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

Computer-assisted therapy in psychiatry: be brave-it's a new world

The capacity to deliver some forms of behavioral treatment via computers may prove to be a small revolution in the delivery of mental health care. Although early research on the efficacy of these approaches has yielded mixed results, this new strategy offers tremendous potential to provide empirically supported therapies to many individuals who would never access psychiatric care, to extend the time and expertise of clinicians, and to offer improved care and monitoring. However, the great promise of computer-assisted therapies may be diminished if their benefits are overstated or if they are broadly released or disseminated before being carefully evaluated using the same methodologic standards that are requirements for evaluating clinician-delivered therapies. In this article, we review the current status of empiric support for computer-assisted therapies, advocating for enhanced rigor to identify those that are most effective, as well as the need to more thoroughly assess possible adverse effects, recognizing that even a modestly effective computer-assisted intervention could have enormous impact.

A meta-analysis on the effectiveness of computer-based education in nursing

Objectives

The purpose of this study was to conduct a comparative analysis of education effectiveness between computer-based education and traditional education methods in nursing.

Methods

Medical and nursing literature databases were searched to identify studies regarding the effectiveness of computer-based education in nursing. Overall effect sizes for three outcome variables (knowledge, attitude, and practice level) were calculated. The effects of study characteristics on the outcome variables were analyzed.

Results

Twenty-seven studies published from 1990 to February 2009, which that met the inclusion criteria, were included in the analysis. The meta-analysis showed that computer-based education generally had positive effects on knowledge, attitude, and practice, with overall effect sizes of 0.43, 0.35, and 0.34, respectively. This study also showed that the type of learner and the total education period had different effects on knowledge.

Conclusions

This metaanalysis found that computer-based education in nursing had positive effects on knowledge, attitude, and practice.

Effects of internet-based tailored advice on the use of cholesterol-lowering interventions: a randomized controlled trial

Background

Elevated low-density lipoprotein (LDL) cholesterol is a leading risk factor for cardiovascular disease. Despite the availability of proven interventions to lower LDL cholesterol, their use remains subobtimal. Many websites provide interactive, tailored advice on cardiovascular risk in an attempt to help bridge this evidence-practice gap, yet there is little evidence that provision of such a tool is effective in changing practice.

Objectives

The objective was to define the effects on use of cholesterol-lowering interventions of a consumer-targeted tailored advice website.

Methods

This was a prospective, double-blind, randomized controlled trial open to any adult Australian with access to the Internet. A total of 2099 participants were randomized. Of these, 45% were male, the mean age of all participants was 56, and 1385 (66%) self-reported hypercholesterolemia. Follow-up information was obtained for 1945 (93%). Participants completed a brief online questionnaire. Individuals assigned to intervention received immediate, fully automated, personally tailored advice (based on current guidelines) regarding the need for commencement of statin therapy, increased statin therapy in those already on treatment, and nondrug intervention strategies. Control group participants were directed to static Web pages providing general information about cholesterol management.

Results

The primary outcome was the proportion of participants that commenced or increased use of prescribed cholesterol-lowering therapy. Of the total 2099 randomized participants, 304 (14%) met eligibility criteria for cholesterol-lowering therapy but were not prescribed treatment, and 254 (12%) were prescribed treatment but were not achieving the recommended target level. Treatment was commenced or increased in 64 (6.0%) of the 1062 intervention group participants and 79 (7.6%) of the 1037 control group participants (% difference = -1.6%, 95% confidence interval [CI] -3.75 to 0.57, P = .15). No differences were found between the randomized groups for the secondary outcomes of “discussed treatment with a health professional” (% difference = -3.8%, 95% confidence interval [CI] -8.16 to 0.19, P = .08), “had their cholesterol checked” (% difference = -1.5%, 95% CI -5.79 to 2.71, P = .48), “had their blood pressure checked” (% difference = 1.4%, 95% CI -2.55 to 5.34, P = .49) or made a lifestyle change (P values between .49 and .96).

Conclusions

Despite providing specific carefully tailored advice, this website had no detectable effect on cholesterol management strategies. This finding raises considerable uncertainty about the value of Internet-based tools providing tailored advice directly to consumers.

Trial Registration

NCT00220974; http://clinicaltrials.gov/ct2/show/NCT00220974 (Archived by WebCite at http://www.webcitation.org/5sdq63rrY)

Interactive computer-based interventions for sexual health promotion

BACKGROUND

Sexual health promotion is a major public health challenge; there is huge potential for health promotion via technology such as the Internet.

