.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
All medical students should know about this site and this approach.
All clinics should have workstations so that those that do not otherwise have internet availability should be able to do so.
USB Sandisk Cruzer drives (or equivalent) should be customizable so that a person can carry around a ~10 dollar USB drive with a customized and encouraged entry to this website whenever the person plugs into any computer anywhere.
Get a site license for Polyedit (www.polyedit.com) and everybody in a community can have a Microsoft Word like program to carry around on the USB drive whereby the person can take notes, download images.....etc.
Then for 10 bucks or so everyone has a "computer" with directed access to this kind of website.
Customize dtsearch (www.dtsearch.com) for folks to put in what they want and be pattern matched with files on the USB drive and with the web services available.
Being redundant: train medical students, community health workers...etc to be able to deliver this service with gusto advice to try it for all folks who might benefit.
Charles Beauchamp MD, PhD
Associate Professor of Community Health
Boonshoft School of Medicine
Wright State University
Dayton Ohio (First in Future Health)
Having evidence-based Web interventions available anywhere where there is Web access would empower community health workers to provide these interventions to third world populations whether they live in developing or developed countries. For example, community health workers in developing countries could help individuals who smoke or are depressed to use the Web interventions. Similarly, public health clinics in the U.S. or Europe could make available interventions in languages for which there are no trained providers to people who speak those languages. For example, public health clinics in San Francisco could develop a screening module for depression in Laotian, and thus be able to identify someone who needs a depression intervention in that language. Then, they could get antidepressants from their primary care provider, plus a cognitive behavioral intervention in Laotian via an Internet health resource room at the clinic. The Laotian language intervention could then be shared with Laotian-speaking individuals throughout the U.S., Europe, and, of course, Laos. Laotian professionals from Laos could be invited to collaborate in the preparation of the intervention, in order to ensure that it would be culturally appropriate.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
I am from Colombia too. My english is not so good as others that had made an opinion. I think that this is a great idea. But im wondering about the quality of interventions. You said tha they are based on evidency, I guess they are cognitive-behavioral methods. But i would like to see how it works, as it pointed olga paredes in a previus commentary. And i was thinking too about the mayor desadvantages of treatment for problems like anxiety and depresion. In face to face treatment sometimes is not easy to create a relationship with the paciente, to understand the complexity of dyagnosis and to choose and managment the treatment. So, how can internet intervention resolve this chalenges?
This site is very interesting, i will visit it with frecuency.
Juan Francisco Muñoz
Psychologist
Popayán
Colombia
The issue of whether Internet interventions can be effective without the creation of the therapeutic relationships that are part of a face-to-face intervention is an important one.
Two thoughts:
First, the ideal situation would be for everyone who needs a therapist to be able to have one who speaks his or her language. We should all strive to make that happen. However, it seems to me that that is going to take a very long time, and may never happen. Given that, we need to develop innovations until that ideal situation becomes a reality. The development of evidence-based Web interventions is one such idea. There will probably be many other ways of doing this. What is important about the disruptive innovation I have proposed is that we have proof of concept with the work we have been doing with smoking cessation. We now want to test the hypothesis that this could be done with other health problems. There is evidence from other studies that this is the case.
it is possible that for some people, learning how to change one's behavior may be possible without the creation of a therapeutic relationship. We want to make Web interventions available to as many people as possible, so that those who can utilize this method can do so. Also, most people in the world do not have access to face-to-face therapists, and may never have such access. So, I see the Web interventions not as replacing live therapists, but as providing something instead of providing nothing.
