Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review

Feasibility of a personal health technology-based psychological intervention for men with stress and mood problems: randomized controlled pilot trial

BACKGROUND

Work-related stress is a significant problem for both people and organizations. It may lead to mental illnesses such as anxiety and depression, resulting in increased work absences and disabilities. Scalable interventions to prevent and manage harmful stress can be delivered with the help of technology tools to support self-observations and skills training.

OBJECTIVE

The aim of this study was to assess the feasibility of the P4Well intervention in treatment of stress-related psychological problems. P4Well is a novel intervention which combines modern psychotherapy (the cognitive behavioral therapy and the acceptance and commitment therapy) with personal health technologies to deliver the intervention via multiple channels, includinggroup meetings, Internet/Web portal, mobile phone applications, and personal monitoring devices.

METHODS

This pilot study design was a small-scale randomized controlled trial that compared the P4Well intervention with a waiting list control group. In addition to personal health technologies for self-assessment, the intervention consisted of 3 psychologist-assisted group meetings. Self-assessed psychological measures through questionnaires were collected offline pre- and post-intervention, and 6 months after the intervention for the intervention group. Acceptance and usage of technology tools were measured with user experience questionnaires and usage logs.

RESULTS

A total of 24 subjects were randomized: 11 participants were followed up in the intervention group (1 was lost to follow-up) and 12 participants did not receive any intervention (control group). Depressive and psychological symptoms decreased and self-rated health and working ability increased. All participants reported they had benefited from the intervention. All technology tools had active users and 10/11 participants used at least 1 tool actively. Physiological measurements with personal feedback were considered the most useful intervention component.

CONCLUSIONS

Our results confirm the feasibility of the intervention and suggest that it had positive effects on psychological symptoms, self-rated health, and self-rated working ability. The intervention seemed to have a positive impact on certain aspects of burnout and job strain, such as cynicism and over-commitment. Future studies need to investigate the effectiveness, benefits, and possible problems of psychological interventions which incorporate new technologies.

TRIAL REGISTRATION

The Finnish Funding Agency for Technology and Innovation (TEKES), Project number 40011/08.

Health information, behavior change, and decision support for patients with type 2 diabetes: development of a tailored, preference-sensitive health communication application

PURPOSE

Patient involvement in diabetes treatment such as shared decision-making and patient self-management has significant effects on clinical parameters. As a prerequisite for active involvement, patients need to be informed in an adequate and preference-sensitive way. Interactive Health Communication Applications (IHCAs) that combine web-based health information for patients with additional support offer the opportunity to reach great numbers of patients at low cost and provide them with high-quality information and support at the time, place, and learning speed they prefer. Still, web-based interventions often suffer from high attrition. Tailoring the intervention to patients' needs and preferences might reduce attrition and should thereby increase effectiveness. The purpose of this study was to develop a tailored IHCA offering evidence-based, preference-sensitive content and treatment decision support to patients with type 2 diabetes. The content was developed based on a needs assessment and two evidence-based treatment guidelines. The delivery format is a dialogue-based, tunneled design tailoring the content and tone of the dialogue to relevant patient characteristics (health literacy, attitudes toward self-care, and psychological barriers to insulin treatment). Both content and tailoring were revised by an interdisciplinary advisory committee.

CONCLUSION

The World Wide Web holds great potential for patient information and self-management interventions. With the development and evaluation of a tailored IHCA, we complement face-to-face consultations of patients with their health care practitioners and make them more efficient and satisfying for both sides. Effects of the application are currently being tested within a randomized controlled trial.

Consumer acceptance of an SMS-assisted smoking cessation intervention: a multicountry study

This study assesses smokers' perceptions, motivations, and intentions towards using an SMS-assisted smoking cessation intervention in Australia, France, and Mexico through an extended technology acceptance model with mediating variables. Data was collected through online surveys. Results show that perceived usefulness and vicarious innovativeness predict use intentions for all three countries. Perceived ease of use is significant only for Mexico. Subjective norms are significant only for Mexico and Australia. Perceived monetary value and perceived annoyance are significant mediating variables for all three countries, whereas perceived enjoyment is significant only for Mexico and Australia. These results contribute to theory and practice.

Mindless eating challenge: retention, weight outcomes, and barriers for changes in a public web-based healthy eating and weight loss program

Background

Most dietary programs fail to produce lasting outcomes because participants soon return to their old habits. Small behavioral and environmental changes based on simple heuristics may have the best chance to lead to sustainable habit changes over time.

Objective

To evaluate participant retention, weight outcomes, and barriers for changes in a publicly available web-based healthy eating and weight loss program.

Methods

The National Mindless Eating Challenge (NMEC) was a publicly available, online healthy eating and weight loss program with ongoing recruitment of participants. This volunteer sample consisted of 2053 participants (mean age 39.8 years, 89% female, 90% white/Caucasian, BMI mean 28.14). Participants completed an initial profiling survey and were assigned three targeted habit change suggestions (tips). After each month, participants were asked to complete a follow-up survey and then receive new suggestions for the subsequent month.

