Computer-delivered interventions for health promotion and behavioral risk reduction: a meta-analysis of 75 randomized controlled trials, 1988-2007

What design features are used in effective e-health interventions? A review using techniques from Critical Interpretive Synthesis

The effectiveness of e-health interventions varies greatly. Despite this, there has been relatively little formal consideration of how differences in the design of an intervention (i.e., how the content is delivered) may explain why some interventions are more effective than others. This review primarily examines the use of the Internet to provide educational and self-management interventions to promote health. The article develops hypotheses about how the design of these interventions may be associated with outcomes. In total, 52 published reports from both a diversity sample and a representative sample were reviewed using techniques from Critical Interpretive Synthesis. Four core interactive design features were identified that may mediate the effects of intervention design on outcomes: Social context and support, contacts with intervention, tailoring, and self-management. A conceptual framework to summarize the design of e-health interventions delivered using the Internet is proposed. The framework provides a guide for systematic research to identify the effects of specific design features on intervention outcomes and to identify the mechanisms underlying any effects. To optimize the design of e-health interventions more work is needed to understand how and why these design features may affect intervention outcomes and to investigate the optimal implementation and dosage of each design feature.

Long-term effectiveness and mediators of a need-supportive physical activity coaching among Flemish sedentary employees

This study examined the long-term and mediation effects of a need-supportive coaching programme on physical activity. Sedentary employees (n = 92) of the university of Leuven received 4 months of physical activity coaching, based on the self-determination theory, by coaches with a bachelor's degree in kinesiology who are specializing in health-related physical activity (n = 30). The programme consisted of a limited number of individual contact moments (i.e. an intake session, three follow-up contacts and an out-take session), either face-to-face, by phone or by e-mail. Self-reported physical activity, social support, self-efficacy and autonomous motivation were assessed in the coaching group (n = 92) and a control group (n = 34) at three moments: before the intervention (i.e. pre-test), after the intervention (i.e. post-test) and 1 year after pre-test measurements (i.e. follow-up test). Results revealed significant 3 (time) × 2 (groups) interaction effects on strenuous and total physical activity. Moreover, whereas the control group remained stable from pre- to post-test, the coaching group increased significantly in moderate, strenuous and total physical activity. Additionally, the coaching group increased significantly in mild, moderate, strenuous and total physical activity from pre- to follow-up tests, whereas the control group did not change. Bootstrapping analyses indicated that self-efficacy and autonomous motivation significantly mediated the intervention effect on physical activity from pre- to post-test, while social support significantly mediated the long-term effect. This study provides evidence for the long-term effectiveness of a need-supportive physical activity programme that might be efficient at the community level.

Online self-administered training for post-traumatic stress disorder treatment providers: design and methods for a randomized, prospective intervention study

This paper presents the rationale and methods for a randomized controlled evaluation of web-based training in motivational interviewing, goal setting, and behavioral task assignment. Web-based training may be a practical and cost-effective way to address the need for large-scale mental health training in evidence-based practice; however, there is a dearth of well-controlled outcome studies of these approaches. For the current trial, 168 mental health providers treating post-traumatic stress disorder (PTSD) were assigned to web-based training plus supervision, web-based training, or training-as-usual (control). A novel standardized patient (SP) assessment was developed and implemented for objective measurement of changes in clinical skills, while on-line self-report measures were used for assessing changes in knowledge, perceived self-efficacy, and practice related to cognitive behavioral therapy (CBT) techniques. Eligible participants were all actively involved in mental health treatment of veterans with PTSD. Study methodology illustrates ways of developing training content, recruiting participants, and assessing knowledge, perceived self-efficacy, and competency-based outcomes, and demonstrates the feasibility of conducting prospective studies of training efficacy or effectiveness in large healthcare systems.

Meta-analysis of internet-delivered interventions to increase physical activity levels

Many internet-delivered physical activity behaviour change programs have been developed and evaluated. However, further evidence is required to ascertain the overall effectiveness of such interventions. The objective of the present review was to evaluate the effectiveness of internet-delivered interventions to increase physical activity, whilst also examining the effect of intervention moderators. A systematic search strategy identified relevant studies published in the English-language from Pubmed, Proquest, Scopus, PsychINFO, CINHAL, and Sport Discuss (January 1990 - June 2011). Eligible studies were required to include an internet-delivered intervention, target an adult population, measure and target physical activity as an outcome variable, and include a comparison group that did not receive internet-delivered materials. Studies were coded independently by two investigators. Overall effect sizes were combined based on the fixed effect model. Homogeneity and subsequent exploratory moderator analysis was undertaken. A total of 34 articles were identified for inclusion. The overall mean effect of internet-delivered interventions on physical activity was d = 0.14 (p = 0.00). Fixed-effect analysis revealed significant heterogeneity across studies (Q = 73.75; p = 0.00). Moderating variables such as larger sample size, screening for baseline physical activity levels and the inclusion of educational components significantly increased intervention effectiveness. Results of the meta-analysis support the delivery of internet-delivered interventions in producing positive changes in physical activity, however effect sizes were small. The ability of internet-delivered interventions to produce meaningful change in long-term physical activity remains unclear.

Emergency department patients' preferences for technology-based behavioral interventions

STUDY OBJECTIVE

To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences.

METHODS

A cross-sectional survey of a random sample of urban ED patients (≥13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic.

RESULTS

Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions.

CONCLUSION

ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

Reductions in employee productivity impairment observed after implementation of web-based worksite health promotion programs

OBJECTIVE

To assess changes in employee productivity impairment observed after the implementation of several Web-based health promotion programs.

METHODS

Health risk assessments and self-report measures of productivity impairment were administered on-line to more than 43,000 participants of Web-based health promotion programs.

RESULTS

Reductions in productivity impairment were observed after 1 month of program utilization. Productivity impairment at 90- and 180-day follow-ups also decreased relative to baseline. Improvements in employee health were associated with reductions in employee productivity impairment.

