Critical Appraisal Review

1. Cellular phone and Internet-based individual intervention on
blood pressure and obesity in obese patients with
hypertension Park MJ, Kim HS, Kim KS (2009),
Click to edit Master subtitle style
Presented By: Plumaletta Berry
HAD5726
University of Toronto
October 5, 2009

2. Research Paper
5/10/2009 5/10/200924/10/09 22
2

3. About the Authors
Hee-Seung Kim
Professor Degree Ph.D. in nursing Major Adult nursing care
College of Nursing, Catholic University, 505 Banpo-Dong,
Socho-Gu, Seoul 137-701, South Korea
Min-Jeong Park **
College of Nursing, Catholic University, 505 Banpo-Dong,
Socho-Gu, Seoul 137-701, South Korea
Kyung-Soo Kim **
Family Medicine & Integrative Medicine, Seoul St. Mary’s
Hospital, Catholic University Medical Center, #505
Banpo-dong, Seocho-gu, Seoul 137-701, South Korea
5/10/2009 5/10/200924/10/09 33
3

4. Why is the paper interesting,
why was it picked?
The ICT Development Index. Measuring the Information Society. International Telecommunication Union, 2009
[http://www.itu.int/ITUD/ict/publications/idi/2009/material/IDI2009_w5.pdf]
5/10/2009 5/10/200924/10/09 44
4

5. About Chronic Disease Management
(CDM) - WHO Perspective
 Coordination and strengthening of global
advocacy and communication on key
messages, resource mobilization, and the
development of partnerships.
 Aim is to ensure increased prominence of
chronic disease and health promotion issues
on the global health agenda
World Health Organization: Chronic diseases and health promotion 2009 [2009 October 2];
5/10/2009 5/10/200924/10/09 online : http://www.who.int/chp/about/en/
Available 55
5

6. For whom is this paper interesting,
and why?
Key health care stakeholders : health promotion and chronic disease
(CD) prevention and control - low cost but effective technological
evidence-based interventions (both developed and developing
countries).
Why?
• CD highly dependent on self-efficacy
• Remote patient monitoring – motivation and intervention to
promote adherence and self reporting of behaviours
Potential for supporting health through information and
communication technology (ICT) is increasingly recognized given the
exponential growth in cellular phones around the world.
A.M. Prentice, The emerging epidemic of obesity in developing countries, Int. J. Epidemiol. 35 (2006), pp. 93–99. Cited By in Scopus (105)
5/10/2009 5/10/200924/10/09 66
6

7. Intervention
Usage of short message service (SMS) by cellular phone and Internet
A quasi-experimental design with pre- and follow-up tests.
Intervention group - should be able to measure blood pressure, take
medicine, and input data web based diary through the Internet or by
cellular phones by themselves.
Researchers compare individual data with basic personal history, including
historical data, family history, smoking habits, BMI, blood pressure, and baseline
laboratory data.
Sent optimal recommendations as an intervention to each patient, by both
SMS on cellular phone and Internet weekly.
Control Group: Did not log into the website and were only informed of
the study
Goal of intervention - bring blood pressure, body weight, and serum lipids
5/10/2009 levels close to normal ranges.
5/10/200924/10/09 77
77

8. Setting
Location: Urban city of South Korea
Family medicine outpatient department
- tertiary care hospital
Population: 28 patients - assigned to an intervention group
21 patients – assigned to a control group.
Intervention - Logged into website whenever it was convenient
group and wherever Internet access was possible by the
Internet or cellular phone.
Physician Visit: Both groups met the hypertension doctor (attending
physician) - one or two times during the 8 weeks.
Physician - no knowledge of group patient belonged to.
5/10/2009 5/10/200924/10/09 88
88

9. Outcome Measures
Chi square test, t-test, and Fisher’s exact tests :
Test for the homogeneity of demographic and clinical characteristics
between the intervention and control groups.
Repeated-measures analysis of variance (ANOVA) :
Determine the difference between groups and over time.
When a significant difference was found by repeated-measures
ANOVA, paired t-tests with Bonferroni correction were applied to
identify specific differences.
5/10/2009 The data were analyzed using the SAS (version 8.12, SAS Institute, Cary, NC) program.
5/10/200924/10/09 99
9

