Interapy: A controlled randomized trial of the standardized treatment of posttraumatic stress through the internet

Psychological treatments for chronic post-traumatic stress disorder. Systematic review and meta-analysis

BACKGROUND

The relative efficacy of different psychological treatments for chronic post-traumatic stress disorder (PTSD) is unclear.

AIMS

To determine the efficacy of specific psychological treatments for chronic PTSD.

METHOD

In a systematic review of randomised controlled trials, eligible studies were assessed against methodological quality criteria and data were extracted and analysed.

RESULTS

Thirty-eight randomised controlled trials were included in the meta-analysis. Trauma-focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group cognitive-behavioural therapy improved PTSD symptoms more than waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR but there was some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress management was superior to other therapies.

CONCLUSIONS

The first-line psychological treatment for PTSD should be trauma-focused (TFCBT or EMDR).

Treating erectile dysfunction through electronic consultation: a pilot study

We investigated a group of men suffering from electric dysfunction (ED) who visited the website www.erectie.info and who had received consultation through the Internet (n = 219). We measured the treatment's effectiveness using the 5-item version of the International Index of Erectile Function (IIEF-5; Rosen et al., 1996; Rosen, Cappelleri, Smith, Lipsky, & Pena, 1999) and a global assessment question (GAQ). We investigated the motives and characteristics of the users of electronics consultation using a questionnaire. After a few months, the consultation group showed a considerably higher IIEF-5 score compared with their baseline score. Eighty-one percent replied in the affirmative to the GAQ. E-consultation is likely to be effective when treating ED, especially among men who find the medium convenient and for men who experience much embarrassment.

Directions for the International Society for Research on Internet Interventions (ISRII)

In 2004, the International Society for Research on Internet Interventions (ISRII) was formed to encourage eHealth researchers to collaborate in their efforts to further the science behind developing, testing, and disseminating Web-based treatment programs. The group held its second meeting (April 2006) to clarify the Society's direction and identify key issues that need addressing in the field. These issues are identified and examined in the current paper. Given the success of using the Internet to treat a range of medical and mental health problems, and the growing need for better dissemination of health care, Internet interventions will almost certainly play a prominent role in global health. ISRII plans to provide the necessary venue to ensure the science driving this field is strong, enabling researchers to conduct the highest quality research and permitting meaningful conclusions from completed studies.

Dresden PTSD treatment study: randomized controlled trial of motor vehicle accident survivors

BACKGROUND

We translated, modified, and extended a cognitive behavioral treatment (CBT) protocol by Blanchard and Hickling (2003) for the purpose of treating survivors of MVA with full or subsyndromal posttraumatic stress disorder (PTSD) whose native language is German. The treatment manual included some additional elements, e. g. cognitive procedures, imaginal reliving, and facilitating of posttraumatic growth. The current study was conducted in order to test the efficacy of the modified manual by administering randomized controlled trial in which a CBT was compared to a wait-list control condition.

METHODS

Forty-two motor vehicle accident survivors with chronic or severe subsyndromal posttraumatic stress disorder (PTSD) completed the treatment trial with two or three detailed assessments (pre, post, and 3-month follow-up).

RESULTS

CAPS-scores showed significantly greater improvement in the CBT condition as compared to the wait list condition (group x time interaction effect size d = 1.61). Intent-to-treat analysis supported the outcome (d = 1.34). Categorical diagnostic data indicated clinical recovery of 67% (post-treatment) and 76% (3 months FU) in the treatment group. Additionally, patients of the CBT condition showed significantly greater reductions in co-morbid major depression than the control condition. At follow-up the improvements were stable in the active treatment condition.

CONCLUSION

The degree of improvement in our treatment group was comparable to that in previously reported treatment trials of PTSD with cognitive behavioral therapy.

TRIAL REGISTRATION

ISRCTN66456536.

Why are health care interventions delivered over the internet? A systematic review of the published literature

Background

As Internet use grows, health interventions are increasingly being delivered online. Pioneering researchers are using the networking potential of the Internet, and several of them have evaluated these interventions.

Objective

The objective was to review the reasons why health interventions have been delivered on the Internet and to reflect on the work of the pioneers in this field in order to inform future research.

Methods

We conducted a qualitative systematic review of peer-reviewed evaluations of health interventions delivered to a known client/patient group using networked features of the Internet. Papers were reviewed for the reasons given for using the Internet, and these reasons were categorized.