CONCLUSION

The use of Web-based health promotion programs was associated with reductions in productivity impairment and improvements in employee health. After the implementation of Web-based health promotion programs, reductions in productivity impairment may be observed before reductions in direct health care costs.

Computerized assessment facilitates disclosure of sensitive HIV risk behaviors among African Americans entering substance abuse treatment

BACKGROUND

Individuals entering substance abuse treatment are at elevated risk for HIV infection, and clinicians must generally rely on patient self-report to gauge their involvement in risk behaviors. Strategies to improve accurate reporting of personally sensitive or stigmatizing risk behaviors are needed.

OBJECTIVE

This study compared computerized and face-to-face interview methods in eliciting self-disclosure of HIV risk behaviors among a high-risk sample of urban African Americans entering substance abuse treatment (N = 146).

METHODS

Participants completed a standardized HIV risk behavior screening as a face-to-face interview. Several days later, the same participants completed a computerized self-interview with the same measure, covering the same time frame.

RESULTS

Disclosure rates for many sensitive risk behaviors were considerably higher on the computerized interview. Participants had significantly higher odds of disclosure on the computerized interview compared to the face-to-face interview on 2 of 6 drug risk behaviors examined (ORs between 2.75 and 3.15) and 9 of 13 sex risk behaviors examined (ORs between 1.60 and 6.45). The advantage of the computerized interview was most evident for highly stigmatized behaviors, such as unprotected sex with someone other than a spouse or main partner (OR = 3.93; p < .001), unprotected sex during a commercial sex transaction (OR = 5.63; p < .001), unprotected anal sex (OR = 6.45; p < .001), and using unsterilized syringes (OR = 3.15; p < .05).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Findings support the utility of computerized risk behavior assessment with African Americans entering substance abuse treatment. Computerized assessment of HIV risk behaviors may be clinically useful in substance abuse treatment and other healthcare venues serving high-risk populations.

The role of user control in adherence to and knowledge gained from a website: randomized comparison between a tunneled version and a freedom-of-choice version

Background

Internet-delivered interventions can effectively change health risk behaviors and their determinants, but adherence to these interventions once they are accessed is very low. Therefore, it is relevant and necessary to systematically manipulate website characteristics to test their effect on website use. This study focuses on user control as a website characteristic.

Objective

To test whether and how user control (the freedom of choice to skip pages) can increase website use and knowledge gained from the website.

Methods

Participants older than 18 years were drawn from the Dutch Internet population (in June 2011) and completed a hepatitis knowledge questionnaire. Subsequently, they were randomly assigned to three groups: (1) a tunneled version of the website with less user control; (2) a high user control version of the website where visitors had the freedom of choice to skip pages; and (3) a control group that was not exposed to the website. Participants completed (1) a questionnaire of validated measures regarding user perceptions immediately after exposure to the website (except for the control group), and (2) a hepatitis knowledge questionnaire after one week to test whether participants in the experimental groups only clicked through the website or actually processed and learned its content. Server registrations were used to assess website use. Analyses of covariance (ANCOVA) using all available data were conducted to determine whether user control increases website use. Structural equation models (SEM) using all available data were constructed to test how user control increases website use—a latent variable derived from number of pages visited and time on website.

Results

Of the 1044 persons invited to participate, 668 took part (668/1044, 64.0%). One half of participants (332/668 49.7%) were female and the mean age was 49 years (SD 16). A total of 571 participants completed the one-week follow-up measure regarding hepatitis knowledge (571/668, 85.5%). The findings demonstrate that having less user control (ie, a tunneled version of the website) had a negative effect on users’ perception of efficiency (F_1,452 = 97.69, P < .001), but a positive effect on number of pages visited (F_1,452 = 171.49, P < .001), time on the website (F_1,452 = 6.32, P = .01), and knowledge gained from the website (F_1,452 = 134.32, P < .001). The direct effect of having less user control appeared to surpass the effect mediated by efficiency, because website use was higher among participants exposed to the tunneled version of the website in comparison with those having the freedom of choice to skip pages.

Conclusions

The key finding that visitors demonstrated increased website use in the tunneled version of the website indicates that visitors should be carefully guided through the intervention for future intervention websites.

A systematic review of emergency department technology-based behavioral health interventions

OBJECTIVES

This systematic review evaluated the evidence for use of computer technologies to assess and reduce high-risk health behaviors in emergency department (ED) patients.

METHODS

A systematic search was conducted of electronic databases, references, key journals, and conference proceedings. Studies were included if they evaluated the use of computer-based technologies for ED-based screening, interventions, or referrals for high-risk health behaviors (e.g., unsafe sex, partner violence, substance abuse, depression); were published since 1990; and were in English, French, or Spanish. Study selection and assessment of methodologic quality were performed by two independent reviewers. Data extraction was performed by one reviewer and then independently checked for completeness and accuracy by a second reviewer.

RESULTS

Of 17,744 unique articles identified by database search, 66 underwent full-text review, and 20 met inclusion criteria. The greatest number of studies targeted alcohol/substance use (n = 8, 40%), followed by intentional or unintentional injury (n = 7, 35%) and then mental health (n = 4, 20%). Ten of the studies (50%) were randomized controlled trials; the remainder were observational or feasibility studies. Overall, studies showed high acceptability and feasibility of individual computer innovations, although study quality varied greatly. Evidence for clinical efficacy across health behaviors was modest, with few studies addressing meaningful clinical outcomes. Future research should aim to establish the efficacy of computer-based technology for meaningful health outcomes and to ensure that effective interventions are both disseminable and sustainable.

CONCLUSIONS

The number of studies identified in this review reflects recent enthusiasm about the potential of computers to overcome barriers to behavioral health screening, interventions, and referrals to treatment in the ED. The available literature suggests that these types of tools will be feasible and acceptable to patients and staff.