10. Results
5/10/2009 5/10/200924/10/09 10

11. Results Cont’d
5/10/2009 5/10/200924/10/09 11

12. Conclusions
The intervention using SMS of cellular phone and
Internet improved blood pressure, body weight,
waist circumference, and HDL-C at 8 weeks in
obese hypertensive patients.
5/10/2009 5/10/200924/10/09 12

13. Cited Related Publishings
 M. Korhonen, M. Kastarinen, M. Uusitupa, P. Puska and A. Nissinen, The effect of intensified
diet counseling on the diet of hypertensive subjects in primary health care: a 2-year
open randomized controlled trial of lifestyle intervention against hypertension in
eastern Finland, Prev. Med. 36 (2003), pp. 8–16. Abstract | PDF (72 K) | View Record in
Scopus | Cited By in Scopus (14)
 D.F. Tate, R.R. Wing and R.A. Winett, Using Internet technology to deliver a behavioral
weight loss program, JAMA 285 (2001), pp. 1172–1177. Full Text via CrossRef | View Record
in Scopus | Cited By in Scopus (246)
 A.P. Nunes, A.C. Rios, G.A. Cunha, A.C. Barretto and C.E. Negrão, The effects of
nonsupervised exercise program, via Internet, on blood pressure and body composition
in normotensive and prehypertensive individuals, Arq. Bras. Cardiol. 86 (2006), pp. 289–296.
View Record in Scopus | Cited By in Scopus (4)
 A.G. Logan, W.J. McIsaac, A. Tisler, M.J. Irvine, A. Saunders, A. Dunai, C.A. Rizo, D.S. Feig, M.
Hamill, M. Trudel and J.A. Cafazzo, Mobile phone-based remote patient monitoring system
for management of hypertension in diabetic patients, Am. J. Hypertens. 20 (2007), pp. 942–
948. Article | PDF (475 K) | View Record in Scopus | Cited By in Scopus (10)
 J. Morak, K. Schindler, E. Goerzer, P. Kastner, H. Toplak, B. Ludvik and G. Schreier, A pilot study
of mobile phone-based therapy for obese patients, J. Telemed.Telecare 14 (2008), pp. 147–
149. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (1)
5/10/2009 5/10/200924/10/09 13

14. Articles Previously Published
 S.I. Kim and H.S. Kim, Effectiveness of mobile and Internet intervention in patients with obese type 2
diabetes, Int. J. Med. Inform. 77 (2008), pp. 399–404. Article | PDF (367 K) | View Record in Scopus | Cited By in
Scopus (4)
 Kim & Jeong, 2007 H.S. Kim and H.S. Jeong, A short-message service by cellular phone in type-2 diabetic
patients for six months, Journal of Clinical Nursing 16 (2007), pp. 1082–1087. Full Text via CrossRef | View
Record in Scopus | Cited By in Scopus (10)
 Yoon & Kim, 2007 K.H.Yoon and H.S. Kim, A short message service by cellular phone in type 2 diabetic
patients for 12 months, Diabetes Research and Clinical Practice 79 (2007), pp. 256–261.
 H.S. Kim, M.S. Song, Technological intervention for patients with obesity and type 2 diabetes,Appl. Nurs.
Res. (2007), in press. Cited By in Scopus (2)
 Kim, 2007 H.S. Kim, A randomized controlled trial of a nurse short-message service by cellular phone for
people with diabetes, International Journal of Nursing Studies 44 (2007), pp. 687–692. Article | PDF (139 K) |
View Record in Scopus | Cited By in Scopus (10)
 H.S. Kwon, J.H. Cho, H.S. Kim, B.R. Song, S.H. Ko, J.M. Lee, S.R. Kim, S.A. Chang, H.S. Kim, B.Y. Cha, K.W. Lee, H.Y.
Son, J.H. Lee,W.C. Lee and K.H.Yoon, Establishment of blood glucose monitoring system using the internet,
Diab. Care 27 (2004), pp. 478–483. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (46)
 S.A. Chang, H.S. Kim, K.H.Yoon, S.H. Ko, H.S. Kwon, S.R. Kim,W.C. Lee, S.J.Yoo, H.S. Son, B.Y. Cha, K.W. Lee, H.Y.
Son and S.K. Kang, Body mass index is the most Important determining factor for the degree of insulin
resistance in non-obese type 2 diabetic patients in Korea, Metabolism 53 (2004), pp. 142–146. Article | PDF
(371 K) | View Record in Scopus | Cited By in Scopus (15)
5/10/2009 5/10/200924/10/09 14