OBJECTIVES

To determine effects of interactive computer-based interventions (ICBI) for sexual health promotion, considering cognitive, behavioural, biological and economic outcomes.

SEARCH STRATEGY

We searched more than thirty databases for randomised controlled trials (RCTs) on ICBI and sexual health, including CENTRAL, DARE, MEDLINE, EMBASE, CINAHL, British Nursing Index, and PsycINFO. We also searched reference lists of published studies and contacted authors. All databases were searched from start date to November 2007, with no language restriction.

SELECTION CRITERIA

RCTs of interactive computer-based interventions for sexual health promotion, involving participants of any age, gender, sexual orientation, ethnicity or nationality. 'Interactive' was defined as packages that require contributions from users to produce tailored material and feedback that is personally relevant.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts, applied eligibility and quality criteria and extracted data. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) for continuous outcomes and odds ratios (ORs) for binary outcomes. We assessed heterogeneity using the I(2) statistic. Separate meta-analyses were conducted by type of comparator: 1) minimal intervention such as usual practice or leaflet, 2) face-to-face intervention or 3) a different design of ICBI; and by type of outcome (cognitive, behavioural, biological outcomes).

MAIN RESULTS

We identified 15 RCTs of ICBI conducted in various settings and populations (3917 participants). Comparing ICBI to 'minimal interventions' such as usual practice, meta-analyses showed statistically significant effects as follows: moderate effect on sexual health knowledge (SMD 0.72, 95% CI 0.27 to 1.18); small effect on safer sex self-efficacy (SMD 0.17, 95% CI 0.05 to 0.29); small effect on safer-sex intentions (SMD 0.16, 95% CI 0.02 to 0.30); and also an effect on sexual behaviour (OR 1.75, 95% CI 1.18 to 2.59). Data were insufficient for meta-analysis of biological outcomes and analysis of cost-effectiveness.In comparison with face-to-face sexual health interventions, meta-analysis was only possible for sexual health knowledge, showing that ICBI were more effective (SMD 0.36, 95% CI 0.13 to 0.58). Two further trials reported no difference in knowledge between ICBI and face-to-face intervention, but data were not available for pooling. There were insufficient data to analyse other types of outcome.No studies measured potential harms (apart from reporting any deterioration in measured outcomes).

AUTHORS' CONCLUSIONS

ICBI are effective tools for learning about sexual health, and they also show positive effects on self-efficacy, intention and sexual behaviour. More research is needed to establish whether ICBI can impact on biological outcomes, to understand how interventions might work, and whether they are cost-effective.

Perceptions of risk: understanding cardiovascular disease

Cardiovascular disease (CVD) is still the leading cause of death and disability worldwide despite the availability of well-established and effective preventive options. Accurate perception of a patient’s risk by both the patient and the doctors is important as this is one of the components that determine health-related behavior. Doctors tend to not use cardiovascular (CV) risk calculators and underestimate the absolute CV risk of their patients. Patients show optimistic bias when considering their own risk and consistently underestimate it. Poor patient health literacy and numeracy must be considered when thinking about this problem. Patients must possess a reasonably high level of understanding of numerical processes when doctors discuss risk, a level that is not possessed by large numbers of the population. In order to overcome this barrier, doctors need to utilize various tools including the appropriate use of visual aids to accurately communicate risk with their patients. Any intervention has been shown to be better than nothing in improving health understanding. The simple process of repeatedly conveying risk information to a patient has been shown to improve accuracy of risk perception. Doctors need to take responsibility for the accurate assessment and effective communication of CV risk in their patients in order to improve patient uptake of cardioprotective lifestyle choices and preventive medications.

A meta-analysis of computer-tailored interventions for health behavior change

OBJECTIVE

Computer-tailored interventions have become increasingly common for facilitating improvement in behaviors related to chronic disease and health promotion. A sufficient number of outcome studies from these interventions are now available to facilitate the quantitative analysis of effect sizes, permitting moderator analyses that were not possible with previous systematic reviews.

METHOD

The present study employs meta-analytic techniques to assess the mean effect for 88 computer-tailored interventions published between 1988 and 2009 focusing on four health behaviors: smoking cessation, physical activity, eating a healthy diet, and receiving regular mammography screening. Effect sizes were calculated using Hedges g. Study, tailoring, and demographic moderators were examined by analyzing between-group variance and meta-regression.

RESULTS

Clinically and statistically significant overall effect sizes were found across each of the four behaviors. While effect sizes decreased after intervention completion, dynamically tailored interventions were found to have increased efficacy over time as compared with tailored interventions based on one assessment only. Study effects did not differ across communication channels nor decline when up to three behaviors were identified for intervention simultaneously.