Results

In terms of overall attrition, 75% (1549/2053) of participants who completed the intake survey never returned to follow up. Overall mean weight loss among returning participants was 0.4% of initial weight (P=.019). Participants who stayed in the program at least three calendar months and completed at least two follow-up surveys (38%, 189/504) lost on average 1.8 lbs (1.0%) of their initial weight over the course of the program (P=.009). Furthermore, participants who reported consistent adherence (25+ days/month) to the suggested changes reported an average monthly weight loss of 2.0 lbs (P<.001). Weight loss was less for those who discontinued after 1-2 months or who did not adhere to the suggested changes. Participants who reported having lost weight reported higher monthly adherence to suggestions (mean 14.9 days, SD 7.92) than participants who maintained (mean 12.4 days, SD 7.63) or gained weight (mean 12.0 days, SD 7.50; F=14.17, P<.001). Common reported barriers for changes included personally unsuitable or inapplicable suggestions, forgetting or being too busy to implement changes, unusual circumstances, and emotional eating.

Conclusions

Because the bulk of the free and commercially available online diet and nutritional tools conduct no evaluation research, it is difficult to determine which aspects of a program are successful and what are reasonable expectations of results. The results of this study suggest that online interventions based on small changes have the potential to gradually lead to clinically significant weight loss, but high attrition from publically available or “free” programs still remains a challenge. Adherence to and effectiveness of small habit changes may be improved through further tailoring to individual circumstances and psychological needs.

Can multiple lifestyle behaviours be improved in people with familial hypercholesterolemia? Results of a parallel randomised controlled trial

OBJECTIVE

To evaluate the efficacy of an individualised tailored lifestyle intervention on physical activity, dietary intake, smoking and compliance to statin therapy in people with Familial Hypercholesterolemia (FH).

METHODS

Adults with FH (n = 340) were randomly assigned to a usual care control group or an intervention group. The intervention consisted of web-based tailored lifestyle advice and face-to-face counselling. Physical activity, fat, fruit and vegetable intake, smoking and compliance to statin therapy were self-reported at baseline and after 12 months. Regression analyses were conducted to examine between-group differences. Intervention reach, dose and fidelity were assessed.

RESULTS

In both groups, non-significant improvements in all lifestyle behaviours were found. Post-hoc analyses showed a significant decrease in saturated fat intake among women in the intervention group (β = -1.03; CI -1.98/-0.03). In the intervention group, 95% received a log on account, of which 49% logged on and completed one module. Nearly all participants received face-to-face counselling and on average, 4.2 telephone booster calls. Intervention fidelity was low.

CONCLUSIONS

Individually tailored feedback is not superior to no intervention regarding changes in multiple lifestyle behaviours in people with FH. A higher received dose of computer-tailored interventions should be achieved by uplifting the website and reducing the burden of screening questionnaires. Counsellor training should be more extensive.

TRIAL REGISTRATION

Dutch Trial Register NTR1899.

Increasing physical activity with mobile devices: a meta-analysis

Background

Regular physical activity has established physical and mental health benefits; however, merely one quarter of the U.S. adult population meets national physical activity recommendations. In an effort to engage individuals who do not meet these guidelines, researchers have utilized popular emerging technologies, including mobile devices (ie, personal digital assistants [PDAs], mobile phones). This study is the first to synthesize current research focused on the use of mobile devices for increasing physical activity.

Objective

To conduct a meta-analysis of research utilizing mobile devices to influence physical activity behavior. The aims of this review were to: (1) examine the efficacy of mobile devices in the physical activity setting, (2) explore and discuss implementation of device features across studies, and (3) make recommendations for future intervention development.

Methods

We searched electronic databases (PubMed, PsychINFO, SCOPUS) and identified publications through reference lists and requests to experts in the field of mobile health. Studies were included that provided original data and aimed to influence physical activity through dissemination or collection of intervention materials with a mobile device. Data were extracted to calculate effect sizes for individual studies, as were study descriptives. A random effects meta-analysis was conducted using the Comprehensive Meta-Analysis software suite. Study quality was assessed using the quality of execution portion of the Guide to Community Preventative Services data extraction form.

Results

Four studies were of “good” quality and seven of “fair” quality. In total, 1351 individuals participated in 11 unique studies from which 18 effects were extracted and synthesized, yielding an overall weight mean effect size of g = 0.54 (95% CI = 0.17 to 0.91, P = .01).

Conclusions

Research utilizing mobile devices is gaining in popularity, and this study suggests that this platform is an effective means for influencing physical activity behavior. Our focus must be on the best possible use of these tools to measure and understand behavior. Therefore, theoretically grounded behavior change interventions that recognize and act on the potential of smartphone technology could provide investigators with an effective tool for increasing physical activity.