15. What other authors have published
before
Article Authors Year Result
Two-Year Internet-Based Williamson etal 2006 Randomized Weight loss during the first 6
Randomized Controlled Trial controlled trial months - did not yield long-
for Weight Loss in African- term loss due to reduced use
American Girls of the web site over time
http://www.nature.com/oby/journal/v14/n7
/abs/oby2006140a.html
Effectiveness of mobile and Kim SI, Kim 2007 quasi- Intervention using SMS of
internet intervention in HS. experimental personal cellular phone and
patients with obese type 2 design with pre- Internet improved HbA(1)c
diabetes and follow-up and 2HPPT at 3, 6, 9, and 12
tests. months in patients with
obese type 2 diabetes.
An Internet-based diabetes Silje C. 2007 two-group, Study suggests that SE can
self-care intervention tailored Wangberg 1-month function as a moderator in a
to self-efficacy (SE) interval pre- behavioural intervention for
http://her.oxfordjournals.org/cgi/rep test–post-test diabetes self-care, and hence
rint/23/1/170 randomized that initial level of SE
controlled trial provides relevant information
for tailoring such
interventions.
5/10/2009 5/10/200924/10/09 15

16. Background information
Rationale for Research 1: Limitation of studies on the direct efficacy of the
cellular phone or Internet-based system on improving blood pressure, weight
control, and serum lipid for the patients with obese hypertension.
Rationale for Research II: The high death rates attributable to cardiovascular
disease in South Korea are partly due to failure to obtain adequate treatment and
management of hypertension
– what’s not written in the paper
Population size from which sample was drawn
If Participants known to each other (not a selection factor)
No stated means of assuring confidentiality of information collected from clients
provided in paper
Reasons why 4 persons refused the test at the end of the 8 weeks
Norman C, (2004) Response to CATCH-IT Report by Cameron Norman: Evaluation of an Internet-Based Smoking
5/10/2009 5/10/200924/10/09
Cessation Program: Lessons Learned From a Pilot Study" . J Med Internet Res. 2004 Oct–Dec; 6(4): e47. 16

17. Background information – Cont'd
– what’s not written in the paper
No method of accounting for alternative explanations or measure of efficacy was
provided
No indication if measurements were recorded or communicated by the physician
during visits
No mention of where measures were obtained from and literature to support these
No link throughout paper back to the high death rates attributable to cardiovascular
disease and failure to manage hypertension
No specifics on theoretical approach used for this study eg. (Cognitive Behavioral
Therapy (self- and supported treatment) and Social Cognitive Theory) both not
explicitly stated
Norman C, (2004) Response to CATCH-IT Report by Cameron Norman: Evaluation of an Internet-Based Smoking
Cessation Program: Lessons Learned From a Pilot Study" . J Med Internet Res. 2004 Oct–Dec; 6(4): e47.
5/10/2009 5/10/200924/10/09 17

18. What are the methodological issues,
and is the result valid?
5/10/2009 5/10/200924/10/09 18

19. Internal Validity
 Selection bias
 Patients selected based on specific
criteria
 Selection threat
 Control group may become
"contaminated" by accessing a similar
intervention from somewhere else on the
web - Ethical concerns re monitoring
Eysenbach G, Issues in evaluating health websites in an Internet-based randomized controlled trial,
J Med Internet Res 2002;4(3):e17
5/10/2009 5/10/200924/10/09 19
http://www.socialresearchmethods.net/kb/intmult.php

20. Internal Validity- Cont’d
 Selection-History Threat
 Physician may select to disclose particular information, or if
the patient wished, nurse or dietician came to aid with more
individualized and detailed information relating to lifestyle
modification.
 Selection-Maturation Threat
 Intervention group may access to other sources of
information or similar intervention program
 Selection-Instrumentation Threat
 Control group, four subjects refused the test at 8weeks
5/10/2009 5/10/200924/10/09
http://www.socialresearchmethods.net/kb/intmult.php 20