Second, the argument that Web interventions will not be useful to everyone appears to imply that other types of interventions will be useful to everyone. In fact, of course, face-to-face interventions, such as psychotherapy or pharmacotherapy by highly trained professionals is not effective for all. For example, smoking cessation using the nicotine patch has an efficacy of between 14% and 22% at six months. Treatment for depression with the latest antidepressants results in about 33% remission (that is, returning to normal functioning in terms of mood), 33% improving, but not remitting, and 33% not improving. So, a realistic goal of evidence-based Web interventions is not to reach 100% efficacy, but rather, a reasonable level of efficacy, say, comparable to existing face-to-face interventions.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
This proposal seeks to address significant unmet needs for culturally-sensitive mental health services in the U.S. and throughout the world. The proposal presents evidence that internet offers viable alternative means to meet some of the need. Dr. Munoz and his research collaborators have already established that the internet can provide accessible, culturally-relevant, and effective mental health services to a diverse global population. The potential to build on the success of Dr. Munoz's preliminary studies is enormous. The web-based interventions will be particularly useful for low-income and undereducated populations that do not have access to mental health services. I did not find some of the participant demographic data that I think might be of interest to the reviewers. I would like to know more about participant demographic data, such as income-level, educational level, and access to healthcare ( e.g., low-cost clinics, health insurance), to demonstrate the utility of reaching underserved populations. I commend Dr. Munoz and his research collaborators for this pioneering research.
La presente propuesta en mi opinion es un excelente recurso para tratar multiples problemas de salud. Las experiencias previas con los fumadores y con estados de animo han mostrado resultados muy alentadores.
Este sistema tiene la ventaja de la facil accesibilidad, el ahorro de recursos humanos y la posibilidd de ser utilizado por personas de otros paises que de otra manera no tendrian acceso a estos tratamientos.
Ademas, si bien el uso de internet con estos fines parece muy promisorio y la experiencia preliminar pareceria soportarlo, es necesario comprobarlo de manera cientifica y este centro es el lugar ideal para hacerlo
Gracias por su comentario.
Efectivamente, lo que deseamos hacer es comprobar si cada intervención enfocada en cada problema de salud es eficaz (y para que grupo de personas no es eficaz).
Lo maravilloso de este forma de ofrecer intervenciones efectivas es que, una vez que han sido comprobadas, se pueden compartir con toda personal en el mundo quien habla el idioma en que la intervención se ha desarrollado, y que tiene acceso a Internet.
Una vez que clínicas de salud pública descubran este recurso, tal vez proveerán acceso a Internet a sus pacientes.
Saludos de San Francisco
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
Comments
isaacmarks:
A very forward-looking proposal that could make a substantial contribution to health improvement on a broad international scale by adding a cost-effective arrow to the quiver of interventions needed to manage major public health problems. A crucial part of this enterprise is its ability to identify elements critical for efficacy: `In the studies we have already published, the most effective additional element was individually timed educational messages (“ITEMs”), that is, email reminders to return to the Web site and read specific sections of the smoking cessation guide keyed to where they were in the quitting process.' Another of its many impressive features is the IWHRC's readiness to collaborate with business in a partnership that could be very synergistic.
Thank you for your comment.
It is important to note that the UK’s National Institute for Health and Clinical Excellence (NICE) has approved two computer-based programs for use by the UK National Health Service (NHS) — Fear Fighter for treating people who have phobias or suffer from panic attacks, and Beating the Blues for treating people with mild to moderate depression.
This decision was taken after a very thorough review of the empirical evidence for computerized therapies.
We should follow the example of the UK, and expand the use of these interventions to other health problems, other languages, and share the interventions with the world.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
This is the type of global, public health thiking necessary to truly impact health issues both nationally and internationally. Dr. Muñoz is one of the leaders in this cutting edge approach of evidence-based Web interventions. There will never be enough people to personally help everyone who needs help. However, if you operationalize interventions and deliver them using the web, the potential reach is enormous. Fantastic idea.
The issue of whether we will ever be able to train enough professionals is a key element in this proposal.
I have been training clinical psychologists and psychiatrists at San Francisco General Hospital for 30 years.
When I first became professor at the University of California in 1977, I thought that within 10 or 20 years we would be able to train at least enough Spanish-speaking psychologists to serve the Spanish-speaking patients we see at San Francisco General. Now, 30 years later, we still have trouble recruiting enough Spanish-speaking psychologists. The waiting lists for Spanish-speaking patients are longer than for English-speaking patients. And the waiting lists for English-speaking patients are also longer than we would wish. Services for people who speak other languages are even harder to provide. The best we can do is often a translator, which is not optimal, especially for psychological treatment.