CONCLUSION

This study demonstrates that computer-tailored interventions have the potential to improve health behaviors and suggests strategies that may lead to greater effectiveness of these techniques.

Do brief online planning interventions increase physical activity amongst university students? A randomised controlled trial

Brief planning interventions, usually delivered within paper and pencil questionnaires, have been found to be effective in changing health behaviours. Using a double-blind randomised controlled trial, this study examined the efficacy of two types of planning interventions (action plans and coping plans) in increasing physical activity levels when they are delivered via the internet. Following the completion of self-reported physical activity (primary outcome) and theory of planned behaviour (TPB) measures at baseline, students (N = 1273) were randomised into one of four conditions on the basis of a 2 (received instructions to form action plans or not) × 2 (received instructions to form coping plans or not) factorial design. Physical activity (primary outcome) and TPB measures were completed again at two-month follow-up. An objective measure (attendance at the university's sports facilities) was employed 6 weeks after a follow-up for a duration of 13 weeks (secondary outcome). The interventions did not change self-reported physical activity, attendance at campus sports facilities or TPB measures. This might be due to low adherence to the intervention protocol (ranging from 58.8 to 76.7%). The results of this study suggest that the planning interventions under investigation are ineffective in changing behaviour when delivered online to a sample of participants unaware of the allocation to different conditions. Possible moderators of the effectiveness of planning interventions in changing health behaviours are discussed.

A brief motivational interview in a pediatric emergency department, plus 10-day telephone follow-up, increases attempts to quit drinking among youth and young adults who screen positive for problematic drinking

OBJECTIVES

Adolescents in their late teens and early 20s have the highest alcohol consumption in the United States; binge drinking peaks at age 21-25 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks.

METHODS

A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months and to compare the AC group with a minimally assessed control (MAC) group to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14-21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT) or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The I group received a peer-conducted motivational intervention, referral to community resources and treatment if indicated, and a 10-day booster in addition to assessment. Measurements included 30-day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to 1-year follow-up.

RESULTS

Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I, n = 283; AC, n = 284; MAC, n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in Reaching Adolescents for Prevention (RAP) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At 3 months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio (OR) for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group and 54.8% among the MAC group).

CONCLUSIONS

Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.

Effect of a worksite-based intervention program on metabolic parameters in middle-aged male white-collar workers: a randomized controlled trial

OBJECTIVE

An effective program for preventing metabolic diseases through lifestyle modification is urgently needed. We investigated the effects of the Life Style Modification Program for Physical Activity and Nutrition program (LiSM10!) on metabolic parameters in middle-aged male Japanese white-collar workers.

METHODS

One hundred and one male office workers, 30 to 59 years of age, with metabolic syndrome risk factors, were randomly allocated into no-treatment control (n=49) and LiSM intervention (n=52) groups. The LiSM group attended individualized assessment and collaborative goal setting sessions based on food group intake and physical activity, followed by two individual counseling sessions with a registered dietitian and physical trainer, and received monthly website advice during the 4-month period from December 2006 to May 2007, in Tokyo, Japan. They were encouraged to enter current targeted food intakes and pedometer data on self-monitoring websites during the entire study period.

RESULTS

Habitual food group intakes changed significantly in the LiSM group, showing improvements in 14 anthropometric and biochemical parameters contributing to inter-group differences in body weight, body mass index, fasting plasma glucose, insulin and homeostasis model assessment of insulin resistance changes (p<0.01).

CONCLUSION

The LiSM10! program effectively improved insulin resistance-related metabolic parameters in middle-aged male white-collar workers.

Evaluation of an HIV nucleic acid testing program with automated Internet and voicemail systems to deliver results

BACKGROUND

Nucleic acid testing (NAT) in routine HIV testing programs can increase the detection of infected individuals, but the most effective implementation of NAT remains unclear.

OBJECTIVE

To determine how many HIV cases can be identified with NAT and how many persons can be contacted, to identify predictors of acute and early HIV infection cases, and to test reporting of negative results by automated Internet and voicemail systems.

DESIGN

Prospective study.

SETTING

San Diego County, California.

PARTICIPANTS

Persons seeking HIV testing.

MEASUREMENTS

Rates and predictors of HIV infection by stage, notification of positive NAT results, use of automated Internet or voicemail systems to access negative NAT results, and estimated HIV infections prevented.