Persuasive system design does matter: a systematic review of adherence to web-based interventions

Background

Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed. Technology as a means to communicate the content in web-based interventions has been neglected in research. Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content. In this paper we examine technology from a holistic perspective. We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence.

Objective

This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention.

Methods

We conducted a systematic review of studies into web-based health interventions. Per intervention, intervention characteristics, persuasive technology elements and adherence were coded. We performed a multiple regression analysis to investigate whether these variables could predict adherence.

Results

We included 101 articles on 83 interventions. The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention. Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 2.9 out of a possible 7.0). Dialogue support and social support are less commonly employed (mean 1.5 and 1.2 out of a possible 7.0, respectively). When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = .004), setup (p < .001), updates (p < .001), frequency of interaction with a counselor (p < .001), the system (p = .003) and peers (p = .017), duration (F = 6.068, p = .004), adherence (F = 4.833, p = .010) and the number of primary task support elements (F = 5.631, p = .005). Our final regression model explained 55% of the variance in adherence. In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence.

Conclusions

Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained. Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence. Rather, the differences in technology and interaction predict adherence. The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere.

Using a resource effect study pre-pilot to inform a large randomized trial: the Decide2Quit.Org Web-assisted tobacco intervention

Resource effect studies can be useful in highlighting areas of improvement in informatics tools. Before a large randomized trial, we tested the functions of the Decide2Quit.org Web-assisted tobacco intervention using smokers (N=204) recruited via Google advertisements. These smokers were given access to Decide2Quit.org for six months and we tracked their usage and assessed their six months cessation using a rigorous follow-up. Multiple, interesting findings were identified: we found the use of tailored emails to dramatically increase participation for a short period. We also found varied effects of the different functions. Functions supporting "seeking social support" (Your Online Community and Family Tools), Healthcare Provider Tools, and the Library had positive effects on quit outcomes. One surprising finding, which needs further investigation, was that writing to our Tobacco Treatment Specialists was negatively associated with quit outcomes.

A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the internet

ISSUES

The use of alcohol and drugs amongst young people is a serious concern and the need for effective prevention is clear. This paper identifies and describes current school-based alcohol and other drug prevention programs facilitated by computers or the Internet.

APPROACH

The Cochrane Library, PsycINFO and PubMed databases were searched in March 2012. Additional materials were obtained from reference lists of papers. Studies were included if they described an Internet- or computer-based prevention program for alcohol or other drugs delivered in schools.

KEY FINDINGS

Twelve trials of 10 programs were identified. Seven trials evaluated Internet-based programs and five delivered an intervention via CD-ROM. The interventions targeted alcohol, cannabis and tobacco. Data to calculate effect size and odds ratios were unavailable for three programs. Of the seven programs with available data, six achieved reductions in alcohol, cannabis or tobacco use at post intervention and/or follow up. Two interventions were associated with decreased intentions to use tobacco, and two significantly increased alcohol and drug-related knowledge.

CONCLUSION

This is the first study to review the efficacy of school-based drug and alcohol prevention programs delivered online or via computers. Findings indicate that existing computer- and Internet-based prevention programs in schools have the potential to reduce alcohol and other drug use as well as intentions to use substances in the future. These findings, together with the implementation advantages and high fidelity associated with new technology, suggest that programs facilitated by computers and the Internet offer a promising delivery method for school-based prevention.

Exploring the reach and program use of Hello World, an email-based health promotion program for pregnant women in the Netherlands

Background

In 2006, the Dutch government initiated Hello World, an email-based program promoting healthy lifestyles among pregnant women through quizzes with pregnancy-related questions. In 2008, an updated version was released.

The present study aimed to (1) examine the reach of Hello World and the representativeness of its users for all pregnant women in the Netherlands, (2) explore the relationship between program engagement and lifestyle characteristics, and (3) explore the relationship between the program content participants accessed (content on smoking, physical activity, and nutrition) and their lifestyle characteristics.

Methods

Data from 4,363 pregnant women were included. After registration, women received an online questionnaire with demographic and lifestyle questions. To evaluate their representativeness, their demographic characteristics were compared with existing data for Dutch (pregnant) women. Women were classified on the following lifestyle characteristics: smoking, nutrition, physical activity, and pre-pregnancy weight status. Program use was tracked and the relationships between lifestyle characteristics, program engagement, and the percentage of smoking, physical activity, and nutrition questions accessed after opening a quiz were explored using Mann–Whitney U tests and Kruskal-Wallis tests.

Results

Hello World reached ±4% of its target population. Ten percent of participants were low educated and 22% immigrants. On average, women received 6.1 (SD:2.8) quiz emails and opened 32% of the associated quizzes (2.0, SD:2.1). A significant positive association was found between the number of quizzes opened and the number of healthy lifestyle characteristics. After opening a quiz, women accessed most smoking, nutrition, and physical activity questions. Significant relationships were found between several lifestyle characteristics and the percentage of smoking, physical activity, and nutrition questions accessed. However, between-group differences were small, quiz topics were largely unrelated to their lifestyle characteristics, and inconsistencies were found regarding the directions of these associations.