Design and methodological considerations of an effectiveness trial of a computer-assisted intervention: an example from the NIDA Clinical Trials Network

Computer-assisted interventions hold the promise of minimizing two problems that are ubiquitous in substance abuse treatment: the lack of ready access to treatment and the challenges to providing empirically-supported treatments. Reviews of research on computer-assisted treatments for mental health and substance abuse report promising findings, but study quality and methodological limitations remain an issue. In addition, relatively few computer-assisted treatments have been tested among illicit substance users. This manuscript describes the methodological considerations of a multi-site effectiveness trial conducted within the National Institute on Drug Abuse's (NIDA's) National Drug Abuse Treatment Clinical Trials Network (CTN). The study is evaluating a web-based version of the Community Reinforcement Approach, in addition to prize-based contingency management, among 500 participants enrolled in 10 outpatient substance abuse treatment programs. Several potential effectiveness trial designs were considered and the rationale for the choice of design in this study is described. The study uses a randomized controlled design (with independent treatment arm allocation), intention-to-treat primary outcome analysis, biological markers for the primary outcome of abstinence, long-term follow-up assessments, precise measurement of intervention dose, and a cost-effectiveness analysis. Input from community providers during protocol development highlighted potential concerns and helped to address issues of practicality and feasibility. Collaboration between providers and investigators supports the utility of infrastructures that enhance research partnerships to facilitate effectiveness trials and dissemination of promising, technologically innovative treatments. Outcomes from this study will further the empirical knowledge base on the effectiveness and cost-effectiveness of computer-assisted treatment in clinical treatment settings.

Using Google Analytics as a process evaluation method for Internet-delivered interventions: an example on sexual health

The study aimed to demonstrate the potential of Google Analytics as a process evaluation method for Internet-delivered interventions, using a website about sexual health as an example. This study reports visitors' behavior until 21 months after the release of the website (March 2009-December 2010). In total, there were 850 895 visitors with an average total visiting time (i.e. dose) of 5:07 min. Google Analytics provided data to answer three key questions in terms of process evaluation of an Internet-delivered intervention: (i) How do visitors behave?; (ii) Where do visitors come from? and (iii) What content are visitors exposed to? This real-life example demonstrated the potential of Google Analytics as a method to be used in a process evaluation of Internet-delivered interventions. This is highly relevant given the current expansion of these interventions within the field of health promotion.

Evaluating Efficacy and Validating Games for Health

The field of games for health is growing rapidly, but many games for health are not validated for their use as a tool to improve outcomes. The few research studies that do exist are often poorly designed, and their conclusions cannot be considered valid evidence to support or refute efficacy. Based on lessons learned from the field of digital game-based learning in education and recent efforts to systematically review games for health in meta-analyses, guidelines are suggested for conducting high-quality efficacy studies on games for health.

An empowerment-based approach to developing innovative e-health tools for self-management

E-health is seen as an important technological tool in achieving self-management; however, there is little evidence of how effective e-health is for self-management. Example tools remain experimental and there is limited knowledge yet about the design, use, and effects of this class of tools. By way of introducing a new view on the development of e-health tools dedicated to self-management we aim to contribute to the discussion for further research in this area. Our assumption is that patient empowerment is an important mechanism of e-health self-management and we suggest incorporating it within the development of self-management tools. Important components of empowerment selected from literature are: communication, education and health literacy, information, self-care, decision aids and contact with fellow patients. All components require skills of both patients and the physicians. In this discussion paper we propose how the required skills can be used to specify effective self-management tools.

Reach of a kiosk-based pediatric injury prevention program

While controlled trials are important for determining the efficacy of public health programs, implementation studies are critical to guide the translation of efficacious programs to general practice. To implement an evidence-based injury prevention program and examine program use and completion rates in two implementation phases, Safe N' Sound, an evidence-based program, was implemented in five pediatric clinics. Data on program use were collected from program files and patient census data. Program use averaged 12.1% of eligible patients during implementation and 9.5% during the continuation phase. Program completion averaged 9.7% and 6.5%, respectively. Findings from this study can inform the dissemination of evidence-based public health programs, particularly in practice-based clinical settings.

Computer-based intervention in HIV clinical care setting improves antiretroviral adherence: the LifeWindows Project

We evaluated the efficacy of LifeWindows, a theory-based, computer-administered antiretroviral (ARV) therapy adherence support intervention, delivered to HIV + patients at routine clinical care visits. 594 HIV + adults receiving HIV care at five clinics were randomized to intervention or control arms. Intervention vs. control impact in the intent-to-treat sample (including participants whose ARVs had been entirely discontinued, who infrequently attended care, or infrequently used LifeWindows) did not reach significance. Intervention impact in the On Protocol sample (328 intervention and control arm participants whose ARVs were not discontinued, who attended care and were exposed to LifeWindows regularly) was significant. On Protocol intervention vs. control participants achieved significantly higher levels of perfect 3-day ACTG-assessed adherence over time, with sensitivity analyses maintaining this effect down to 70% adherence. This study supports the utility of LifeWindows and illustrates that patients on ARVs who persist in care at clinical care sites can benefit from adherence promotion software.

Bringing loyalty to e-Health: theory validation using three internet-delivered interventions

Background

Internet-delivered interventions can effectively change health risk behaviors, but the actual use of these interventions by the target group once they access the website is often very low (high attrition, low adherence). Therefore, it is relevant and necessary to focus on factors related to use of an intervention once people arrive at the intervention website. We focused on user perceptions resulting in e-loyalty (ie, intention to visit an intervention again and to recommend it to others). A background theory for e-loyalty, however, is still lacking for Internet-delivered interventions.

Objective

The objective of our study was to propose and validate a conceptual model regarding user perceptions and e-loyalty within the field of eHealth.

Methods

We presented at random 3 primary prevention interventions aimed at the general public and, subsequently, participants completed validated measures regarding user perceptions and e-loyalty. Time on each intervention website was assessed by means of server registrations.

Results

Of the 592 people who were invited to participate, 397 initiated the study (response rate: 67%) and 351 (48% female, mean age 43 years, varying in educational level) finished the study (retention rate: 88%). Internal consistency of all measures was high (Cronbach alpha > .87). The findings demonstrate that the user perceptions regarding effectiveness (beta_range .21–.41) and enjoyment (beta_range .14–.24) both had a positive effect on e-loyalty, which was mediated by active trust (beta_range .27–.60). User perceptions and e-loyalty had low correlations with time on the website (r_range .04–.18).