Results

We included studies evaluating 28 interventions plus 9 interventions that were evaluated in pilot studies. The interventions were aimed at a range of health conditions. Reasons for Internet delivery included low cost and resource implications due to the nature of the technology; reducing cost and increasing convenience for users; reduction of health service costs; overcoming isolation of users; the need for timely information; stigma reduction; and increased user and supplier control of the intervention. A small number of studies gave the existence of Internet interventions as the only reason for undertaking an evaluation of this mode of delivery.

Conclusions

One must remain alert for the unintended effects of Internet delivery of health interventions due to the potential for reinforcing the problems that the intervention was designed to help. Internet delivery overcomes isolation of time, mobility, and geography, but it may not be a substitute for face-to-face contact. Future evaluations need to incorporate the evaluation of cost, not only to the health service but also to users and their social networks. When researchers report the outcomes of Internet-delivered health care interventions, it is important that they clearly state why they chose to use the Internet, preferably backing up their decision with theoretical models and exploratory work. Evaluation of the effectiveness of a health care intervention delivered by the Internet needs to include comparison with more traditional modes of delivery to answer the following question: What are the added benefits or disadvantages of Internet use that are particular to this mode of delivery?

Why are health care interventions delivered over the internet? A systematic review of the published literature

BACKGROUND

As Internet use grows, health interventions are increasingly being delivered online. Pioneering researchers are using the networking potential of the Internet, and several of them have evaluated these interventions.

OBJECTIVE

The objective was to review the reasons why health interventions have been delivered on the Internet and to reflect on the work of the pioneers in this field in order to inform future research.

METHODS

We conducted a qualitative systematic review of peer-reviewed evaluations of health interventions delivered to a known client/patient group using networked features of the Internet. Papers were reviewed for the reasons given for using the Internet, and these reasons were categorized.

RESULTS

We included studies evaluating 28 interventions plus 9 interventions that were evaluated in pilot studies. The interventions were aimed at a range of health conditions. Reasons for Internet delivery included low cost and resource implications due to the nature of the technology; reducing cost and increasing convenience for users; reduction of health service costs; overcoming isolation of users; the need for timely information; stigma reduction; and increased user and supplier control of the intervention. A small number of studies gave the existence of Internet interventions as the only reason for undertaking an evaluation of this mode of delivery.

CONCLUSIONS

One must remain alert for the unintended effects of Internet delivery of health interventions due to the potential for reinforcing the problems that the intervention was designed to help. Internet delivery overcomes isolation of time, mobility, and geography, but it may not be a substitute for face-to-face contact. Future evaluations need to incorporate the evaluation of cost, not only to the health service but also to users and their social networks. When researchers report the outcomes of Internet-delivered health care interventions, it is important that they clearly state why they chose to use the Internet, preferably backing up their decision with theoretical models and exploratory work. Evaluation of the effectiveness of a health care intervention delivered by the Internet needs to include comparison with more traditional modes of delivery to answer the following question: What are the added benefits or disadvantages of Internet use that are particular to this mode of delivery?

Internet-based cognitive-behavioral therapy for complicated grief: a randomized controlled trial

The present study investigates the efficacy of an Internet-based cognitive-behavioral therapy program for bereaved people suffering complicated grief. The program combines established methods of psychotherapy with new technology--therapists and patients communicated exclusively by e-mail. Bereaved individuals diagnosed with complicated grief (n = 55) were randomly assigned to either the treatment group or a waiting list control condition. The 5-week intervention consisted of three modules: (1) exposure to bereavement cues; (2) cognitive reappraisal; and (3) integration and restoration. The Impact of Event Scale (IES), a failure to adapt scale, and the depression and anxiety subscales of the Brief Symptom Inventory (BSI) were used to assess treatment outcomes. Participants in the treatment group (n = 26) improved significantly relative to participants in the waiting condition on symptoms of intrusion, avoidance, maladaptive behavior, and general psychopathology, and showed a large treatment effect. Follow-up results show that this improvement was maintained after 3 months.