Conclusions

Hello World reached ±4% of its target population, which is lower than the reach of its previous version (±8%). Relatively few low educated and immigrant women registered for the program. Active participation in the program was positively associated with the number of healthy behaviours participants engaged in. The program content participants chose to access was largely unrelated to their lifestyle characteristics.

Computer skills and internet use in adults aged 50-74 years: influence of hearing difficulties

BACKGROUND

The use of personal computers (PCs) and the Internet to provide health care information and interventions has increased substantially over the past decade. Yet the effectiveness of such an approach is highly dependent upon whether the target population has both access and the skill set required to use this technology. This is particularly relevant in the delivery of hearing health care because most people with hearing loss are over 50 years (average age for initial hearing aid fitting is 74 years). Although PC skill and Internet use by demographic factors have been examined previously, data do not currently exist that examine the effects of hearing difficulties on PC skill or Internet use in older adults.

OBJECTIVE

To explore the effect that hearing difficulty has on PC skill and Internet use in an opportunistic sample of adults aged 50-74 years.

METHODS

Postal questionnaires about hearing difficulty, PC skill, and Internet use (n=3629) were distributed to adults aged 50-74 years through three family physician practices in Nottingham, United Kingdom. A subsample of 84 respondents completed a second detailed questionnaire on confidence in using a keyboard, mouse, and track pad. Summed scores were termed the "PC confidence index." The PC confidence index was used to verify the PC skill categories in the postal questionnaire (ie, never used a computer, beginner, and competent).

RESULTS

The postal questionnaire response rate was 36.78% (1298/3529) and 95.15% (1235/1298) of these contained complete information. There was a significant between-category difference for PC skill by PC confidence index (P<.001), thus verifying the three-category PC skill scale. PC and Internet use was greater in the younger respondents (50-62 years) than in the older respondents (63-74 years). The younger group's PC and Internet use was 81.0% and 60.9%, respectively; the older group's PC and Internet use was 54.0% and 29.8%, respectively. Those with slight hearing difficulties in the older group had significantly greater odds of PC use compared to those with no hearing difficulties (odds ratio [OR]=1.57, 95% confidence interval [CI] 1.06-2.30, P=.02). Those with moderate+ hearing difficulties had lower odds of PC use compared with those with no hearing difficulties, both overall (OR=0.58, 95% CI 0.39-0.87, P=.008) and in the younger group (OR=0.49, 95% CI 0.26-0.86, P=.008). Similar results were demonstrated for Internet use by age group (older: OR=1.57, 95% CI 0.99-2.47, P=.05; younger: OR=0.32, 95% CI 0.16-0.62, P=.001).

CONCLUSIONS

Hearing health care is of particular relevance to older adults because of the prevalence of age-related hearing loss. Our data show that older adults experiencing slight hearing difficulty have increased odds of greater PC skill and Internet use than those reporting no difficulty. These findings suggest that PC and Internet delivery of hearing screening, information, and intervention is feasible for people between 50-74 years who have hearing loss, but who would not typically present to an audiologist.

Electronic reminders for cancer prevention: factors associated with preference for automated voice reminders or text messages

OBJECTIVE

Prompting may promote engagement with behavior change interventions. Prompts can be delivered inexpensively via automated voice response (AVR) reminders or short message service (SMS) text messages. We examined the association between participants' characteristics and preferred reminder modality.

METHODS

Healthy Directions 2 is a cluster randomized controlled trial implemented in Boston, Massachusetts to promote change in multiple behavioral cancer risk factors. At baseline (2009), participants completed a survey assessing socio-demographics, health status, height/weight, and factors associated with technology. One-third of participants randomized to receive the intervention (n=598) were randomized to receive automated reminders, with participants selecting modality.

RESULTS

28% (167/598) of participants selected SMS reminders. Controlling for clustering by primary care provider, younger participants (OR=0.97, 95% CI=(0.95, 0.99), p<0.01), those most comfortable with computers (very uncomfortable OR=0.54, 95% CI=(0.29, 1.01), p≤0.05: referent group = very comfortable), and those who frequently sent/received text messages (never OR=0.09 CI=(0.04, 0.16) p<0.01; 1-3 times/month OR=0.38, 95% CI=(0.15, 0.93) p=0.04: referent group=1-5 times/week) were more likely to choose SMS.

CONCLUSIONS

Interventions should make both modalities available to ensure that more participants can benefit from prompting. Studies examining the effect of automated reminders may have reduced effectiveness or generalizability if they employ only one modality.