RESULTS

Of 3151 persons tested, 79 had newly diagnosed cases of HIV: 64 had positive results from rapid HIV test, and 15 had positive results only by NAT (that is, NAT increased the HIV detection yield by 23%). Of all HIV infections, 44% (in 35 persons) were in the acute and early stages. Most participants (56%) and persons with HIV (91%) were men who have sex with men (MSM). All persons with NAT-positive results were notified within 1 week. Of all 3070 uninfected patients, 2105 (69%) retrieved their negative NAT results, with 1358 using the Internet system. After adjustment for covariates, persons reporting MSM behavior, higher incomes, younger ages, no testing at substance abuse rehabilitation centers, no recent syphilis, and no methamphetamine use were more likely to access negative NAT results by either Internet or voicemail systems.

LIMITATION

Findings may not be generalizable to other populations and testing programs.

CONCLUSION

Nucleic acid testing programs that include automated systems for result reporting can increase case yield, especially in settings that cater to MSM.

Evaluation of an HIV nucleic acid testing program with automated Internet and voicemail systems to deliver results

BACKGROUND

Nucleic acid testing (NAT) in routine HIV testing programs can increase the detection of infected individuals, but the most effective implementation of NAT remains unclear.

OBJECTIVE

To determine how many HIV cases can be identified with NAT and how many persons can be contacted, to identify predictors of acute and early HIV infection cases, and to test reporting of negative results by automated Internet and voicemail systems.

DESIGN

Prospective study.

SETTING

San Diego County, California.

PARTICIPANTS

Persons seeking HIV testing.

MEASUREMENTS

Rates and predictors of HIV infection by stage, notification of positive NAT results, use of automated Internet or voicemail systems to access negative NAT results, and estimated HIV infections prevented.

RESULTS

Of 3151 persons tested, 79 had newly diagnosed cases of HIV: 64 had positive results from rapid HIV test, and 15 had positive results only by NAT (that is, NAT increased the HIV detection yield by 23%). Of all HIV infections, 44% (in 35 persons) were in the acute and early stages. Most participants (56%) and persons with HIV (91%) were men who have sex with men (MSM). All persons with NAT-positive results were notified within 1 week. Of all 3070 uninfected patients, 2105 (69%) retrieved their negative NAT results, with 1358 using the Internet system. After adjustment for covariates, persons reporting MSM behavior, higher incomes, younger ages, no testing at substance abuse rehabilitation centers, no recent syphilis, and no methamphetamine use were more likely to access negative NAT results by either Internet or voicemail systems.

LIMITATION

Findings may not be generalizable to other populations and testing programs.

CONCLUSION

Nucleic acid testing programs that include automated systems for result reporting can increase case yield, especially in settings that cater to MSM.

An exploratory study of engagement in a technology-supported substance abuse intervention

BACKGROUND

The continuing gap between the number of people requiring treatment for substance use disorders and those receiving treatment suggests the need to develop new approaches to service delivery. Meanwhile, the use of technology to provide counseling and support in the substance abuse field is exploding. Despite the increase in the use of technology in treatment, little is known about the impact of technology-supported interventions on access to services for substance use disorders. The E-TREAT intervention brings together the evidence-based practice of Motivational Interviewing and theories of Persuasive Technology to sustain clients' motivation to change substance use behaviors, provide support for change, and facilitate continuity across treatment settings.

METHODS

This study used descriptive statistics, tests of statistical significance, and logistic regression to explore the characteristics and perceptions of the first 157 people who agreed to participate in E-TREAT and the predictors of their active engagement in E-TREAT services. In addition, responses to open-ended questions about the participants' experiences with the intervention were analyzed.

RESULTS

The data reveal that clients who engaged in E-TREAT were more likely than those who did not engage to be female, have children and report a positive relationship with their recovery coach, and were less likely to have completed treatment for a substance use disorder in the past. A majority of people engaging in E-TREAT reported that it was helpful to talk with others with similar problems and that the program assisted them in developing a sense of community.

CONCLUSIONS

The authors conclude that technology-assisted interventions hold promise in expanding access to treatment for substance use disorders especially for women and parents. Further, the characteristics of the relationship with a coach or helper may be critical to engagement in technology-supported interventions. Additional investigation into ways technology may be useful to enhance treatment access for certain subgroups is needed.

The validity and reliability of an interactive computer tobacco and alcohol use survey in general practice

BACKGROUND

Uncertainty regarding the accuracy of the computer as a data collection or patient screening tool persists. Previous research evaluating the validity of computer health surveys have tended to compare those responses to that of paper survey or clinical interview (as the gold standard). This approach is limited as it assumes that the paper version of the self-report survey is valid and an appropriate gold standard.