The internet as psychological laboratory

This chapter reviews studies published in American Psychological Association (APA) journals from 2003-2004 and additional studies (received in response to listserv requests) that used the Internet to collect data (N=121 total studies). Specific examples of three kinds of Web-based research are reviewed: (a) translational (established methods and research questions are adapted to the Web), (b) phenomenological (behavior on the Web is the focus of study), and (c) novel (methodologically innovations unique to Web-based research). Among other findings, our review indicated that 21% of APA journals published at least one article that reported on Web-based research, most Web-based psychological research uses experimental methods, a surprising number use college student samples, and deception in Web-based research is not uncommon. Strengths and weaknesses of Web-based psychological research in general, and our sample of studies in particular, are reviewed with special attention to possible concerns about sampling and the use of deception.

The acceptability and preference for the psychological treatment of PTSD

The acceptability and preference of psychological treatments is important in understanding patient treatment seeking, choice, engagement and attrition and possibly treatment response in health care. The acceptability of, and preference for, 14 different types of psychological treatment for posttraumatic stress disorder (PTSD) were investigated in a student population through invitation to participate in a web-based survey. Respondents were asked to rate each treatment on 10 scales and to rank the treatments in order of preference. Respondents were also asked whether they would seek treatment themselves, recommend treatment to friends and family, feel stigmatised by suffering from PTSD, had any prior knowledge of the treatments and if this had been positive or negative and whether they had a history of psychological problems or treatment. A total of 330 respondents completed the survey. A past or current history of psychological problems and treatment was surprisingly high. Almost all respondents indicated that they would seek or recommend treatment in spite of high levels of stigmatisation. Factor analysis of the 10 scales indicated two factors: Endorsement and Discomfort. Rank ordering on preference and Endorsement scores was highly consistent. The highly preferred and endorsed treatments involved cognitive therapy, exposure or psycho-education in spite of high levels of discomfort anticipated with exposure. Treatments involving new technologies, EMDR and psychodynamic psychotherapy received the lowest Endorsement and preference. There was a modest influence of prior knowledge of a treatment.

Technological innovations in clinical assessment and psychotherapy

In this paper the application of computer technology and the use of the Internet in mental health care are critically reviewed. A number of on-line screening devices have been developed for anxiety disorders, mood disorders, and substance abuse disorders, with great potential for clinical practice. On line assessment is generally equivalent to clinical assessment. A number of studies have shown that self-help treatment programmes on stand-alone computers are as effective as routine clinical care. The Internet enhances the therapeutic possibilities of computers by offering feedback of therapists and more tailor-made treatment. A number of randomized clinical trials (RCTs) have shown that Internet-based treatment is more effective than no-treatment and as effective as face-to-face treatment. Research so far has been limited to anxiety disorders, burn-out, depression, headache, insomnia, tinnitus and obesity. Further, exposure through virtual reality has been found effective in a number of RCTs in specific phobias, but results with respect to the effects of the use of virtual reality techniques to other disorders are inconclusive. It is concluded that computer-driven assessment and treatment has many advantages and few disadvantages. A number of reasons are discussed which will preclude large-scale implementation of computer-driven assessment and therapy in the near future.

An Internet-based self-change program for traumatic event related fear, distress, and maladaptive coping

This study compared the efficacy of an Internet-based, 8-week self-help program for traumatic event-related consequences (SHTC) (n = 13) to a wait-list (WL) condition (n = 14). The SHTC consisted of cognitive-behavioral modules that progressed from the least anxiety-provoking component (i.e., information) to the most anxiety-provoking (i.e., exposure). Participants were those who had experienced a traumatic event and had been experiencing subclinical levels of symptoms associated with the event. Participants mastered the material in each module before proceeding to the next module. Pre- and post-treatment assessments revealed that SHTC participants decreased avoidance behavior, frequency of intrusive symptoms, state anxiety, and depressive symptoms, and increased coping skills and coping self-efficacy significantly more than WL participants. SHTC participants demonstrated more clinically significant improvement than WL individuals.

Bandwidth constraints to using video and other rich media in behavior change websites

Background

Web-based behavior change interventions often include rich media (eg, video, audio, and large graphics). The rationale for using rich media includes the need to reach users who are not inclined or able to use text-based website content, encouragement of program engagement, and following the precedent set by news and sports websites.

Objectives

We describe the development of a bandwidth usage index, which seeks to provide a practical method to gauge the extent to which websites can successfully be used within different Internet access scenarios (eg, dial-up and broadband).