Active assistance technology for health-related behavior change: an interdisciplinary review

Background

Information technology can help individuals to change their health behaviors. This is due to its potential for dynamic and unbiased information processing enabling users to monitor their own progress and be informed about risks and opportunities specific to evolving contexts and motivations. However, in many behavior change interventions, information technology is underused by treating it as a passive medium focused on efficient transmission of information and a positive user experience.

Objective

To conduct an interdisciplinary literature review to determine the extent to which the active technological capabilities of dynamic and adaptive information processing are being applied in behavior change interventions and to identify their role in these interventions.

Methods

We defined key categories of active technology such as semantic information processing, pattern recognition, and adaptation. We conducted the literature search using keywords derived from the categories and included studies that indicated a significant role for an active technology in health-related behavior change. In the data extraction, we looked specifically for the following technology roles: (1) dynamic adaptive tailoring of messages depending on context, (2) interactive education, (3) support for client self-monitoring of behavior change progress, and (4) novel ways in which interventions are grounded in behavior change theories using active technology.

Results

The search returned 228 potentially relevant articles, of which 41 satisfied the inclusion criteria. We found that significant research was focused on dialog systems, embodied conversational agents, and activity recognition. The most covered health topic was physical activity. The majority of the studies were early-stage research. Only 6 were randomized controlled trials, of which 4 were positive for behavior change and 5 were positive for acceptability. Empathy and relational behavior were significant research themes in dialog systems for behavior change, with many pilot studies showing a preference for those features. We found few studies that focused on interactive education (3 studies) and self-monitoring (2 studies). Some recent research is emerging in dynamic tailoring (15 studies) and theoretically grounded ontologies for automated semantic processing (4 studies).

Conclusions

The potential capabilities and risks of active assistance technologies are not being fully explored in most current behavior change research. Designers of health behavior interventions need to consider the relevant informatics methods and algorithms more fully. There is also a need to analyze the possibilities that can result from interaction between different technology components. This requires deep interdisciplinary collaboration, for example, between health psychology, computer science, health informatics, cognitive science, and educational methodology.

Cost-effectiveness of a long-term Internet-delivered worksite health promotion programme on physical activity and nutrition: a cluster randomized controlled trial

This study aims to evaluate the cost-effectiveness of a long-term workplace health promotion programme on physical activity (PA) and nutrition. In total, 924 participants enrolled in a 2-year cluster randomized controlled trial, with departments (n = 74) within companies (n = 6) as the unit of randomization. The intervention was compared with a standard programme consisting of a physical health check with face-to-face advice and personal feedback on a website. The intervention consisted of several additional website functionalities: action-oriented feedback, self-monitoring, possibility to ask questions and monthly e-mail messages. Primary outcomes were meeting the guidelines for PA and fruit and vegetable intake. Secondary outcomes were self-perceived health, obesity, elevated blood pressure, elevated cholesterol level and maximum oxygen uptake. Direct and indirect costs were calculated from a societal perspective, and a process evaluation was performed. Of the 924 participants, 72% participated in the first and 60% in the second follow-up. No statistically significant differences were found on primary and secondary outcomes, nor on costs. Average direct costs per participant over the 2-year period were €376, and average indirect costs were €9476. In conclusion, no additional benefits were found in effects or cost savings. Therefore, the programme in its current form cannot be recommended for implementation.

Is the process of delivery of an individually tailored lifestyle intervention associated with improvements in LDL cholesterol and multiple lifestyle behaviours in people with familial hypercholesterolemia?

Background

More insight in the association between reach, dose and fidelity of intervention components and effects is needed. In the current study, we aimed to evaluate reach, dose and fidelity of an individually tailored lifestyle intervention in people with Familial Hypercholesterolemia (FH) and the association between intervention dose and changes in LDL-Cholesterol (LDL-C), and multiple lifestyle behaviours at 12-months follow-up.

Methods

Participants (n = 181) randomly allocated to the intervention group received the PRO-FIT intervention consisting of computer-tailored lifestyle advice (PRO-FIT*advice) and counselling (face-to-face and telephone booster calls) using Motivational Interviewing (MI). According to a process evaluation plan, intervention reach, dose delivered and received, and MI fidelity were assessed using the recruitment database, website/counselling logs and the Motivational Interviewing Treatment Integrity (MITI 3.1.1.) code. Regression analyses were conducted to explore differences between participant and non-participant characteristics, and the association between intervention dose and change in LDL-C, and multiple lifestyle behaviours.

Results

A 34% (n = 181) representative proportion of the intended intervention group was reached during the recruitment phase; participants did not differ from non-participants (n = 623) on age, gender and LDL-C levels. Of the participants, 95% received a PRO-FIT*advice log on account, of which 49% actually logged on and completed at least one advice module. Nearly all participants received a face-to-face counselling session and on average, 4.2 telephone booster calls were delivered. None of the face-to-face sessions were implemented according to MI guidelines. Overall, weak non-significant positive associations were found between intervention dose and LDL-C and lifestyle behaviours.