Conclusions

The consistent pattern of findings speaks in favor of their robustness and contributes to theory validation regarding e-loyalty. The importance of a theory-driven solution to a practice-based problem (ie, low actual use) needs to be stressed in view of the importance of the Internet in terms of intervention development. Longitudinal studies are needed to investigate whether people will actually revisit intervention websites and whether this leads to changes in health risk behaviors.

Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups

BACKGROUND

In recent years there has been increasing interest in transferring new knowledge into health care practices, a process often referred to as implementation. The various subcultures that exist among health care workers may be an obstacle in this process. The aim of this study was to explore how professional groups and managers experienced the implementation of a new tool for lifestyle intervention in primary health care (PHC). The computer-based tool was introduced with the intention of facilitating the delivery of preventive services.

METHODS

Focus group interviews with staff and individual interviews with managers at six PHC units in the southeast of Sweden were performed 9 months after the introduction of the new working tool. Staff interviews were conducted in groups according to profession, and were analysed using manifest content analysis. Experiences and opinions from the different staff groups and from managers were analysed.

RESULTS

Implementation preconditions, opinions about the lifestyle test, and opinions about usage were the main areas identified. In each of the groups, managers and professionals, factors related to the existing subcultures seemed to influence their experiences of the implementation. Managers were visionary, GPs were reluctant, nurses were open, and nurse assistants were indifferent.

CONCLUSION

This study indicates that the existing subcultures in PHC influence how the implementation of an innovation is perceived by managers and the different professionals. In PHC, an organization with several subcultures and an established hierarchical structure, an implementation strategy aimed at all groups did not seem to result in a successful uptake of the new method.

Multivariate meta-analysis: a robust approach based on the theory of U-statistic

Meta-analysis is the methodology for combining findings from similar research studies asking the same question. When the question of interest involves multiple outcomes, multivariate meta-analysis is used to synthesize the outcomes simultaneously taking into account the correlation between the outcomes. Likelihood-based approaches, in particular restricted maximum likelihood (REML) method, are commonly utilized in this context. REML assumes a multivariate normal distribution for the random-effects model. This assumption is difficult to verify, especially for meta-analysis with small number of component studies. The use of REML also requires iterative estimation between parameters, needing moderately high computation time, especially when the dimension of outcomes is large. A multivariate method of moments (MMM) is available and is shown to perform equally well to REML. However, there is a lack of information on the performance of these two methods when the true data distribution is far from normality. In this paper, we propose a new nonparametric and non-iterative method for multivariate meta-analysis on the basis of the theory of U-statistic and compare the properties of these three procedures under both normal and skewed data through simulation studies. It is shown that the effect on estimates from REML because of non-normal data distribution is marginal and that the estimates from MMM and U-statistic-based approaches are very similar. Therefore, we conclude that for performing multivariate meta-analysis, the U-statistic estimation procedure is a viable alternative to REML and MMM. Easy implementation of all three methods are illustrated by their application to data from two published meta-analysis from the fields of hip fracture and periodontal disease. We discuss ideas for future research based on U-statistic for testing significance of between-study heterogeneity and for extending the work to meta-regression setting.

A methodological analysis of randomized clinical trials of computer-assisted therapies for psychiatric disorders: toward improved standards for an emerging field

OBJECTIVE

Computer-assisted therapies offer a novel, cost-effective strategy for providing evidence-based therapies to a broad range of individuals with psychiatric disorders. However, the extent to which the growing body of randomized trials evaluating computer-assisted therapies meets current standards of methodological rigor for evidence-based interventions is not clear.

METHOD

A methodological analysis of randomized clinical trials of computer-assisted therapies for adult psychiatric disorders, published between January 1990 and January 2010, was conducted. Seventy-five studies that examined computer-assisted therapies for a range of axis I disorders were evaluated using a 14-item methodological quality index.

RESULTS

Results indicated marked heterogeneity in study quality. No study met all 14 basic quality standards, and three met 13 criteria. Consistent weaknesses were noted in evaluation of treatment exposure and adherence, rates of follow-up assessment, and conformity to intention-to-treat principles. Studies utilizing weaker comparison conditions (e.g., wait-list controls) had poorer methodological quality scores and were more likely to report effects favoring the computer-assisted condition.

CONCLUSIONS

While several well-conducted studies have indicated promising results for computer-assisted therapies, this emerging field has not yet achieved a level of methodological quality equivalent to those required for other evidence-based behavioral therapies or pharmacotherapies. Adoption of more consistent standards for methodological quality in this field, with greater attention to potential adverse events, is needed before computer-assisted therapies are widely disseminated or marketed as evidence based.

Persuasive features in web-based alcohol and smoking interventions: a systematic review of the literature

Background

In the past decade, the use of technologies to persuade, motivate, and activate individuals’ health behavior change has been a quickly expanding field of research. The use of the Web for delivering interventions has been especially relevant. Current research tends to reveal little about the persuasive features and mechanisms embedded in Web-based interventions targeting health behavior change.

Objectives

The purpose of this systematic review was to extract and analyze persuasive system features in Web-based interventions for substance use by applying the persuasive systems design (PSD) model. In more detail, the main objective was to provide an overview of the persuasive features within current Web-based interventions for substance use.

Methods

We conducted electronic literature searches in various databases to identify randomized controlled trials of Web-based interventions for substance use published January 1, 2004, through December 31, 2009, in English. We extracted and analyzed persuasive system features of the included Web-based interventions using interpretive categorization.

