Defining participant exposure measures in Web-based health behavior change programs

Web-assisted tobacco interventions: empowering change in the global fight for the public's (e)Health

Tobacco control in the 21^st century faces many of the same challenges as in the past, but in different contexts, settings and enabled by powerful new tools including those delivered by information and communication technologies via computer, videocasts, and mobile handsets to the world. Building on the power of electronic networks, Web-assisted tobacco interventions (WATI) provide a vehicle for delivering tobacco prevention, cessation, social support and training opportunities on-demand and direct to practitioners and the public alike. The Framework Convention on Tobacco Control, the world’s first global public health treaty, requires that all nations develop comprehensive tobacco control strategies that include provision of health promotion information, population interventions, and decision-support services. WATI research and development has evolved to provide examples of how eHealth can address all of these needs and provide exemplars for other areas of public health to follow. This paper discusses the role of WATI in supporting tobacco control and introduces a special issue of the Journal of Medical Internet Research that broadens the evidence base and provides illustrations of how new technologies can support health promotion and population health overall, empowering change and ushering in a new era of public eHealth.

Comparing two web-based smoking cessation programs: randomized controlled trial

Background

Smoking cessation remains a significant public health problem. Innovative interventions that use the Internet have begun to emerge that offer great promise in reaching large numbers of participants and encouraging widespread behavior change. To date, the relatively few controlled trials of Web-based smoking cessation programs have been limited by short follow-up intervals.

Objective

We describe the 6-month follow-up results of a randomized controlled trial in which participants recruited online were randomly assigned to either a Web-based smoking cessation program (Quit Smoking Network; QSN) or a Web-based exercise enhancement program (Active Lives) adapted somewhat to encourage smoking cessation.

Methods

The study was a two-arm randomized controlled trial that compared two Web-based smoking cessation programs: (1) the QSN intervention condition presented cognitive-behavioral strategies, and (2) the Active Lives control condition provided participants with guidance in developing a physical activity program to assist them with quitting. The QSN condition provided smoking cessation information and behavior change strategies while the Active Lives condition provided participants with physical activity recommendations and goal setting. The QSN condition was designed to be more engaging (eg, it included multimedia components) and to present much greater content than is typically found in smoking cessation programs.

Results

Contrary to our hypotheses, no between-condition differences in smoking abstinence were found at 3- and 6-month follow-up assessments. While participants in the QSN intervention condition spent more time than controls visiting the online program, the median number of 1.0 visit in each condition and the substantial attrition (60.8% at the 6-month follow-up) indicate that participants were not as engaged as we had expected.

Conclusions

Contrary to our hypothesis, our test of two Web-based smoking cessation conditions, an intervention and an attention placebo control, failed to show differences at 3- and 6-month assessments. We explored possible reasons for this finding, including limited engagement of participants and simplifying program content and architecture. Future research needs to address methods to improve participant engagement in online smoking cessation programs. Possible approaches in this regard can include new informed consent procedures that better explain the roles and responsibilities of being a research participant, new program designs that add more vitality (changing content from visit to visit), and new types of reminders pushed out to participants to encourage return visits. Simplifying program content through a combination of enhanced tailoring and information architecture also merits further research attention.

The role of engagement in a tailored web-based smoking cessation program: randomized controlled trial

BACKGROUND

Web-based programs for health promotion, disease prevention, and disease management often experience high rates of attrition. There are 3 questions which are particularly relevant to this issue. First, does engagement with program content predict long-term outcomes? Second, which users are most likely to drop out or disengage from the program? Third, do particular intervention strategies enhance engagement?

OBJECTIVE

To determine: (1) whether engagement (defined by the number of Web sections opened) in a Web-based smoking cessation intervention predicts 6-month abstinence, (2) whether particular sociodemographic and psychographic groups are more likely to have lower engagement, and (3) whether particular components of a Web-based smoking cessation program influence engagement.

METHODS

A randomized trial of 1866 smokers was used to examine the efficacy of 5 different treatment components of a Web-based smoking cessation intervention. The components were: high- versus low-personalized message source, high- versus low-tailored outcome expectation, efficacy expectation, and success story messages. Moreover, the timing of exposure to these sections was manipulated, with participants randomized to either a single unified Web program with all sections available at once, or sequential exposure to each section over a 5-week period of time. Participants from 2 large health plans enrolled to receive the online behavioral smoking cessation program and a free course of nicotine replacement therapy (patch). The program included: an introduction section, a section focusing on outcome expectations, 2 sections focusing on efficacy expectations, and a section with a narrative success story (5 sections altogether, each with multiple screens). Most of the analyses were conducted with a stratification of the 2 exposure types. Measures included: sociodemographic and psychosocial characteristics, Web sections opened, perceived message relevance, and smoking cessation 6-months following quit date.