Conclusions

Implementation of the PRO-FIT intervention in practice appears feasible, particularly PRO-FIT*advice, since it can be relative easily implemented with a high dose delivered. However, only less than half of the intervention group received the complete intervention-package as intended. Strategies to let participants optimally engage in using web-based computer-tailored interventions like PRO-FIT*advice are needed. Further, more emphasis should be put on more extensive MI training and monitoring/supervision.

Trial registration

NTR1899 at ww.trialregister.nl.

Internet based computer tailored feedback on sunscreen use

Background

Skin cancer incidence rates signify the need for effective programs for the prevention of skin cancer and for helping skin cancer patients. Internet and computer tailored (CT) technology fosters the development of highly individualized health communication messages. Yet, reactions to Internet CT programs may differ per level of involvement and education level and remain understudied.

Objective

First, we identified perceptions concerning sunscreen use in Dutch adults and assessed differences in differences between the general public and skin cancer patients, and between low and high educated respondents. Second, we assessed program evaluations of these groups about a new Dutch CT Internet-based program promoting sunscreen use, and potential differences between groups

Methods

A cross-sectional research design was used. In total, 387 respondents participated and filled out an online questionnaire based on the I-Change Model assessing socio-demographics, history of skin cancer, sunscreen use, and beliefs about sunscreen use. The responses were fed into a computer program that generated personal tailored feedback on screen; next we assessed their program evaluations

Results

Of the 132 patients, 92 were female (69.7%) and 40 were male (30.3%). In the general population (N = 225), 139 (54.5%) respondents were female and 116 (45.5%) were male. Men (50.9 years) were 8 years older than women (43.1 years). Most patients were diagnosed with basal cell carcinoma (N = 65; 49.2%), followed by melanoma (N = 28; 21.2%) and squamous cell carcinoma (N = 10; 7.6%); 22% (N = 29) did not remember their skin cancer type. Patients had higher knowledge levels, felt significantly more at risk, were more convinced of the pros of sunscreen, experienced more social support to use sunscreen, had higher self-efficacy, and made more plans to use sunscreen than respondents without skin cancer (N=255; all P’s< .01). Low (N=196) educated respondents scored lower on knowledge (P<.003) but made more action plans (P<.03) than higher educated respondents (N=191). The CT feedback was evaluated positively by all respondents, and scored a 7.8 on a 10 point scale. Yet, patients evaluated the CT program slightly more (P<.05) positive (8.1) than non-patients. (7.6). Lower educated respondents were significantly (P<.05) more positive about the advantages of the program.

Conclusions

First, involvement with skin cancer was reflected in more positive beliefs toward sunscreen use in patients in comparison with non-patients. Second, the CT Internet program was well accepted by both patients and non-patients, and low and high educated respondents, perhaps because higher educated respondents were more knowledgeable about sunscreen use and skin cancer. Third, a pro-active approach as conducted in our study is very well suited to reach various groups of people and is more likely to be successful than a reactive approach

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.

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.

Initial and sustained participation in an internet-delivered long-term worksite health promotion program on physical activity and nutrition

Background

Determinants of participation in health promotion programs are largely unknown. To evaluate and implement interventions, information is needed regarding their reach as well as regarding the characteristics of program users and non-users.

Objective

In this study, individual, lifestyle, and health indicators were investigated in relation to initial, and sustained participation in an Internet-delivered physical activity and healthy nutrition program in the workplace setting. In addition, determinants of program website use were studied.

Methods

Determinants of participation were investigated in a longitudinal study among employees from six workplaces participating in a two-year cluster randomized controlled trial. The employees were invited by email to participate. At baseline, all participants visited a website to fill out the questionnaire on lifestyle, work, and health factors. Subsequently, a physical health check was offered, followed by face-to-face advice. Throughout the study period, all participants had access to a website with information on lifestyle and health, and to fully automated personalized feedback on the questionnaire results. Only participants in the intervention received monthly email messages to promote website visits during the first year and had access to additional Web-based tools (self-monitors, a food frequency questionnaire assessing saturated fat intake, and the possibility to ask questions) to support behavior change. Website use was monitored by website statistics measuring access. Logistic regression analyses were conducted to identify characteristics of employees who participated in the program and used the website.

Results

Complete baseline data were available for 924 employees (intervention: n=456, reference: n=468). Lifestyle and health factors were not associated with initial participation. Employees aged 30 years and older were more likely to start using the program and to sustain their participation. Workers with a low intention to increase their physical activity level were less likely to participate (Odds Ratio (OR)=0.60, 95% Confidence interval (95%CI), 0.43-0.85) but more likely to sustain participation throughout the study period (ORs ranging from 1.40 to 2.06). Furthermore, it was found that smokers were less likely to sustain their participation in the first and second year (OR=0.54, 95%CI 0.35-0.82) and to visit the website (OR=0.72, 95%CI 0.54-0.96). Website use was highest in the periods immediately after the baseline (73%) and follow-up questionnaires (71% and 87%). Employees in the intervention were more likely to visit the website in the period they received monthly emails (OR=5.88, 95%CI 3.75-9.20) but less likely to visit the website in the subsequent period (OR=0.62, 95%CI 0.45-0.85).