21. Internal Validity - Cont’d
 Selection-Mortality Threat
 Low sample size (control group below effect size and drop off rate
differs)
 Low statistical power will limit greatly the level of confidence in all
inferences that might be drawn from this study’s results.
 Social Interaction threats
 Opportunity for researchers to introduce bias in the interaction
with patients via the intervention as SMS tailored in a particular
way
5/10/2009 http://www.socialresearchmethods.net/kb/intmult.php
5/10/200924/10/09 21

22. External Validity
three major threats to external validity --
people, places or times.
 Population controlled to urban city of
one hospital total of 49 persons (Cannot
Generalize)
5/10/2009 5/10/200924/10/09 22

23. Results Valid?
 daily living can have substantial and variable effects on blood
pressure
 patient preparation and measurement technique
 equipment used is often inaccurate: No indication if blood
pressure instruments by patient were properly calibrated and
validated instrument was used; similarly for the body weight
scale
 All data were self-reported, and there was no objective
confirmation of any of the data reported here.
 Serium Lipid measures –3 out of the 4 required had no
significant change – short period of study
5/10/2009 http://www.swinburne.edu.au/hosting/ijets/journal/V6N2/pdf/Article3Beddows.pdf
5/10/200924/10/09 randomized Controlled trial J Med Internet Res 2002;4(3):e17 23
Eysenbach G, Issues in evaluating health websites in an Internet-based

24. What are the methodological
issues, and is the result valid?
"Correlation does not imply causation"
Given the limits on control of factors reported
for the intervention and the external/internal
validity issues, results cannot determine whether
this association was causal.
RESULTS NOT VALID
http://www.swinburne.edu.au/hosting/ijets/journal/V6N2/pdf/Article3Beddows.pdf
5/10/2009 5/10/200924/10/09
Eysenbach G, Issues in evaluating health websites in an Internet-based randomized Controlled trial J Med Internet Res 2002;4(3):e17
24

25. Learn from this study
Stakeholder Lessons
Health professionals Pursuit of better health outcomes:-
- a regularly based education from the medical
team and
- continuous self-monitoring through ICT
intervention
may be used as a tool in changing patient’s
behaviour for self care at home in the short term.
Consumers Can benefit from an individualized approach in
which the care plan was formulated according to
each persons characteristics.
Intervention may promote greater self efficacy in
stimulating and motivating the patients to
perform self plan more enthusiastically from home.
5/10/2009 5/10/200924/10/09 25

26. Learn from this study
Stakeholder Lesson
Policy makers Initial level of research provide relevant information for
tailoring behavioural intervention for diabetes education
and self-care.
Assessing the potential value of innovations in ICT
interventions to advance the management and prevention
of chronic disease over a sustainable period
Researchers Addition to the body of literature on behavioural change
through online interventions and will prompt
development of more in-depth research.
Results must be taken with caution based on the
methodological issues associated with research.
Inadequacies of the research will ease constraints
previously associated with social research
5/10/2009 5/10/200924/10/09 26

27. What further research is required?
Future work should explore whether long-term follow-up for a randomized
controlled population using an intervention of SMS by cellular phone and
Internet would affect the measurable factors of the patients with obese
hypertension.
This should evaluate if adherence to behaviour in self reporting of these
factors would be sustainably over time or whether the association between use
of the program and improved outcomes is causal.
5/10/2009 5/10/200924/10/09 27

28. What questions for the author arise?
How were selection criteria for the measures determined?
How was hypertension self-efficacy measured?
How did you assure that the intervention group was actually using the intervention?
How did you control for data quality?
How do you propose researchers address the issue of validating self-reporting using
remotely-delivered interventions?
How did they determine persons who knew how to enter data using a computer versus the
persons who didnot?
Was the web-based diary developed on the guidelines for interactive health communication
from SciPICH3 ?
Will there be any follow-up research done on this and what is the period considered for
the pre and post test?
5/10/2009 5/10/200924/10/09 28

29. 5/10/2009 5/10/200924/10/09 29

30. Blog Comments Summary
 Generalizeability of the study to the general population is
questionable.
 Limited time period to examine lifestyle change - law of attrition
 Sample not randomize – selection bias
 Impact of study - general idea about entering data into a website,
intervention not clearly defined
 comparison between a face-to-face intervention and an online
service is not part of the original objective of the study
 Self reporting by the intervention group may not yield the most
accurate data.
5/10/2009 5/10/200924/10/09 30

31. QUESTIONS??
5/10/200924/10/09 31