RESULTS

The total number of Web sections opened was related to subsequent smoking cessation. Participants who were younger, were male, or had less formal education were more likely to disengage from the Web-based cessation program, particularly when the program sections were delivered sequentially over time. More personalized source and high-depth tailored self-efficacy components were related to a greater number of Web sections opened. A path analysis model suggested that the impact of high-depth message tailoring on engagement in the sequentially delivered Web program was mediated by perceived message relevance.

CONCLUSIONS

Results of this study suggest that one of the mechanisms underlying the impact of Web-based smoking cessation interventions is engagement with the program. The source of the message, the degree of message tailoring, and the timing of exposure appear to influence Web-based program engagement.

Mediators of a successful web-based smokeless tobacco cessation program

AIM

To examine self-efficacy and program exposure as possible mediators observed treatment effects for a web-based tobacco cessation intervention.

DESIGN

The ChewFree trial used a two-arm design to compare tobacco abstinence at both the 3- and 6-month follow-up for participants randomized to either an enhanced intervention condition or a basic information-only control condition.

SETTING

Internet in US and Canada.

PARTICIPANTS

Our secondary analyses focused upon 402 participants who visited the web-based program at least once, whose baseline self-efficacy rating showed room for improvement, who reported that they were still using tobacco at the 6-week assessment, and for whom both 3- and 6-month follow-up data were available.

INTERVENTION

An enhanced web-based behavioral smokeless tobacco cessation intervention delivered program content using text, interactive activities, testimonial videos and an ask-an-expert forum and a peer forum. The basic control condition delivered tobacco cessation content using static text only.

MEASUREMENTS

Change in self-efficacy and program exposure from baseline to 6 weeks were tested as simple and multiple mediators on the effect of treatment condition on point-prevalence tobacco abstinence measured at 3- and 6-month follow-up.

FINDINGS

While both participant self-efficacy and program exposure satisfied the requirements for simple mediation, only self-efficacy emerged as a mediator when we used the more robust test of multiple mediation.

CONCLUSIONS

Results confirm the importance of self-efficacy change as a probable underlying mechanism in a successful web-based behavioral intervention. While program exposure was found to be a simple mediator of tobacco abstinence, it failed to emerge as a mediator when tested with self-efficacy change in a multiple mediator test suggesting that self-efficacy and program exposure share a complex, possibly reciprocal relationship with the tobacco abstinence outcome. Our results underscore the utility of searching for mediators in research on web-based interventions.

Brief report: Web-based management of adolescent chronic pain: development and usability testing of an online family cognitive behavioral therapy program

OBJECTIVES

This study evaluates the usability and feasibility of a Web-based intervention (Web-MAP) to deliver cognitive behavioral therapy (CBT) to adolescents with chronic pain and their parents.

METHODS

The Web site was evaluated in two stages. In stage one, recovered adolescents and parents (n = 5 dyads), who had completed office-based CBT through a pediatric pain management clinic, completed ratings of Web site content, usability, appearance, and theme. In stage two, treatment-seeking adolescents and their parents (n = 6 dyads) completed the full-length Web program. Program usage data were obtained to assess interaction with the Web site.

RESULTS

Participants rated moderate to strong acceptability of the program. Usage data indicated that participants interacted with the site and used communication features.

CONCLUSIONS

Feedback from usability testing provided important information in the process of designing a feasible Web-based treatment for adolescents with chronic pain for use in a randomized controlled trial.

An exploration of factors related to dissemination of and exposure to internet-delivered behavior change interventions aimed at adults: a Delphi study approach

Background

The Internet is an attractive medium for delivering individualized, computer-tailored behavior change interventions to large numbers of people. However, the actual numbers of people reached seem to fall behind the high expectations. Insight into factors that determine use of and exposure to these Internet interventions is important to be able to increase the reach and improve exposure.

Objective

The aim was to identify potentially important factors that determine whether adults visit an Internet-delivered behavior change intervention, extend their visit, and revisit the intervention.