Conclusions

Modest initial participation and high attrition in program use were found. Workers with a low intention to change their behavior were less likely to participate, but once enrolled they were more likely to sustain their participation. Lifestyle and health indicators were not related to initial participation, but those with an unhealthy lifestyle were less likely to sustain. This might influence program effectiveness. Regular email messages prompted website use, but the use of important Web-based tools was modest. There is a need for more appealing techniques to enhance retention and to keep those individuals who need it most attracted to the program.

Trial Registration

ISRCTN52854353; http://www.controlled-trials.com/ISRCTN52854353

The influence of user characteristics and a periodic email prompt on exposure to an internet-delivered computer-tailored lifestyle program

BACKGROUND

The Internet is a promising medium in the field of health promotion for offering tailored and targeted lifestyle interventions applying computer-tailored (CT) techniques to the general public. Actual exposure to CT interventions is not living up to its high expectations, as only a (limited) proportion of the target group is actually using these programs.

OBJECTIVE

To investigate exposure to an Internet-delivered, CT lifestyle intervention, targeting physical activity, fruit and vegetable intake, smoking behavior, and alcohol intake, we focused on three processes: first use, prolonged use, and sustained use. The first objectives were to identify user characteristics that predict initiation of an online CT lifestyle program (first use) and completion of this program (prolonged use). Furthermore, we studied the effect of using a proactive strategy, consisting of periodic email prompts, on program revisits (sustained use).

METHODS

The research population for this study consisted of Dutch adults participating in the Adult Health Monitor, offered by the regional public health services. We used a randomized controlled trial design to assess predictors of first use, prolonged use, and sustained use. Demographics and behavioral characteristics, as well as the strategy used for revisiting, were included as predictors in the model.

RESULTS

A total of 9169 participants indicated their interest in the new program and 5168 actually logged in to the program. Participants significantly more likely to initiate one of the CT modules were male, older, and employed, and had a lower income, higher body mass index, and relatively unhealthy lifestyle. Participants significantly more likely to complete one of the CT modules were older and had a higher income and a relatively healthier lifestyle. Finally, using a proactive strategy influenced sustained use, with people from the prompting condition being more likely to revisit the program (odds ratio 28.92, 95% confidence interval 10.65-78.52; P < .001).

CONCLUSIONS

Older, male, and employed participants, and those with a lower income, higher body mass index, and a relatively unhealthy lifestyle were more likely to initiate a CT module. Module completers predominantly had a higher income and age. The current program therefore succeeded in reaching those people who benefit most from online lifestyle interventions. However, these people tended to disengage from the program. This underlines the importance of additional research into program adjustments and strategies that can be used to stimulate prolonged program use. Furthermore, sending periodic email prompts significantly increased revisits to the program. Though promising, this effect was modest and needs to be further examined, in order to maximize the potential of periodic email prompting.

TRIAL REGISTRATION

Nederlands Trial Register (NTR: 1786) and Medical Ethics Committee of Maastricht University and the University Hospital Maastricht (NL2723506809/MEC0903016); http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1786 (Archived by WebCite at http://www.webcitation.org/65hBXA6V7).

Patient-focused internet interventions in reproductive medicine: a scoping review

BACKGROUND

The Internet has revolutionized fertility care since it became a popular source of information and support for infertile patients in the last decade. The aim of this scoping review is to map (i) the main categories of patient-focused Internet interventions within fertility care, (ii) the detailed composition of the interventions and (iii) how these interventions were evaluated.

METHODS

A literature search used various 'Internet' and 'Infertility' search terms to identify relevant studies published up to 1 September 2011. The selected studies had to include patients facing infertility and using an infertility-related Internet intervention. We charted data regarding categories of interventions, components of interventions and evaluation methodology. We categorized the stages of research using the UK's Medical Research Council framework for evaluating complex interventions.

RESULTS

We included 20 studies and identified 3 educational interventions, 2 self-help interventions, 1 human-supported therapeutic intervention, 9 online support groups and 2 counselling services. Information provision, support and mental health promotion were common aims. Few interactive online components were present in the online programmes. Three studies were in the pilot phase and 17 were in the evaluation phase.

CONCLUSIONS

Several categories of patient-focused Internet-based interventions in fertility care are primarily applied to provide support and education and promote mental health. The interventions could be improved by using more interactive and dynamic elements as their key components. Finally, more emphasis on methodological standards for complex interventions is needed to produce more rigorous evaluations. This review shows where further development or research into patient-focused Internet interventions in fertility-care practice may be warranted.