We really need to think of a stepped system of care: first, providing evidence-based services for the most common behavioral health problems in as many languages as we can in an automated fashion. Then, for those who do not improve with these services, advance to face-to-face services. The big advantage of developing the Internet-based automated services is that, once developed, they could be shared with people all over the world without taking anything away from our local patients. That will never happen with face-to-face services.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
Dr. Muñoz. I´m writing you form Colombia, actually I don´t know if I need to write you in english.....I could´t enter to the page you send, constantly there is an error on the page!
But for you at least: I found the website very interesting and beneficial for a large group of users, either professionals, patients, common people. The objectives explicited are clear (The development of health interventions delivered via the Web; Internet recruitment of participants for research studies and data collection). I don´t think there is enough information for people about HOW all these objectives work, they can write and ask for, but there is a phrase in Colombia that everything should be “a prueba de bobos”. Even if it is obvious,things must be very simple, especially if people from all educational levels are using it. Well that´s my point of view. I am a psychologist, graduated from the Javeriana University of Bogotá, 7 years ago. I am a young researcher at a medicine faculty, currently attending
a master in psychology with emphasis in health psychology. I did a research about Burnout prevalence in medical surgical residents and obtaining information by email or web was disastrous, I hope delivering the results can improve and can be useful for them. I wish you the best results with your site and any information about your develpments.
Thanks for your comments.
I agree that Web-based health interventions should be as simple as possible.
In our studies focused on smoking cessation, we have been finding that additional elements beyond the basic stop smoking guide we provide do not seem to increase efficacy on the average. However, there are subsets of users who do seem to quit at higher rates if provided with additional interventions (e.g., a mood management intervention in addition to a stop smoking intervention).
The issue of reaching people at all educational levels is also very important.
We feel that the ideal evidence-based Web intervention would have primarily a graphic and audio interface, so it would be useful for people who cannot read and write, plus additional material that someone with higher levels of literacy could drill down to, if they so wished.
Our plan is to be able to make behavioral health interventions that have been shown to work in scientific studies available to all.
Thanks again for your comments.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
All medical students should know about this site and this approach.
All clinics should have workstations so that those that do not otherwise have internet availability should be able to do so.
USB Sandisk Cruzer drives (or equivalent) should be customizable so that a person can carry around a ~10 dollar USB drive with a customized and encouraged entry to this website whenever the person plugs into any computer anywhere.
Get a site license for Polyedit (www.polyedit.com) and everybody in a community can have a Microsoft Word like program to carry around on the USB drive whereby the person can take notes, download images.....etc.
Then for 10 bucks or so everyone has a "computer" with directed access to this kind of website.
Customize dtsearch (www.dtsearch.com) for folks to put in what they want and be pattern matched with files on the USB drive and with the web services available.
Being redundant: train medical students, community health workers...etc to be able to deliver this service with gusto advice to try it for all folks who might benefit.
Charles Beauchamp MD, PhD
Associate Professor of Community Health
Boonshoft School of Medicine
Wright State University
Dayton Ohio (First in Future Health)
Having evidence-based Web interventions available anywhere where there is Web access would empower community health workers to provide these interventions to third world populations whether they live in developing or developed countries. For example, community health workers in developing countries could help individuals who smoke or are depressed to use the Web interventions. Similarly, public health clinics in the U.S. or Europe could make available interventions in languages for which there are no trained providers to people who speak those languages. For example, public health clinics in San Francisco could develop a screening module for depression in Laotian, and thus be able to identify someone who needs a depression intervention in that language. Then, they could get antidepressants from their primary care provider, plus a cognitive behavioral intervention in Laotian via an Internet health resource room at the clinic. The Laotian language intervention could then be shared with Laotian-speaking individuals throughout the U.S., Europe, and, of course, Laos. Laotian professionals from Laos could be invited to collaborate in the preparation of the intervention, in order to ensure that it would be culturally appropriate.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
I am from Colombia too. My english is not so good as others that had made an opinion. I think that this is a great idea. But im wondering about the quality of interventions. You said tha they are based on evidency, I guess they are cognitive-behavioral methods. But i would like to see how it works, as it pointed olga paredes in a previus commentary. And i was thinking too about the mayor desadvantages of treatment for problems like anxiety and depresion. In face to face treatment sometimes is not easy to create a relationship with the paciente, to understand the complexity of dyagnosis and to choose and managment the treatment. So, how can internet intervention resolve this chalenges?