Methods

We conducted three studies to measure bandwidth consumption. In Study 1, we measured the bandwidth usage index for three video-rich websites (for smoking cessation, for caregivers, and for improving eldercare by family members). We then estimated the number of concurrent users that could be accommodated by each website under various Internet access scenarios. In Study 2, we sought to validate our estimated threshold number of concurrent users by testing the video-rich smoking cessation website with different numbers of concurrent users. In Study 3, we calculated the bandwidth usage index and threshold number of concurrent users for three versions of the smoking cessation website: the video-rich version (tested in Study 1), an audio-rich version, and a Web-enabled CD-ROM version in which all media-rich content was placed on a CD-ROM on the client computer.

Results

In Study 1, we found that the bandwidth usage index of the video-rich websites ranged from 144 Kbps to 93 Kbps. These results indicated that dial-up modem users would not achieve a “good user experience” with any of the three rich media websites. Results for Study 2 confirmed that usability was compromised when the estimated threshold number of concurrent users was exceeded. Results for Study 3 indicated that changing a website from video- to audio-rich content reduced the bandwidth requirement by almost 50%, but it remained too large to allow satisfactory use in dial-up modem scenarios. The Web-enabled CD-ROM reduced bandwidth requirements such that even a dial-up modem user could have a good user experience with the rich media content.

Conclusions

We conclude that the bandwidth usage index represents a practical tool that can help developers and researchers to measure the bandwidth requirements of their websites as well as to evaluate the feasibility of certain website designs in terms of specific use cases. These findings are discussed in terms of reaching different groups of users as well accommodating the intended number of concurrent users. We also discuss the promising option of using Web-enabled CD-ROMs to deliver rich media content to users with dial-up Internet access. We introduce a number of researchable themes for improving our ability to develop Web-based behavior change interventions that can better deliver what they promise.

The information architecture of behavior change websites

The extraordinary growth in Internet use offers researchers important new opportunities to identify and test new ways to deliver effective behavior change programs. The information architecture (IA)—the structure of website information—is an important but often overlooked factor to consider when adapting behavioral strategies developed in office-based settings for Web delivery. Using examples and relevant perspectives from multiple disciplines, we describe a continuum of website IA designs ranging from a matrix design to the tunnel design. The free-form matrix IA design allows users free rein to use multiple hyperlinks to explore available content according to their idiosyncratic interests. The more directive tunnel IA design (commonly used in e-learning courses) guides users step-by-step through a series of Web pages that are arranged in a particular order to improve the chances of achieving a goal that is measurable and consistent. Other IA designs are also discussed, including hierarchical IA and hybrid IA designs. In the hierarchical IA design, program content is arranged in a top-down manner, which helps the user find content of interest. The more complex hybrid IA design incorporates some combination of components that use matrix, tunnel, and/or hierarchical IA designs. Each of these IA designs is discussed in terms of usability, participant engagement, and program tailoring, as well as how they might best be matched with different behavior change goals (using Web-based smoking cessation interventions as examples). Our presentation underscores the role of considering and clearly reporting the use of IA designs when creating effective Web-based interventions. We also encourage the adoption of a multidisciplinary perspective as we move towards a more mature view of Internet intervention research.

Psychological treatment of post-traumatic stress disorder (PTSD)

BACKGROUND

Psychological interventions are widely used in the treatment of post-traumatic stress disorder (PTSD).

OBJECTIVES

To perform a systematic review of randomised controlled trials of all psychological treatments except eye movement desensitisation and reprocessing following the guidelines of the Cochrane Collaboration.

SEARCH STRATEGY

Systematic searches of computerised databases, hand search of the Journal of Traumatic Stress, searches of reference lists, known websites and discussion fora, and personal communication with key workers.

SELECTION CRITERIA

Types of studies - Any randomised controlled trial of a psychological treatment. Types of participants - Adults suffering from traumatic stress symptoms for three months or more. Types of interventions - Trauma-focused cognitive behavioural therapy/exposure therapy (TFCBT); stress management (SM); other therapies (supportive therapy, non-directive counselling, psychodynamic therapy and hypnotherapy); group cognitive behavioural therapy (group CBT). Types of outcomes - Severity of clinician rated traumatic stress symptoms. Secondary measures included self-reported traumatic stress symptoms, depressive symptoms, anxiety symptoms, adverse effects and dropouts.

DATA COLLECTION AND ANALYSIS

Data was entered using the Review Management software. Quality assessments were performed. The data were analysed for summary effects using the RevMan 4.2 programme.