Results

The primary task support components were utilized and reported relatively widely in the reviewed studies. Reduction, self-monitoring, simulation, and personalization seem to be the most used features to support accomplishing user’s primary task. This is an encouraging finding since reduction and self-monitoring can be considered key elements for supporting users to carry out their primary tasks. The utilization of tailoring was at a surprisingly low level. The lack of tailoring may imply that the interventions are targeted for too broad an audience. Leveraging reminders was the most common way to enhance the user-system dialogue. Credibility issues are crucial in website engagement as users will bind with sites they perceive credible and navigate away from those they do not find credible. Based on the textual descriptions of the interventions, we cautiously suggest that most of them were credible. The prevalence of social support in the reviewed interventions was encouraging.

Conclusions

Understanding the persuasive elements of systems supporting behavior change is important. This may help users to engage and keep motivated in their endeavors. Further research is needed to increase our understanding of how and under what conditions specific persuasive features (either in isolation or collectively) lead to positive health outcomes in Web-based health behavior change interventions across diverse health contexts and populations.

A systematic review of information and communication technology-based interventions for promoting physical activity behavior change in children and adolescents

Background

A growing body of research has employed information and communication technologies (ICTs) such as the Internet and mobile phones for disseminating physical activity (PA) interventions with young populations. Although several systematic reviews have documented the effects of ICT-based interventions on PA behavior, very few have focused on children and adolescents specifically.

Objectives

The present review aimed to systematically evaluate the efficacy and methodological quality of ICT-based PA interventions for children and adolescents based on evidence from randomized controlled trials.

Methods

Electronic databases Medline, PsycInfo, CINAHL, and Web of Science were searched to retrieve English language articles published in international academic peer-reviewed journals from January 1, 1997, through December 31, 2009. Included were articles that provided descriptions of interventions designed to improve PA-related cognitive, psychosocial, and behavioral outcomes and that used randomized controlled trial design, included only children (6-12 years old) and adolescents (13-18 years old) in both intervention and control groups, and employed Internet, email, and/or short message services (SMS, also known as text messaging) as one or more major or assistive modes to deliver the intervention.

Results

In total, 9 studies were analyzed in the present review. All studies were published after 2000 and conducted in Western countries. Of the 9 studies, 7 demonstrated positive and significant within-group differences in at least one psychosocial or behavioral PA outcome. In all, 3 studies reported positive and significant between-group differences favoring the ICT group. When between-group differences were compared across studies, effect sizes were small in 6 studies and large in 3 studies. With respect to methodological quality, 7 of the 9 studies had good methodological quality. Failure to report allocation concealment, blinding to outcome assessment, and lack of long-term follow-up were the criteria met by the fewest studies. In addition, 5 studies measured the intervention exposure rate and only 1 study employed objective measures to record data.

Conclusion

The present review provides evidence supporting the positive effects of ICTs in PA interventions for children and adolescents, especially when used with other delivery approaches (ie, face-to-face). Because ICT delivery approaches are often mixed with other approaches and these studies sometimes lack a comparable control group, additional research is needed to establish the true independent effects of ICT as an intervention delivery mode. Although two-thirds of the studies demonstrated satisfactory methodological quality, several quality criteria should be considered in future studies: clear descriptions of allocation concealment and blinding of outcome assessment, extension of intervention duration, and employment of objective measures in intervention exposure rate. Due to the small number of studies that met inclusion criteria and the lack of consistent evidence, researchers should be cautious when interpreting the findings of the present review.

Interventions promoting physical activity among obese populations: a meta-analysis considering global effect, long-term maintenance, physical activity indicators and dose characteristics

As the benefits that regular physical activity (PA) have on obesity are well known, many interventions promote active lifestyle adoption among obese populations. This meta-analysis aims to determine (i) the global effect that interventions promoting PA among obese populations have on their PA behaviour; (ii) variations in the effect of interventions depending on the PA indicator used; (iii) the programme's dose characteristics and (iv) maintenance of the intervention effects after the intervention has ended. A comprehensive search through databases and review articles was completed. Forty-six studies met the inclusion criteria. Calculations of effect size (Cohen's d) and a moderator analysis were conducted. The meta-analysis showed that interventions globally have an impact on the PA behaviour of obese populations (d = 0.44; 95% CI = 0.31, 0.57). The moderator analysis revealed that interventions of less than 6 months reported significantly larger effects than longer interventions. Moreover, the interventions had a stronger impact on the number of steps and the PA indexes (i.e. composite scores reflecting PA practice) than on other PA indicators. Finally, the analysis revealed that interventions succeed in maintaining PA behaviour after the intervention is over. However, relatively few studies addressed this issue (n = 9). Despite global positive effects, further research is needed to determine the optimal dose for interventions and to evaluate the maintenance of intervention effects.

Effectiveness of E-self-help interventions for curbing adult problem drinking: a meta-analysis

Background

Self-help interventions without professional contact to curb adult problem drinking in the community are increasingly being delivered via the Internet.

Objective

The objective of this meta-analysis was to assess the overall effectiveness of these eHealth interventions.

Methods

In all, 9 randomized controlled trials (RCTs), all from high-income countries, with 9 comparison conditions and a total of 1553 participants, were identified, and their combined effectiveness in reducing alcohol consumption was evaluated by means of a meta-analysis.

Results

An overall medium effect size (g = 0.44, 95% CI 0.17-0.71, random effect model) was found for the 9 studies, all of which compared no-contact interventions to control conditions. The medium effect was maintained (g = 0.39; 95% CI 0.23-0.57, random effect model) after exclusion of two outliers. Type of control group, treatment location, type of analysis, and sample size did not have differential impacts on treatment outcome. A significant difference (P = .04) emerged between single-session personalized normative feedback interventions (g = 0.27, 95% CI 0.11-0.43) and more extended e- self-help (g = 0.61, 95% CI 0.33-0.90).

Conclusion

E-self-help interventions without professional contact are effective in curbing adult problem drinking in high-income countries. In view of the easy scalability and low dissemination costs of such interventions, we recommend exploration of whether these could broaden the scope of effective public health interventions in low- and middle-income countries as well.