OBJECTIVES

First, to compare the accuracy of computer and paper methods of assessing self-reported smoking and alcohol use in general practice with biochemical measures as gold standard. Second, to compare the test re-test reliability of computer administration, paper administration and mixed methods of assessing self-reported smoking status and alcohol use in general practice.

METHODS

A randomised cross-over design was used. Consenting patients were randomly assigned to one of four groups; Group 1. C-C : completing a computer survey at the time of that consultation (Time 1) and a computer survey 4-7 days later (Time 2); Group 2. C-P: completing a computer survey at Time 1 and a paper survey at Time 2; Group 3. P-C: completing a paper survey at Time 1 and a computer survey at Time 2; and Group 4. P-P: completing a paper survey at Time 1 and 2. At Time 1 all participants also completed biochemical measures to validate self-reported smoking status (expired air carbon monoxide breath test) and alcohol consumption (ethyl alcohol urine assay).

RESULTS

Of the 618 who were eligible, 575 (93%) consented to completing the Time 1 surveys. Of these, 71% (N=411) completed Time 2 surveys. Compared to CO, the computer smoking self-report survey demonstrated 91% sensitivity, 94% specificity, 75% positive predictive value (PPV) and 98% negative predictive value (NPV). The equivalent paper survey demonstrated 86% sensitivity, 95% specificity, 80% PPV, and 96% NPV. Compared to urine assay, the computer alcohol use self-report survey demonstrated 92% sensitivity, 50% specificity, 10% PPV and 99% NPV. The equivalent paper survey demonstrated 75% sensitivity, 57% specificity, 6% PPV, and 98% NPV. Level of agreement of smoking self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.95 to 0.98 in each group and hazardous alcohol use self-reports at Time 1 and Time 2 revealed kappa coefficients ranging from 0.90 to 0.96 in each group.

CONCLUSION

The collection of self-reported health risk information is equally accurate and reliable using computer interface in the general practice setting as traditional paper survey. Computer survey appears highly reliable and accurate for the measurement of smoking status. Further research is needed to confirm the adequacy of the quantity/frequency measure in detecting those who drink alcohol. Interactive computer administered health surveys offer a number of advantages to researchers and clinicians and further research is warranted.

Longitudinal outcomes of an alcohol abuse prevention program for urban adolescents

PURPOSE

This randomized clinical trial examined longitudinal outcomes from an alcohol abuse prevention program aimed at urban youths.

METHODS

Study participants were an ethnically and racially heterogeneous sample of early adolescents, recruited from community-based agencies in greater New York City and its environs. Once they assented to study participation and gained parental permission, youths were divided into three arms: youth intervention delivered by CD-ROM (CD), the same youth intervention plus parent intervention (CD(P)), and control. Once all youths completed baseline measures, those in CD and CD(P) arms received a computerized 10-session alcohol abuse prevention program. Parents of youths in the CD(P) arm received supplemental materials to support and strengthen their children's learning. All youths completed postintervention and annual follow-up measures, and CD- and CD(P)-arm participants received annual booster intervention sessions.

RESULTS

Seven years following postintervention testing and relative to control-arm youths, youths in CD and CD(P) arms reported less alcohol use, cigarette use, binge drinking, and peer pressure to drink; fewer drinking friends; greater refusal of alcohol use opportunities; and lower intentions to drink. No differences were observed between CD and CD(P) arms.

CONCLUSIONS

Study findings lend support to the potential of computerized, skills-based prevention programs to help urban youth reduce their risks for underage drinking.

Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy

BACKGROUND

The Internet is increasingly used as a medium for the delivery of interventions designed to promote health behavior change. However, reviews of these interventions to date have not systematically identified intervention characteristics and linked these to effectiveness.

OBJECTIVES

The present review sought to capitalize on recently published coding frames for assessing use of theory and behavior change techniques to investigate which characteristics of Internet-based interventions best promote health behavior change. In addition, we wanted to develop a novel coding scheme for assessing mode of delivery in Internet-based interventions and also to link different modes to effect sizes.

METHODS

We conducted a computerized search of the databases indexed by ISI Web of Knowledge (including BIOSIS Previews and Medline) between 2000 and 2008. Studies were included if (1) the primary components of the intervention were delivered via the Internet, (2) participants were randomly assigned to conditions, and (3) a measure of behavior related to health was taken after the intervention.