This site is very interesting, i will visit it with frecuency.
Juan Francisco Muñoz
Psychologist
Popayán
Colombia
The issue of whether Internet interventions can be effective without the creation of the therapeutic relationships that are part of a face-to-face intervention is an important one.
Two thoughts:
First, the ideal situation would be for everyone who needs a therapist to be able to have one who speaks his or her language. We should all strive to make that happen. However, it seems to me that that is going to take a very long time, and may never happen. Given that, we need to develop innovations until that ideal situation becomes a reality. The development of evidence-based Web interventions is one such idea. There will probably be many other ways of doing this. What is important about the disruptive innovation I have proposed is that we have proof of concept with the work we have been doing with smoking cessation. We now want to test the hypothesis that this could be done with other health problems. There is evidence from other studies that this is the case.
it is possible that for some people, learning how to change one's behavior may be possible without the creation of a therapeutic relationship. We want to make Web interventions available to as many people as possible, so that those who can utilize this method can do so. Also, most people in the world do not have access to face-to-face therapists, and may never have such access. So, I see the Web interventions not as replacing live therapists, but as providing something instead of providing nothing.
Second, the argument that Web interventions will not be useful to everyone appears to imply that other types of interventions will be useful to everyone. In fact, of course, face-to-face interventions, such as psychotherapy or pharmacotherapy by highly trained professionals is not effective for all. For example, smoking cessation using the nicotine patch has an efficacy of between 14% and 22% at six months. Treatment for depression with the latest antidepressants results in about 33% remission (that is, returning to normal functioning in terms of mood), 33% improving, but not remitting, and 33% not improving. So, a realistic goal of evidence-based Web interventions is not to reach 100% efficacy, but rather, a reasonable level of efficacy, say, comparable to existing face-to-face interventions.
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
This proposal seeks to address significant unmet needs for culturally-sensitive mental health services in the U.S. and throughout the world. The proposal presents evidence that internet offers viable alternative means to meet some of the need. Dr. Munoz and his research collaborators have already established that the internet can provide accessible, culturally-relevant, and effective mental health services to a diverse global population. The potential to build on the success of Dr. Munoz's preliminary studies is enormous. The web-based interventions will be particularly useful for low-income and undereducated populations that do not have access to mental health services. I did not find some of the participant demographic data that I think might be of interest to the reviewers. I would like to know more about participant demographic data, such as income-level, educational level, and access to healthcare ( e.g., low-cost clinics, health insurance), to demonstrate the utility of reaching underserved populations. I commend Dr. Munoz and his research collaborators for this pioneering research.
La presente propuesta en mi opinion es un excelente recurso para tratar multiples problemas de salud. Las experiencias previas con los fumadores y con estados de animo han mostrado resultados muy alentadores.
Este sistema tiene la ventaja de la facil accesibilidad, el ahorro de recursos humanos y la posibilidd de ser utilizado por personas de otros paises que de otra manera no tendrian acceso a estos tratamientos.
Ademas, si bien el uso de internet con estos fines parece muy promisorio y la experiencia preliminar pareceria soportarlo, es necesario comprobarlo de manera cientifica y este centro es el lugar ideal para hacerlo
Gracias por su comentario.
Efectivamente, lo que deseamos hacer es comprobar si cada intervención enfocada en cada problema de salud es eficaz (y para que grupo de personas no es eficaz).
Lo maravilloso de este forma de ofrecer intervenciones efectivas es que, una vez que han sido comprobadas, se pueden compartir con toda personal en el mundo quien habla el idioma en que la intervención se ha desarrollado, y que tiene acceso a Internet.
Una vez que clínicas de salud pública descubran este recurso, tal vez proveerán acceso a Internet a sus pacientes.
Saludos de San Francisco
Ricardo F. Muñoz, Ph.D.
Professor of Psychology
University of California, San Francisco
San Francisco General Hospital
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