Preliminary efficacy of a computer-based HIV intervention for African-American women

This study evaluated the preliminary efficacy of a computer-based HIV intervention to enhance HIV-protective sexual behaviours, based on a randomised controlled trial among 135 African-American women, 21-29 years of age, seeking services at Planned Parenthood in Atlanta, GA. Participants were randomised either to a control session two, 60-minute computer-based HIV intervention sessions administered on a laptop computer that each concluded with a 15-minute small group session or to a control session of general health information including discussion on HIV prevention. Relative to controls, participants in the computer-based HIV intervention were more knowledgeable about HIV/STD prevention and reported higher scores on the measure of condom use self-efficacy at 3 months post-intervention; they also reported a higher percentage of condom-protected sex and were more likely to use condoms consistently for vaginal sex (odds ratio, OR = 5.9; p < 0.039) and were more likely to use condoms consistently for oral sex (OR = 13.83; p < 0.037). This relatively brief intervention provides preliminary support that an evidence-based group-based HIV prevention intervention for young African-American women can be adapted to a computer-based HIV intervention.

Computerized stress management training for HIV+ women: a pilot intervention study

HIV+women have unique psychosocial stressors, but few interventions have been designed for this population. To address this gap in the literature, we developed a brief, theory-guided, computer-administered, stress management intervention for HIV+ women. To obtain initial evidence of the intervention's efficacy, we recruited 60 HIV+ female participants (70% African American) and randomized them to an immediate or delayed intervention condition. Psychological functioning, perceived stress, coping self-efficacy, and stress management knowledge were assessed at baseline and at a one month follow-up. Compared with the delayed treatment control group, women who received the intervention demonstrated improved stress management knowledge at the follow-up (p<0.01). However, depressive symptoms, psychological distress, perceived stress, and coping self-efficacy did not differ between the immediate and delayed intervention groups (ps>0.05). Computerized psychosocial interventions require continued refinement to meet the needs of HIV+ women.

Harnessing social media for health promotion and behavior change

Rapid and innovative advances in participative Internet communications, referred to as "social media," offer opportunities for modifying health behavior. Social media let users choose to be either anonymous or identified. People of all demographics are adopting these technologies whether on their computers or through mobile devices, and they are increasingly using these social media for health-related issues. Although social media have considerable potential as tools for health promotion and education, these media, like traditional health promotion media, require careful application and may not always achieve their desired outcomes. This article summarizes current evidence and understanding of using social media for health promotion. More important, it discusses the need for evaluating the effectiveness of various forms of social media and incorporating outcomes research and theory in the design of health promotion programs for social media.

A new computer-based counselling system for the promotion of physical activity in patients with chronic diseases--results from a pilot study

OBJECTIVE

To develop a computer-based counselling system (CBCS) for the improvement of attitudes towards physical activity in chronically ill patients and to pilot its efficacy and acceptance in primary care.

METHODS

The system is tailored to patients' disease and motivational stage. During a pilot study in five German general practices, patients answered questions before, directly and 6 weeks after using the CBCS. Outcome criteria were attitudes and self-efficacy. Qualitative interviews were performed to identify acceptance indicators.

RESULTS

Seventy-nine patients participated (mean age: 64.5 years, 53% males; 38% without previous computer experience). Patients' affective and cognitive attitudes changed significantly, self-efficacy showed only minor changes. Patients mentioned no difficulties in interacting with the CBCS. However, perception of the system's usefulness was inconsistent.

CONCLUSION

Computer-based counselling for physical activity related attitudes in patients with chronic diseases is feasible, but the circumstances of use with respect to the target group and its integration into the management process have to be clarified in future studies.

PRACTICE IMPLICATION

This study adds to the understanding of computer-based counselling in primary health care. Acceptance indicators identified in this study will be validated as part of a questionnaire on technology acceptability in a subsequent study.

An artificially intelligent chat agent that answers adolescents' questions related to sex, drugs, and alcohol: an exploratory study

PURPOSE

The aim of this study was to investigate if and how an artificially intelligent chat agent (chatbot) that answers questions about sex, drugs, and alcohol is used and evaluated by adolescents, especially in comparison with information lines and search engines.

METHODS

A sample of 929 adolescents (64% girls, mean age = 15), varying in urbanization level and educational level, participated in this study. Use of the chatbot was objectively tracked through server registrations (e.g., frequency and duration of conversations with the chatbot, the number and topics of queries), and a web-based questionnaire was used to evaluate the chatbot (e.g., the perception of anonymity, conciseness, ease of use, fun, quality and quantity of information, and speed) and to compare it with information lines and search engines.

RESULTS

The chatbot reached high school attendees in general and not only adolescents with previous experience related to sex, drugs, or alcohol; this is promising from an informed decision-making point of view. Frequency (M = 11) and duration of conversations (3:57 minutes) was high and the chatbot was evaluated positively, especially in comparison with information lines and search engines.

CONCLUSION

The use of chatbots within the field of health promotion has a large potential to reach a varied group of adolescents and to provide them with answers to their questions related to sex, drugs, and alcohol.

An audience-channel-message-evaluation (ACME) framework for health communication campaigns

Recent reviews of the literature have indicated that a number of health communication campaigns continue to fail to adhere to principles of effective campaign design. The lack of an integrated, organizing framework for the design, implementation, and evaluation of health communication campaigns may contribute to this state of affairs. The current article introduces an audience-channel-message-evaluation (ACME) framework that organizes the major principles of health campaign design, implementation, and evaluation. ACME also explicates the relationships and linkages between the varying principles. Insights from ACME include the following: The choice of audience segment(s) to focus on in a campaign affects all other campaign design choices, including message strategy and channel/component options. Although channel selection influences options for message design, choice of message design also influences channel options. Evaluation should not be thought of as a separate activity, but rather should be infused and integrated throughout the campaign design and implementation process, including formative, process, and outcome evaluation activities. Overall, health communication campaigns that adhere to this integrated set of principles of effective campaign design will have a greater chance of success than those using principles idiosyncratically. These design, implementation, and evaluation principles are embodied in the ACME framework.