RESULTS

We found 85 studies that satisfied the inclusion criteria, providing a total sample size of 43,236 participants. On average, interventions had a statistically small but significant effect on health-related behavior (d(+) = 0.16, 95% CI 0.09 to 0.23). More extensive use of theory was associated with increases in effect size (P = .049), and, in particular, interventions based on the theory of planned behavior tended to have substantial effects on behavior (d(+) = 0.36, 95% CI 0.15 to 0.56). Interventions that incorporated more behavior change techniques also tended to have larger effects compared to interventions that incorporated fewer techniques (P < .001). Finally, the effectiveness of Internet-based interventions was enhanced by the use of additional methods of communicating with participants, especially the use of short message service (SMS), or text, messages.

CONCLUSIONS

The review provides a framework for the development of a science of Internet-based interventions, and our findings provide a rationale for investing in more intensive theory-based interventions that incorporate multiple behavior change techniques and modes of delivery.

Twelve-month follow-up results from a randomized controlled trial of a brief personalized feedback intervention for problem drinkers

Aims: To examine the impact of a web-based personalized feedback intervention, the Check Your Drinking (CYD; www.CheckYourDrinking.net) screener at 12-month follow-up.

Methods: Respondents (N = 185) were recruited from a general population telephone survey of Ontario, Canadian adults (≥18 years) by asking risky drinkers if they were willing to help develop and evaluate Internet-based interventions for drinkers. Those randomly assigned to the intervention condition were provided with the web address and a unique password to a study-specific copy of the CYD. Respondents assigned to the control condition were sent a written description of the different components of the CYD and asked how useful they thought each of the components might be. Respondents were followed up at 3, 6 and 12 months.

Results: By the 12-month follow-up, the impact of the intervention previously reported at 3 and 6 months of CYD on problem drinkers’ alcohol consumption was no longer apparent (P > 0.05).

Conclusions: Recognizing that many people with alcohol concerns will never seek treatment, recent years have seen an increase in efforts to find ways to take treatment to problem drinkers. The CYD is one such intervention that has a demonstrated effect on reducing alcohol consumption in the short term (i.e. 6 months). Other more intensive Internet-based interventions or interventions via other modalities may enhance this positive outcome over the short and long term among problem drinkers who would be otherwise unlikely to access treatment for their alcohol concerns.

www.ClinicalTrials.gov registration #NCT00367575.

Randomized controlled trial of an interactive internet smoking cessation program with long-term follow-up

BACKGROUND

Internet programs for smoking cessation are widely available but few controlled studies demonstrate long-term efficacy.

PURPOSE

To determine the 13-month effectiveness of an Internet program presenting a set sequence of interactive steps, and the role of depressed affect.

METHODS

In a randomized controlled trial sponsored by the American Cancer Society, a treatment condition (n = 1,106) was compared to a control site (n = 1,047).

RESULTS

More treatment condition participants were abstinent (30-day point prevalence) than control site participants (12.9% vs. 10.1%, p < .05) at 13 months. This effect was greater among participants not reporting depressed affect (15.0% vs. 10.1%, p < .01). Among smokers who reported depressed affect, there was no difference in abstinence between the treatment and control conditions.

CONCLUSIONS

Data support the long-term efficacy of an Internet intervention for cessation modeled on a structured, in-person treatment approach, especially for participants not experiencing daily depressed affect.

Preventing substance use among adolescent girls: 1-year outcomes of a computerized, mother-daughter program

This study tested a computerized gender-specific, parent-involvement intervention program grounded in family interaction theory and aimed at preventing substance use among adolescent girls. Following program delivery and 1 year later, girls randomly assigned to the intervention arm improved more than girls in a control arm on variables associated with reduced risks for substance use, including communication with their mothers, knowledge of family rules about substance use, awareness of parental monitoring of their discretionary time, non-acceptance of peer substance use, problem-solving skills, and ability to refuse peer pressure to use substances. Relative to control-arm girls, those in the intervention arm also reported less 30-day use of alcohol and marijuana and lower intentions to smoke, drink, and take illicit drugs in the future. Girls' mothers in the intervention arm reported greater improvements after the program and relative to control-arm mothers in their communication with their daughters, establishment of family rules about substance use, and monitoring of their daughters' discretionary time. Study findings lend support to the potential of gender-specific, parent-involvement, and computerized approaches to preventing substance use among adolescent girls.

Online support for smoking cessation: a systematic review of the literature

AIM

To examine the efficacy and acceptability of online, interactive interventions for smoking cessation and to identify treatment effect moderators and mediators.

METHODS

A systematic review and meta-analysis of the literature (1990-2008) was conducted, finding 11 relevant randomized controlled trials. Data were extracted and risk ratios and risk differences estimated with a random effects model.

