---
title: "Digitally augmented ED discharge intervention increases short-term abstinence from health-risk beh"
id: "plos-medicine-1-effect-of-a-digitally-augmented-general-health-promotion-intervention-on"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-1-effect-of-a-digitally-augmented-general-health-promotion-intervention-on"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916"
published_at: "2026-09-08T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Digitally augmented ED discharge intervention increases short-term abstinence from health-risk beh
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-1-effect-of-a-digitally-augmented-general-health-promotion-intervention-on
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916)
- **Published At:** 2026-09-08T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This assessor-blinded randomized controlled trial tested a **digitally augmented general health-promotion** intervention delivered to adults discharged from an emergency department (ED) in Hong Kong. The intervention combined a brief telephone AWARD-model (Ask, Warn, Advise, Refer, Do-it-again) counseling session with weekly WhatsApp or WeChat messages for 6 months. - Eligible participants were 18–65 years, triaged semi-urgent or non-urgent, had at least one health-risk behavior (tobacco use, harmful alcohol use, unhealthy diet, or physical inactivity), and owned a smartphone. - Of 2,134 screened patients, 572 were enrolled and randomized equally (286 per group) to the intervention or to control (brief telephone advice only). - Primary outcome: self-reported abstinence from at least one health-risk behavior at 6 months. Secondary outcomes included abstinence at 12 months and reductions in the number of risk behaviors at 6 and 12 months. - At 6 months, 30.1% of intervention participants vs 19.9% of controls reported abstinence from ≥1 risk behavior (risk ratio 1.51; 95% CI 1.13–2.02; P = 0.006). The intervention also yielded greater reductions in the number of risky behaviors at 6 months (RR = 1.54; P = 0.01) and at 12 months (RR = 1.48; P = 0.02). - The largest single-behavior improvement was in **physical inactivity** at 6 months (31.7% intervention vs 16.2% control; P < 0.001). - Benefits attenuated after booster messaging stopped; sustained effects at 12 months were not observed to the same extent. - Limitations reported include reliance on self-reported outcomes, single-center design, and loss to follow-up, which may limit generalizability. - Authors conclude that a low-cost, scalable ED-delivered program using brief counseling plus mobile instant messaging can produce short-term behavior change, but longer or maintenance strategies and multicenter trials with longer follow-up are needed to determine long-term effectiveness.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1004916) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#citedHeader) * 5 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916#discussedHeader) Open Access Peer-reviewed Research Article # Effect of a digitally augmented general health promotion intervention on abstinence from health-risk behaviors among emergency department discharge patients: A randomized controlled trial * Ho Cheung William Li , Roles Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing * E-mail: williamli@cuhk.edu.hk Affiliation The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-2562-769X ](https://orcid.org/0000-0002-2562-769X "ORCID Registry") ⨯ * Wei Xia, Roles Conceptualization, Methodology, Validation, Writing – review & editing Affiliation School of Nursing, Sun Yat-Sen University, Guangzhou, China ⨯ * Joanna Yeung, Roles Conceptualization, Methodology, Writing – review & editing Affiliation The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-0061-4905 ](https://orcid.org/0000-0002-0061-4905 "ORCID Registry") ⨯ * Laurie Long Kwan Ho, Roles Conceptualization, Investigation, Methodology, Writing – review & editing Affiliation The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-0852-6299 ](https://orcid.org/0000-0002-0852-6299 "ORCID Registry") ⨯ * Tan Ankie Cheung, Roles Conceptualization, Methodology, Writing – review & editing Affiliation The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-6498-0314 ](https://orcid.org/0000-0002-6498-0314 "ORCID Registry") ⨯ * Kai Yeung Cheung, Roles Conceptualization, Investigation, Methodology, Writing – review & editing Affiliation United Christian Hospital, Kowloon, Hong Kong SAR, China ⨯ * Yiu Cheung Chan, Roles Conceptualization, Investigation, Methodology, Resources, Writing – review & editing Affiliation United Christian Hospital, Kowloon, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-2139-2886 ](https://orcid.org/0000-0003-2139-2886 "ORCID Registry") ⨯ * Wai Yee Chan, Roles Conceptualization, Investigation, Methodology, Writing – review & editing Affiliation United Christian Hospital, Kowloon, Hong Kong SAR, China ⨯ * Chin Wai Lui, Roles Conceptualization, Investigation, Methodology, Resources, Writing – review & editing Affiliation United Christian Hospital, Kowloon, Hong Kong SAR, China ⨯ * Hong Chen Roles Data curation, Formal analysis, Software, Validation, Visualization, Writing – original draft, Writing – review & editing Affiliation The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-2606-0039 ](https://orcid.org/0000-0003-2606-0039 "ORCID Registry") ⨯ # Effect of a digitally augmented general health promotion intervention on abstinence from health-risk behaviors among emergency department discharge patients: A randomized controlled trial * Ho Cheung William Li, * Wei Xia, * Joanna Yeung, * Laurie Long Kwan Ho, * Tan Ankie Cheung, * Kai Yeung Cheung, * Yiu Cheung Chan, … * Wai Yee Chan, * Chin Wai Lui, * Hong Chen ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 8, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1004916) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1004916) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004916) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1004916) * [Abstract](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#abstract0) * [Author summary](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#abstract1) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#sec008) * [Methods](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#sec009) * [Results](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#sec022) * [Discussion](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#sec023) * [Supporting