Efficacy of web-based personalized normative feedback: a two-year randomized controlled trial

OBJECTIVE

Web-based brief alcohol interventions have the potential to reach a large number of individuals at low cost; however, few controlled evaluations have been conducted to date. The present study was designed to evaluate the efficacy of gender-specific versus gender-nonspecific personalized normative feedback (PNF) with single versus biannual administration in a 2-year randomized controlled trial targeting a large sample of heavy-drinking college students.

METHOD

Participants included 818 freshmen (57.6% women; 42% non-Caucasian) who reported 1 or more heavy-drinking episodes in the previous month at baseline. Participants were randomly assigned in a 2 (gender-specific vs. gender-nonspecific PNF) × 2 (single vs. biannual administration of PNF) + 1 (attention control) design. Assessments occurred every 6 months for a 2-year period.

RESULTS

Results from hierarchical generalized linear models provided modest effects on weekly drinking and alcohol-related problems but not on heavy episodic drinking. Relative to control, gender-specific biannual PNF was associated with reductions over time in weekly drinking (d = -0.16, 95% CI [-0.02, -0.31]), and this effect was partially mediated by changes in perceived norms. For women, but not men, gender-specific biannual PNF was associated with reductions over time in alcohol-related problems relative to control (d = -0.29, 95% CI [-0.15, -0.58]). Few other effects were evident.

CONCLUSIONS

The present research provides modest support for the use of biannually administered web-based gender-specific PNF as an alternative to more costly indicated prevention strategies.

Online interventions for social marketing health behavior change campaigns: a meta-analysis of psychological architectures and adherence factors

Background

Researchers and practitioners have developed numerous online interventions that encourage people to reduce their drinking, increase their exercise, and better manage their weight. Motivations to develop eHealth interventions may be driven by the Internet’s reach, interactivity, cost-effectiveness, and studies that show online interventions work. However, when designing online interventions suitable for public campaigns, there are few evidence-based guidelines, taxonomies are difficult to apply, many studies lack impact data, and prior meta-analyses are not applicable to large-scale public campaigns targeting voluntary behavioral change.

Objectives

This meta-analysis assessed online intervention design features in order to inform the development of online campaigns, such as those employed by social marketers, that seek to encourage voluntary health behavior change. A further objective was to increase understanding of the relationships between intervention adherence, study adherence, and behavioral outcomes.

Methods

Drawing on systematic review methods, a combination of 84 query terms were used in 5 bibliographic databases with additional gray literature searches. This resulted in 1271 abstracts and papers; 31 met the inclusion criteria. In total, 29 papers describing 30 interventions were included in the primary meta-analysis, with the 2 additional studies qualifying for the adherence analysis. Using a random effects model, the first analysis estimated the overall effect size, including groupings by control conditions and time factors. The second analysis assessed the impacts of psychological design features that were coded with taxonomies from evidence-based behavioral medicine, persuasive technology, and other behavioral influence fields. These separate systems were integrated into a coding framework model called the communication-based influence components model. Finally, the third analysis assessed the relationships between intervention adherence and behavioral outcomes.

Results

The overall impact of online interventions across all studies was small but statistically significant (standardized mean difference effect size d = 0.19, 95% confidence interval [CI] = 0.11 - 0.28, P < .001, number of interventions k = 30). The largest impact with a moderate level of efficacy was exerted from online interventions when compared with waitlists and placebos (d = 0.28, 95% CI = 0.17 - 0.39, P < .001, k = 18), followed by comparison with lower-tech online interventions (d = 0.16, 95% CI = 0.00 - 0.32, P = .04, k = 8); no significant difference was found when compared with sophisticated print interventions (d = –0.11, 95% CI = –0.34 to 0.12, P = .35, k = 4), though online interventions offer a small effect with the advantage of lower costs and larger reach. Time proved to be a critical factor, with shorter interventions generally achieving larger impacts and greater adherence. For psychological design, most interventions drew from the transtheoretical approach and were goal orientated, deploying numerous influence components aimed at showing users the consequences of their behavior, assisting them in reaching goals, and providing normative pressure. Inconclusive results suggest a relationship between the number of influence components and intervention efficacy. Despite one contradictory correlation, the evidence suggests that study adherence, intervention adherence, and behavioral outcomes are correlated.

Conclusions

These findings demonstrate that online interventions have the capacity to influence voluntary behaviors, such as those routinely targeted by social marketing campaigns. Given the high reach and low cost of online technologies, the stage may be set for increased public health campaigns that blend interpersonal online systems with mass-media outreach. Such a combination of approaches could help individuals achieve personal goals that, at an individual level, help citizens improve the quality of their lives and at a state level, contribute to healthier societies.

Methodological Overview of A Self-Determination Theory-Based Computerized Intervention to Promote Leisure-Time Physical Activity

OBJECTIVES: To provide a methodological overview of a computerized intervention to promote leisure time physical activity (PA) and to apply self-determination theory (SDT) to PA initiation to better understand the psychological mechanisms underlying PA frequency, intensity, and duration in previously-sedentary individuals. DESIGN: Based on SDT, two computerized personal trainers were developed for use with sedentary young adults. One personal trainer was designed to be need-supportive, empathic, and structured while the other was designed to be more controlling, evaluative, and judgmental. METHOD: Participants are randomly assigned to work with either the need-supportive or controlling computerized personal trainer. They complete a series of 7 weekly training sessions. In between training sessions, participants complete daily records of PA behaviors and experiences including autonomous self-regulation and perceived competence for PA and PA frequency, intensity, and duration. POTENTIAL CONTRIBUTIONS: The design of this intervention and its theoretical basis have important implications for advancing the field of exercise science specifically and health behavior change more broadly. Computerized interventions have the benefit of standardizing intervention content as well as reducing clinical contact burden for practitioners. Daily recording procedures reduce the likelihood of retrospection bias and allow for the modeling of (1) daily fluctuations in PA behavior and (2) the psychological mechanisms believed to be involved in PA behavior (e.g., autonomous self-regulation). Finally, as a broad theory of human motivation, SDT is uniquely positioned to offer explanations for the conditions that are likely to promote both the initiation and maintenance of health behavior change.