RESULTS

There was no evidence of publication bias. Included trials were of variable methodological quality. Web-based, tailored, interactive smoking cessation interventions were effective compared with untailored booklet or e-mail interventions [rate ratio (RR) 1.8; 95% confidence interval (CI) 1.4-2.3] increasing 6-month abstinence by 17% (95% CI 12-21%). No overall effect of interactive compared with static web-based interventions was detected but there was significant heterogeneity, with one study obtaining a clear effect and another failing to find one. Few moderating or mediating factors were evaluated in studies and those that were had little effect. Pooled results suggest that only interventions aimed at smokers motivated to quit were effective (RR 1.3, 95% CI 1.0-1.7). Fully automated interventions increased smoking cessation rates (RR 1.4, 95% CI 1.0-2.0), but evidence was less clear-cut for non-automated interventions. Overall, the web-based interventions evaluated were considered to be acceptable and user satisfaction was generally high.

CONCLUSION

Interactive, web-based interventions for smoking cessation can be effective in aiding cessation. More research is needed to evaluate the relative efficacy of interactive web-based interventions compared with static websites.

Computer-delivered, parent-involvement intervention to prevent substance use among adolescent girls

OBJECTIVE

To test a computer-delivered program for preventing substance use among adolescent girls.

METHODS

Randomly, 916 girls aged 12.76+/-1.0 years and their mothers were assigned to an intervention arm or to a test-only control arm. Intervention-arm dyads engaged in exercises to improve the mother-daughter relationship, build girls' substance use prevention skills, and reduce associated risk factors. Study outcomes were girls' and mothers' substance use and mediator variables related to girls' substance use risk and protective factors. The study was conducted between September 2006 and February 2009 with participants from greater New York City, including southern Connecticut and eastern New Jersey.

RESULTS

At 2-year follow-up and relative to control-arm girls, intervention-arm girls reported lower relevant risk factors and higher protective factors as well as less past 30-day use of alcohol (p<0.006), marijuana (p<0.016), illicit prescription drugs (p<0.03), and inhalants (p<0.024). Intervention-arm mothers showed more positive 2-year outcomes than control-arm mothers on variables linked with reduced risks of substance use among their daughters, and mothers reported lower rates of weekly alcohol consumption (p<0.0001).

CONCLUSIONS

A computer-delivered prevention program for adolescent girls and their mothers was effective in changing girls' risk and protective factors and girls' and mothers' substance use behavior.

Computer-delivered interventions to reduce college student drinking: a meta-analysis

AIMS

This meta-analysis evaluates the efficacy of computer-delivered interventions (CDIs) to reduce alcohol use among college students.

METHODS

We included 35 manuscripts with 43 separate interventions, and calculated both between-group and within-group effect sizes for alcohol consumption and alcohol-related problems. Effects sizes were calculated for short-term (< or =5 weeks) and long-term (> or =6 weeks) intervals. All studies were coded for study descriptors, participant characteristics and intervention components.

RESULTS

The effects of CDIs depended on the nature of the comparison condition: CDIs reduced quantity and frequency measures relative to assessment-only controls, but rarely differed from comparison conditions that included alcohol-relevant content. Small-to-medium within-group effect sizes can be expected for CDIs at short- and long-term follow-ups; these changes are less than or equivalent to the within-group effect sizes observed for more intensive interventions.

CONCLUSIONS

CDIs reduce the quantity and frequency of drinking among college students. CDIs are generally equivalent to alternative alcohol-related comparison interventions.

Alcohol Interventions for College Students Improves Antecedents of Behavioral Change: Results from a Meta-Analysis of 34 Randomized Controlled Trials

The current meta-analysis examined the effects of individual-level alcohol interventions on college students' knowledge and psychological outcomes at first post-intervention assessment. Data from 34 randomized controlled trials published between 1980 and June 2007 (N = 8,569) were included. Independent raters coded participant characteristics, design and methodological features, and intervention content. Weighted mean effect sizes, using both fixed- and random-effects models, were calculated; positive effect sizes indicated greater improvement in alcohol-related knowledge or psychological outcomes. Compared to controls, alcohol interventions improved participants' alcohol-related knowledge, attitudes toward drinking, and descriptive norms (vis-à-vis national college students), and intentions to consume alcohol but did not improve alcohol expectancies or self-efficacy. Several sample, study and intervention characteristics moderated the knowledge and psychological outcomes. Implications of these findings are discussed.

Gender-specific intervention to reduce underage drinking among early adolescent girls: a test of a computer-mediated, mother-daughter program

OBJECTIVE

This study evaluated a gender-specific, computer-mediated intervention program to prevent underage drinking among early adolescent girls.