Methods

A systematic, three-round Delphi study was conducted among national and international experts from Internet intervention research and practice, e-marketing/e-commerce, Web design, and technical website development. In the first round, 30 experts completed a structured, open-ended online questionnaire assessing factors that were, in their opinion, important for a first visit, an extended visit, a revisit and for effective promotion strategies. Based on the responses in this first questionnaire, a closed-ended online questionnaire was developed for use in the second round. A total of 233 experts were invited to complete this questionnaire. Median and interquartile deviation (IQD) scores were computed to calculate agreement and consensus on the importance of the factors. The factors for which no consensus was obtained (IQD > 1) were included in the third-round questionnaire. Factors with a median score of six or higher and with an IQD ≤ 1 were considered to be important.

Results

Of the 62 experts invited for the first round, 30 completed the questionnaire (48% response rate); 93/233 experts completed the second-round questionnaire (40% response rate), and 59/88 completed the third round (67% response rate). Being motivated to visit an Internet intervention and perceiving the intervention as personally relevant appeared to be important factors related to a first visit. The provision of tailored feedback, relevant and reliable information, and an easy navigation structure were related to an extended visit. Provision of regular new content and the possibility to monitor personal progress toward behavior change were identified as important factors to encourage a revisit. Primarily traditional promotion strategies, like word-of-mouth by family and friends, a publicity campaign with simultaneous use of various mass media, and recommendation by health professionals, were indicated as effective ways to encourage adults to visit an Internet intervention.

Conclusions

This systematic study identified important factors related to the dissemination of and exposure to Internet interventions aimed at adults. In order to improve optimal use of and exposure to Internet interventions, potential users may need to be motivated to visit such an intervention and the information provided needs to be personally relevant. Furthermore, several (technical) aspects of the intervention itself need to be taken into account when developing Internet interventions.

Measuring participant rurality in Web-based interventions

BACKGROUND

Web-based health behavior change programs can reach large groups of disparate participants and thus they provide promise of becoming important public health tools. Data on participant rurality can complement other demographic measures to deepen our understanding of the success of these programs. Specifically, analysis of participant rurality can inform recruitment and social marketing efforts, and facilitate the targeting and tailoring of program content. Rurality analysis can also help evaluate the effectiveness of interventions across population groupings.

METHODS

We describe how the RUCAs (Rural-Urban Commuting Area Codes) methodology can be used to examine results from two Randomized Controlled Trials of Web-based tobacco cessation programs: the ChewFree.com project for smokeless tobacco cessation and the Smokers' Health Improvement Program (SHIP) project for smoking cessation.

RESULTS

Using RUCAs methodology helped to highlight the extent to which both Web-based interventions reached a substantial percentage of rural participants. The ChewFree program was found to have more rural participation which is consistent with the greater prevalence of smokeless tobacco use in rural settings as well as ChewFree's multifaceted recruitment program that specifically targeted rural settings.

CONCLUSION

Researchers of Web-based health behavior change programs targeted to the US should routinely include RUCAs as a part of analyzing participant demographics. Researchers in other countries should examine rurality indices germane to their country.

Status of computerized cognitive behavioural therapy for adults

A growing body of evidence supports the efficacy of computerized cognitive behavioural therapy (CCBT). This technology has the potential to increase the capacity of mental health services, and to overcome some of the barriers to accessing mental health services, including stigma, traveling time for rural patients, treatment delays, and the low availability of skilled clinicians. This review discusses key issues around the implementation of CCBT in current mental health services, and summarizes recent evidence for the efficacy of CCBT in anxiety and depression. Many CCBT systems exist, and the evidence for each varies in quality and quantity. It is concluded that CCBT, particularly guided by a therapist, represents a promising resource. However, considerable work needs to be done to develop CCBT techniques that are appropriate to Australasian populations, acceptable to patients and clinicians, easy to use, and are clinically and cost effective. Suggestions are made for further research and useful website addresses are provided to assist clinicians in familiarizing themselves with CCBT.

Rates and determinants of repeated participation in a web-based behavior change program for healthy body weight and healthy lifestyle

BACKGROUND

In recent years, many tailored lifestyle counseling programs have become available through the Internet. Previous research into such programs has shown selective enrollment of relatively healthy people. However, because of the known dose-response relationship between the intensity and frequency of counseling and the behavior change outcomes, selective retention may also be a concern.

OBJECTIVE

The aim of this study was to identify rates and determinants of repeat participation in a Web-based health behavior change program.

METHODS

A Web-based health behavior change program aimed to increase people's awareness of their own lifestyle, to promote physical activity, and to prevent overweight and obesity was available on the Internet from July 2004 onward at no cost. Univariate and multivariate logistic regression analyses were conducted to identify characteristics of people who participated in the program more than once. Age, compliance with physical activity guidelines, body mass index, smoking status, and the consumption of fruit, vegetables, and alcohol were included in the analyses.