Preventing substance use among Black and Hispanic adolescent girls: results from a computer-delivered, mother-daughter intervention approach

This 2008 study involved 546 Black and Hispanic American adolescent girls and their mothers from New York, New Jersey, and Connecticut. Participants provided self-report data. Analysis of covariance indicated that the experimental intervention reduced risk factors, improved protective factors, and lowered girls' alcohol use and their future intentions to use substances. The study supports the value of computer-based and gender-specific interventions that involve girls and their mothers. Future work needs to replicate and strengthen study results.

Strategies to facilitate exposure to internet-delivered health behavior change interventions aimed at adolescents or young adults: a systematic review

The Internet is considered to be a promising delivery channel of interventions aimed at promoting healthful behaviors, especially for adolescents and young adults. Exposure to these interventions, however, is generally low. A more extensive exploration of methods, strategies, and their effectiveness with regard to facilitating exposure is therefore timely, because this knowledge is crucial to improve the use of such interventions and, subsequently, to increase behavioral change. Therefore, a systematic review of the literature was conducted, resulting in 838 studies based on title selection, of which 26 studies met the eligibility criteria. The systematic review resulted in an overview of methods and strategies that have been used to facilitate exposure. Patterns of effective strategies could be observed, such as the combination of tailored communication and the use of reminders and incentives. Nevertheless, exposure-specific theories need to be developed and objective exposure measures should be tracked and reported in future studies.

Identifying the educational needs of menopausal women: a feasibility study

BACKGROUND

The goal of this project was to identify the educational needs of menopausal women and test the feasibility of an online self management program based on social learning theory.

METHODS

The four stages included 1) a needs assessment using a) focus groups with 24 women ages 40 to 55 and b) phone interviews with eight health experts; 2) the use of concept mapping methodology for quantifying qualitative data from stage 1 to identify the core programmatic concepts; 3) development of a demonstration program; and 4) a pilot study with 35 women and 9 health experts to assess knowledge gained and program satisfaction.

RESULTS

Results show that women desire more information about normalcy of menopause and symptom management and found the program to meet a need for menopausal education otherwise perceived as unavailable. The women significantly increased their menopausal knowledge after brief exposure (t(34) = 3.64; p = .001).

CONCLUSION

This project provides support for an online health education program for menopausal women and content ideas for inclusion in women's health education curriculum.

Computer-based interventions for drug use disorders: a systematic review

A range of innovative computer-based interventions for psychiatric disorders have been developed and are promising for drug use disorders due to reduced cost and greater availability compared to traditional treatment. Electronic searches were conducted from 1966 to November 19, 2009, using MEDLINE, Psychlit, and EMBASE. Four hundred sixty-eight nonduplicate records were identified. Two reviewers classified abstracts for study inclusion, resulting in 12 studies of moderate quality. Eleven studies were pilot or full-scale trials compared to a control condition. Interventions showed high acceptability despite substantial variation in type and amount of treatment. Compared to treatment-as-usual, computer-based interventions led to less substance use and higher motivation to change, better retention, and greater knowledge of presented information. Computer-based interventions for drug use disorders have the potential to dramatically expand and alter the landscape of treatment. Evaluation of Internet- and telephone-based delivery that allows for treatment-on-demand in patients' own environment is needed.

A web-based patient activation intervention to improve hypertension care: study design and baseline characteristics in the web hypertension study

BACKGROUND

Despite the known health risks of hypertension, many hypertensive patients still have uncontrolled blood pressure. Clinical inertia, the tendency of physicians not to intensify treatment, is a common barrier in controlling chronic diseases. This trial is aimed at determining the impact of activating patients to ask providers to make changes to their care through tailored feedback.

METHODS

Diagnosed hypertensive patients were enrolled in this RCT and randomized to one of two study groups: (1) the intervention condition--Web-based hypertension feedback, based on the individual patient's self-report of health variables and previous BP measurements, to prompt them to ask questions during their next physician's visit about hypertension care (2) the control condition--Web-based preventive health feedback, based on the individual's self-report of receiving preventive care (e.g., pap testing), to prompt them to ask questions during their next physician's visit about preventive care. The primary outcome of the study is change in blood pressure and change in the percentage of patients in each group with controlled blood pressure.

CONCLUSION

Five hundred participants were enrolled and baseline characteristics include a mean age of 60.0 years; 57.6% female; and 77.6% white. Overall 37.7% participants had uncontrolled blood pressure; the mean body mass index (BMI) was in the obese range (32.4) and 21.8% had diabetes. By activating patients to become involved in their own care, we believe the addition of the web-based intervention will improve blood pressure control compared to a control group who receive web-based preventive messages unrelated to hypertension.

Improving health outcomes with better patient understanding and education

A central plank of health care reform is an expanded role for educated consumers interacting with responsive health care teams. However, for individuals to realize the benefits of health education also requires a high level of engagement. Population studies have documented a gap between expectations and the actual performance of behaviours related to participation in health care and prevention. Interventions to improve self-care have shown improvements in self-efficacy, patient satisfaction, coping skills, and perceptions of social support. Significant clinical benefits have been seen from trials of self-management or lifestyle interventions across conditions such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis. However, the focus of many studies has been on short-term outcomes rather that long term effects. There is also some evidence that participation in patient education programs is not spread evenly across socio economic groups. This review considers three other issues that may be important in increasing the public health impact of patient education. The first is health literacy, which is the capacity to seek, understand and act on health information. Although health literacy involves an individual's competencies, the health system has a primary responsibility in setting the parameters of the health interaction and the style, content and mode of information. Secondly, much patient education work has focused on factors such as attitudes and beliefs. That small changes in physical environments can have large effects on behavior and can be utilized in self-management and chronic disease research. Choice architecture involves reconfiguring the context or physical environment in a way that makes it more likely that people will choose certain behaviours. Thirdly, better means of evaluating the impact of programs on public health is needed. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework has been promoted as one such potential approach.