information](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#sec024) * [Acknowledgments](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#ack) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1004916) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916) [?](https://journals.plos.org/plosmedicine/s/accepted-manuscripts#loc-early-version) ## This is an uncorrected proof. ## Abstract ### Background Noncommunicable diseases (NCDs) are the leading global cause of death and are driven by modifiable behaviors, such as tobacco use, harmful alcohol consumption, unhealthy diet, and physical inactivity. Recognizing that emergency department (ED) visits represent a unique opportunity to promote behavior change, this trial evaluated a digitally augmented, theory based general health promotion approach, combining a brief telephone-based intervention with mobile instant messaging support, to help discharged ED patients abstain from health risk behaviors. ### Methods and findings This assessor-blinded randomized controlled trial was conducted in a major public hospital ED in Hong Kong. Adults (18–65 years) triaged as semi-urgent or non-urgent and with ≥1 health-risk behavior and smartphone access were randomized to receive a digitally augmented, theory‑based general health‑promotion intervention consisting of a brief telephone‑based AWARD‑model intervention (Ask, Warn, Advise, Refer, and Do-it-again) followed by weekly WhatsApp or WeChat messages for 6 months, or to a control group receiving brief telephone advice only. The primary outcome was self-report abstinence from ≥1 health-risk behavior at 6 months; secondary outcomes included the proportion of participants who achieved self-reported abstinence from ≥1 health-risk behavior at 12 months and reduction in the number of behaviors at 6 and 12 months. Of the 2,134 screened patients, 572 were enrolled (286 per group). At 6 months, 30.1% of the intervention participants versus 19.9% of the controls achieved self-reported abstinence (RR = 1.51; 95% CI, 1.13–2.02; _P_ = 0.006). The intervention also significantly increased the likelihood of fewer risky behaviors at 6 (RR = 1.54; _P_ = 0.01) and 12 (RR = 1.48; _P_ = 0.02) months. Physical inactivity showed the greatest improvement at 6 months (31.7% versus 16.2%; _P_ ). No custom code was developed or used for the analyses reported in this manuscript. **Funding:** This work was supported by the Fund for Evidence-based Practice Improvement Collaborative Projects, Nethersole Evidence-based Nursing Practice Unit (NENPU), Nethersole Group Hospitals, Hong Kong SAR, China ( ; ) (to WHCL). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. **Competing interests:** The authors have declared that no competing interests exist. **Abbreviations:** AI, artificial Intelligence; CCA, complete case analysis; ED, emergency department; GEE, generalized estimating equation; ITT, intention-to-treat; NCDs, noncommunicable diseases; RCT, randomized controlled trial; RR, risk ratio; RRs, relative risks ## Introduction Chronic diseases, also known as noncommunicable diseases (NCD), include cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref001)]. Together, NCDs have become the leading causes of morbidity and mortality worldwide and now account for more than 70% of all deaths [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref001)]. The WHO has identified tobacco use, harmful alcohol consumption, unhealthy diet, and physical inactivity as the major behavioral risk factors that significantly contribute to NCDs and increase the risk of premature death [[2](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref002)]. Hypertension, in particular, is one of the most prevalent and frequently underdiagnosed NCDs globally and is a major contributor to cardiovascular morbidity commonly encountered in emergency department (ED) settings [[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref003)]. In Hong Kong, the burden of NCDs is growing, intensified by an aging population [[4](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref004)]. The Hong Kong Hospital Authority projects a 50% increase in NCD cases among middle-aged individuals, with the 2 million cases reported in 2019 expected to rise to 3 million by 2039, thereby creating a serious challenge to the healthcare system and adding to the long-term socioeconomic burden [[5](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref005)]. Most premature deaths from NCDs are preventable through lifestyle modifications [[6](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref006)]. Therefore, supporting individuals’ efforts to abstain from health-risk behaviors, such as quitting smoking, avoiding harmful alcohol consumption, maintaining a balanced diet, and engaging in regular physical activity, can help prevent or control high-prevalence conditions such as hypertension, cardiovascular disease, and diabetes, and improve overall population health [[7](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref007)]. Smoking, in particular, is a well‑established risk factor for hypertension and cardiovascular disease, underscoring the importance of helping smokers quit smoking as part of a broader NCD prevention strategy [[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref003)]. However, many individuals struggle with motivation or find abstaining from health-risk behaviors to be challenging, particularly when they receive minimal guidance and support from healthcare professionals [[8](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref008)–[11](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref011)]. Consequently, ED visits present a valuable opportunity for encouraging positive health behavior changes, as individuals seeking care during episodes of physical discomfort may be more receptive to advice on reducing health-risk behaviors. According to the Hospital Authority Annual Report [[12](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004916#pmed.1004916.ref012)], Hong Kong hospitals reported 1.8 million ED visits between 2021 and 2022, with over half of the cases triaged as semi-urgent (level 4) or non-urgent (level 5). Most of these patients were discharged home after receiving medical attention. Conditions commonly associated with NCDs, including poorly controlled hypertension and other cardiovascular‑related complaints, account for a substan
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