RESULTS

A total of 9774 people participated in the baseline test, of which 940 used the site more than once (9.6%). After exclusion of individuals with incomplete data, 6272 persons were included in the analyses. Of these 6272 people, 5560 completed only the baseline test and 712 also participated in follow-up. Logistic regression predicting repeated use determined that older individuals were more likely to participate in follow-up than people aged 15-20 years. The odds ratios for the age categories 41-50, 51-60, and > 60 years were 1.40 (95% CI = 1.02-1.91), 1.43 (95% CI = 1.02-2.01), and 1.68 (95% CI = 1.03-2.72), respectively. Individuals who never smoked were more likely to participate repeatedly than current smokers and ex-smokers (OR = 1.44, 95% CI = 1.14-1.82 and OR = 1.49, 95% CI = 1.17-1.89, respectively). People meeting the guidelines for physical activity of moderate intensity (OR = 1.23 95% CI = 1.04-1.46) and for vegetable consumption (OR = 1.26 95% CI = 1.01-1.57) were also more likely to participate repeatedly than people who did not, as were obese people compared to individuals with normal weight (OR = 1.41 95% CI = 1.09-1.82).

CONCLUSIONS

For some variables, this study confirms our concern that behavioral intervention programs may reach those who need them the least. However, contrary to most expectations, we found that obese people were more likely to participate in follow-up than people of normal body weight. The non-stigmatizing way of addressing body weight through the Internet may be part of the explanation for this. Our findings suggest that Web-based health behavior change programs may be more successful in the area of weight management than in many other health-related areas. They also stress the importance of adequate coverage of weight management in Web-based health promotion programs, as a driver to continue participation for overweight and obese people.

Rates and determinants of repeated participation in a web-based behavior change program for healthy body weight and healthy lifestyle

BACKGROUND

In recent years, many tailored lifestyle counseling programs have become available through the Internet. Previous research into such programs has shown selective enrollment of relatively healthy people. However, because of the known dose-response relationship between the intensity and frequency of counseling and the behavior change outcomes, selective retention may also be a concern.

OBJECTIVE

The aim of this study was to identify rates and determinants of repeat participation in a Web-based health behavior change program.

METHODS

A Web-based health behavior change program aimed to increase people's awareness of their own lifestyle, to promote physical activity, and to prevent overweight and obesity was available on the Internet from July 2004 onward at no cost. Univariate and multivariate logistic regression analyses were conducted to identify characteristics of people who participated in the program more than once. Age, compliance with physical activity guidelines, body mass index, smoking status, and the consumption of fruit, vegetables, and alcohol were included in the analyses.

RESULTS

A total of 9774 people participated in the baseline test, of which 940 used the site more than once (9.6%). After exclusion of individuals with incomplete data, 6272 persons were included in the analyses. Of these 6272 people, 5560 completed only the baseline test and 712 also participated in follow-up. Logistic regression predicting repeated use determined that older individuals were more likely to participate in follow-up than people aged 15-20 years. The odds ratios for the age categories 41-50, 51-60, and > 60 years were 1.40 (95% CI = 1.02-1.91), 1.43 (95% CI = 1.02-2.01), and 1.68 (95% CI = 1.03-2.72), respectively. Individuals who never smoked were more likely to participate repeatedly than current smokers and ex-smokers (OR = 1.44, 95% CI = 1.14-1.82 and OR = 1.49, 95% CI = 1.17-1.89, respectively). People meeting the guidelines for physical activity of moderate intensity (OR = 1.23 95% CI = 1.04-1.46) and for vegetable consumption (OR = 1.26 95% CI = 1.01-1.57) were also more likely to participate repeatedly than people who did not, as were obese people compared to individuals with normal weight (OR = 1.41 95% CI = 1.09-1.82).

CONCLUSIONS

For some variables, this study confirms our concern that behavioral intervention programs may reach those who need them the least. However, contrary to most expectations, we found that obese people were more likely to participate in follow-up than people of normal body weight. The non-stigmatizing way of addressing body weight through the Internet may be part of the explanation for this. Our findings suggest that Web-based health behavior change programs may be more successful in the area of weight management than in many other health-related areas. They also stress the importance of adequate coverage of weight management in Web-based health promotion programs, as a driver to continue participation for overweight and obese people.