MAIN RESULTS

Twenty-nine studies were included in the review. With regards to reduction of clinician assessed PTSD symptoms TFCBT did significantly better than waitlist/usual care (standardised mean difference (SMD) = -1.36; 95% CI, -1.88 to -0.84; 13 studies; n = 609). There was no significant difference between TFCBT and SM (SMD = -0.27; 95% CI, -0.71 to 0.16; 6 studies; n = 239). TFCBT did significantly better than other therapies (SMD = -0.81; 95% CI, -1.19 to -0.42; 3 studies; n = 120). Stress management did significantly better than waitlist/usual care (SMD = -1.14; 95% CI, -1.62 to -0.67; 3 studies; n = 86) and than other therapies (SMD = -1.22; 95% CI, -2.09 to -0.35; 1 study; n = 25). There was no significant difference between other therapies and waitlist/usual care control (SMD = -0.43; 95% CI, -0.90 to 0.04; 2 studies; n = 72). Group TFCBT was significantly better than waitlist/usual care (SMD = -0.72; 95% CI, -1.14 to -0.31).

AUTHORS' CONCLUSIONS

There was evidence that individual TFCBT, stress management and group TFCBT are effective in the treatment of PTSD. Other non-trauma focused psychological treatments did not reduce PTSD symptoms as significantly. There was some evidence that individual TFCBT is superior to stress management in the treatment of PTSD at between 2 and 5 months following treatment, and also that TFCBT was also more effective than other therapies. There was insufficient evidence to determine whether psychological treatment is harmful. There was some evidence of greater drop-out in active treatment groups.

Usage and longitudinal effectiveness of a Web-based self-help cognitive behavioral therapy program for panic disorder

BACKGROUND

Anxiety disorders are common problems that result in enormous suffering and economic costs. The efficacy of Web-based self-help approaches for anxiety disorders has been demonstrated in a number of controlled trials. However, there is little data regarding the patterns of use and effectiveness of freely available Web-based interventions outside the context of controlled trials.

OBJECTIVE

To examine the use and longitudinal effectiveness of a freely available, 12-session, Web-based, cognitive behavioral therapy (CBT) program for panic disorder and agoraphobia.

METHODS

Cumulative anonymous data were analyzed from 99695 users of the Panic Center. Usage statistics for the website were examined and a longitudinal survey of self-reported symptoms for people who registered for the CBT program was conducted. The primary outcome measures were self-reported panic-attack frequency and severity at the beginning of each session (sessions 2-12).

RESULTS

Between September 1, 2002 and February 1, 2004, there were 484695 visits and 1148097 page views from 99695 users to the Panic Center. In that same time period, 1161 users registered for the CBT program. There was an extremely high attrition rate with only 12 (1.03%) out of 1161 of registered users completing the 12-week program. However, even for those who remained in the program less than 12 weeks we found statistically significant reductions (P<.002) in self-reported panic attack frequency and severity, comparing 2 weeks of data against data after 3, 6, or 8 weeks. For example, the 152 users completing only 3 sessions of the program reduced their average number of attacks per day from 1.03 (week 2) to 0.63 (week 3) (P<.001).

CONCLUSIONS

Freely available Web-based self-help will likely be associated with high attrition. However, for the highly self-selected group who stayed in the program, significant improvements were observed.

Feasibility of collecting diary data from asthma patients through mobile phones and SMS (short message service): response rate analysis and focus group evaluation from a pilot study

Background

Self-management of asthma may improve asthma outcomes. The Internet has been suggested as a tool for the monitoring and self-management of asthma. However, in a recent study we found that a Web interface had some disadvantages and that users stopped using the application after a short while.

Objective

The primary objective of this study was to evaluate, from a user perspective, the feasibility of using short message service (SMS) for asthma diary data collection through mobile phones. The secondary objective was to investigate patient compliance with an SMS diary, as measured by response rates over time.

Methods

The study included quantitative response rate data, based on SMS collection, and qualitative data from a traditional focus group setting. In a period of 2 months, the participants received 4 SMS messages each day, including a medication reminder, a request to enter peak flow, data on sleep loss, and medication dosage. Participants were asked to reply to a minimum of 3 of the messages per day. Diary inputs were collected in a database and the response rate per patient was expressed as the number of diary inputs (SMS replies) divided by diary requests (product of number of days in the study and the number of diary questions per day) for each participant. After the study period, the participants were invited to a focus group interview addressing the participants' attitudes to their disease, their experience with the SMS asthma diary, and their future expectations from the SMS asthma diary.