METHOD

Study participants were adolescent girls and their mothers from New York, New Jersey, and Connecticut. Participants completed pretests online and were randomly divided between intervention and control arms. Intervention-arm girls and their mothers interacted with a computer program aimed to enhance mother-daughter relationships and to teach girls skills for managing conflict, resisting media influences, refusing alcohol and drugs, and correcting peer norms about underage drinking, smoking, and drug use. After intervention, all participants (control and intervention) completed posttest and follow-up measurements.

RESULTS

Two months following program delivery and relative to control-arm participants, intervention-arm girls and mothers had improved their mother-daughter communication skills and their perceptions and applications of parental monitoring and rule-setting relative to girls' alcohol use. Also at follow-up, intervention-arm girls had improved their conflict management and alcohol use-refusal skills; reported healthier normative beliefs about underage drinking; demonstrated greater self-efficacy about their ability to avoid underage drinking; reported less alcohol consumption in the past 7 days, 30 days, and year; and expressed lower intentions to drink as adults.

CONCLUSIONS

Study findings modestly support the viability of a mother-daughter, computer-mediated program to prevent underage drinking among adolescent girls. The data have implications for the further development of gender-specific approaches to combat increases in alcohol and other substance use among American girls.

Efficacy of computer technology-based HIV prevention interventions: a meta-analysis

OBJECTIVES

To conduct a meta-analysis of computer technology-based HIV prevention behavioral interventions aimed at increasing condom use among a variety of at-risk populations.

DESIGN

Systematic review and meta-analysis of existing published and unpublished studies testing computer-based interventions.

METHODS

Meta-analytic techniques were used to compute and aggregate effect sizes for 12 randomized controlled trials that met inclusion criteria. Variables that had the potential to moderate intervention efficacy were also tested.

RESULTS

The overall mean weighted effect size for condom use was d = 0.259 (95% confidence interval = 0.201, 0.317; Z = 8.74, P < 0.001; N = 4639), indicating a statistically significant impact of the interventions. This effect size compares favorably to previously tested interventions delivered by human facilitators. Statistically significant effect sizes were also found for frequency of sexual behavior, number of partners, and incident sexually transmitted diseases. In addition, interventions were significantly more efficacious when they were directed at men or women (versus mixed sex groups), utilized individualized tailoring, used a Stages of Change model, and had more intervention sessions.

CONCLUSION

Computer technology-based HIV prevention interventions have similar efficacy to more traditional human-delivered interventions. Given their low cost to deliver, ability to customize intervention content, and flexible dissemination channels, they hold much promise for the future of HIV prevention.

Evaluating a two-step approach to sexual risk reduction in a publicly-funded STI clinic: rationale, design, and baseline data from the Health Improvement Project-Rochester (HIP-R)

BACKGROUND

Sexually transmitted infection (STI) clinics provide an opportune setting for HIV prevention efforts. This randomized controlled trial evaluated a unique, two-step approach to sexual risk reduction at a publicly-funded STI clinic.

METHODS

During an initial visit, patients completed an audio-computer assisted self-interview (ACASI), were randomized to and received one of two brief interventions, obtained medical care, and completed a post-assessment. Next, two-thirds of the patients were assigned to attend an intensive sexual risk reduction workshop. At 3, 6, and 12 months, patients completed additional ACASIs and provided urine specimens to assess behavior change and incident STIs.

RESULTS

During a 28-month interval, 5613 patients were screened, 2691 were eligible, and 1483 consented to participate and were randomized; the modal reason for declining was lack of time (82%). Consenting patients included 688 women and 795 men; 64% of participants were African-American. The sample was low-income, with 57% reporting an annual income of less than $15,000; most participants (62%) had a high school education or less, and 51% were unemployed. Sexual risk behavior was common, as indicated by multiple sexual partners (mean=32.8, lifetime; mean=2.8, past 3 months), unprotected sex (mean=17.3 episodes, past 3 months), and prior STIs (mean=3.3, lifetime; 23% at baseline). Bivariate analyses confirmed our prediction that HIV-related motivation and behavioral skills would be related to current sexual risk behavior. All patients received a brief intervention; patient satisfaction ratings were uniformly high for both interventions (all means >or=3.7 on 4-point scales). Fifty-six percent of invited patients attended the intensive workshop, and attendance did not differ as a function of brief intervention. Patient satisfaction ratings were also uniformly positive for the workshop interventions (all means >or=3.6). Return to follow-up assessments exceeded 70%.

CONCLUSIONS

Results demonstrate that implementing an HIV preventive program in a busy, public clinic is feasible and well-accepted by patients. Ongoing evaluation will determine if the interventions reduce sexual risk behavior and lower incident STIs.