Results

Twelve patients with asthma (6 males, 6 females) participated in the data collection study. The median age was 38.5 (range: 13 – 57) years. The median response rate per patient was 0.69 (range: 0.03 – 0.98), ie, half the participants reported more than about two thirds of the requested diary data. Furthermore, response rates were relatively steady during the study period with no signs of decreasing usage over time. From the subsequent focus group interview with 9 users we learned that, in general, the participants were enthusiastic about the SMS diary – it became an integrated part of their everyday life. However, the participants wished for a simpler diary with only one SMS message to respond to and a system with a Web interface for system customization and graphical display of diary data history.

Conclusion

This study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases) in motivated and self-efficacious patients because mobile phones are a part of people's everyday lives and enable active requests for data wherever the patient is. The combination of SMS data collection and a traditional Web page for data display and system customization may be a better and more usable tool for patients than the use of Web-based asthma diaries which suffer from high attrition rates.

The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes

Background

A primary focus of self-care interventions for chronic illness is the encouragement of an individual's behavior change necessitating knowledge sharing, education, and understanding of the condition. The use of the Internet to deliver Web-based interventions to patients is increasing rapidly. In a 7-year period (1996 to 2003), there was a 12-fold increase in MEDLINE citations for “Web-based therapies.” The use and effectiveness of Web-based interventions to encourage an individual's change in behavior compared to non-Web-based interventions have not been substantially reviewed.

Objective

This meta-analysis was undertaken to provide further information on patient/client knowledge and behavioral change outcomes after Web-based interventions as compared to outcomes seen after implementation of non-Web-based interventions.

Methods

The MEDLINE, CINAHL, Cochrane Library, EMBASE, ERIC, and PSYCHInfo databases were searched for relevant citations between the years 1996 and 2003. Identified articles were retrieved, reviewed, and assessed according to established criteria for quality and inclusion/exclusion in the study. Twenty-two articles were deemed appropriate for the study and selected for analysis. Effect sizes were calculated to ascertain a standardized difference between the intervention (Web-based) and control (non-Web-based) groups by applying the appropriate meta-analytic technique. Homogeneity analysis, forest plot review, and sensitivity analyses were performed to ascertain the comparability of the studies.

Results

Aggregation of participant data revealed a total of 11,754 participants (5,841 women and 5,729 men). The average age of participants was 41.5 years. In those studies reporting attrition rates, the average drop out rate was 21% for both the intervention and control groups. For the five Web-based studies that reported usage statistics, time spent/session/person ranged from 4.5 to 45 minutes. Session logons/person/week ranged from 2.6 logons/person over 32 weeks to 1008 logons/person over 36 weeks. The intervention designs included one-time Web-participant health outcome studies compared to non-Web participant health outcomes, self-paced interventions, and longitudinal, repeated measure intervention studies. Longitudinal studies ranged from 3 weeks to 78 weeks in duration. The effect sizes for the studied outcomes ranged from -.01 to .75. Broad variability in the focus of the studied outcomes precluded the calculation of an overall effect size for the compared outcome variables in the Web-based compared to the non-Web-based interventions. Homogeneity statistic estimation also revealed widely differing study parameters (Q_w16 = 49.993, P ≤ .001). There was no significant difference between study length and effect size. Sixteen of the 17 studied effect outcomes revealed improved knowledge and/or improved behavioral outcomes for participants using the Web-based interventions. Five studies provided group information to compare the validity of Web-based vs. non-Web-based instruments using one-time cross-sectional studies. These studies revealed effect sizes ranging from -.25 to +.29. Homogeneity statistic estimation again revealed widely differing study parameters (Q_w4 = 18.238, P ≤ .001).

Conclusions

The effect size comparisons in the use of Web-based interventions compared to non-Web-based interventions showed an improvement in outcomes for individuals using Web-based interventions to achieve the specified knowledge and/or behavior change for the studied outcome variables. These outcomes included increased exercise time, increased knowledge of nutritional status, increased knowledge of asthma treatment, increased participation in healthcare, slower health decline, improved body shape perception, and 18-month weight loss maintenance.