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.

Identifying factors for optimal development of health-related websites: a delphi study among experts and potential future users

Background

The Internet has become a popular medium for offering tailored and targeted health promotion programs to the general public. However, suboptimal levels of program use in the target population limit the public health impact of these programs. Optimizing program development is considered as one of the main processes to increase usage rates.

Objective

To distinguish factors potentially related to optimal development of health-related websites by involving both experts and potential users. By considering and incorporating the opinions of experts and potential users in the development process, involvement in the program is expected to increase, consequently resulting in increased appreciation, lower levels of attrition, and higher levels of sustained use.

Methods

We conducted a systematic three-round Delphi study through the Internet. Both national and international experts (from the fields of health promotion, health psychology, e-communication, and technical Web design) and potential users were invited via email to participate. During this study an extensive list of factors potentially related to optimal development of health-related websites was identified, by focusing on factors related to layout, general and risk information provision, questionnaire use, additional services, and ease of use. Furthermore, we assessed the extent to which experts and potential users agreed on the importance of these factors. Differences as well as similarities among experts and potentials users were deduced.

Results

In total, 20 of 62 contacted experts participated in the first round (32% response rate); 60 of 200 contacted experts (30% response rate) and 210 potential users (95% response rate) completed the second-round questionnaire, and 32 of 60 contacted experts completed the third round (53% response rate). Results revealed important factors consented upon by experts and potential users (eg, ease of use, clear structure, and detailed health information provision), as well as differences regarding important factors consented upon by experts (eg, visual aids, self-monitoring tool, and iterative health feedback) or by potential users only (eg, bread crumb navigation and prevention of receiving spam).

Conclusions

This study is an important first step in determining the agreed-upon factors that should be taken into account when developing online health promotion programs. The public health impact of these programs will be improved by optimizing the development process in line with these factors.

Prospective associations between intervention components and website engagement in a publicly available physical activity website: the case of 10,000 Steps Australia

Background

Effectiveness of and engagement with website-delivered physical activity interventions is moderate at best. Increased exposure to Internet interventions is reported to increase their effectiveness; however, there is a lack of knowledge about which specific intervention elements are able to maintain website engagement.

Objective

To prospectively study the associations of website engagement and exposure to intervention components for a publicly available physical activity website (10,000 Steps Australia).

Methods

Between June and July 2006 a total of 348 members of 10,000 Steps completed a Web-based survey to collect demographic characteristics. Website engagement was subsequently assessed over a 2-year period and included engagement data on website components; individual challenges, team challenges, and virtual walking buddies; and indicators of website engagement (average steps logged, days logging steps, and active users).

Results

On average participants logged steps on 169 (SD 228.25) days. Over a 2-year period this equated to an average of 1.6 logons per week. Binary logistic regression showed that individuals who participated in individual challenges were more likely to achieve an average of 10,000 steps per day (odds ratio [OR] = 2.80, 95% confidence interval [CI] 1.45–5.40), log steps on a higher than average number of days (OR = 6.81, 95% CI 2.87–13.31), and remain an active user (OR = 4.36, 95% CI 2.17–8.71). Additionally, those using virtual walking buddies (OR = 5.83, 95% CI 1.27–26.80) and of older age logged steps on a higher than average number of days. No significant associations were found for team challenges.

Conclusions

Overall engagement with the 10,000 Steps website was high, and the results demonstrate the relative effectiveness of interactive components to enhance website engagement. However, only exposure to the interactive individual challenge feature was positively associated with all website engagement indicators. More research is needed to examine the influence of intervention components on website engagement, as well as the relationship between website engagement and physical activity change.

Systematic review and evaluation of web-accessible tools for management of diabetes and related cardiovascular risk factors by patients and healthcare providers

Objective

To identify and evaluate the effectiveness, clinical usefulness, sustainability, and usability of web-compatible diabetes-related tools.

Data sources

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, world wide web.

Study selection

Studies were included if they described an electronic audiovisual tool used as a means to educate patients, care givers, or clinicians about diabetes management and assessed a psychological, behavioral, or clinical outcome.

Data extraction

Study abstraction and evaluation for clinical usefulness, sustainability, and usability were performed by two independent reviewers.

Results

Of 12616 citations and 1541 full-text articles reviewed, 57 studies met inclusion criteria. Forty studies used experimental designs (25 randomized controlled trials, one controlled clinical trial, 14 before–after studies), and 17 used observational designs. Methodological quality and ratings for clinical usefulness and sustainability were variable, and there was a high prevalence of usability errors. Tools showed moderate but inconsistent effects on a variety of psychological and clinical outcomes including HbA1c and weight. Meta-regression of adequately reported studies (12 studies, 2731 participants) demonstrated that, although the interventions studied resulted in positive outcomes, this was not moderated by clinical usefulness nor usability.

Limitation

This review is limited by the number of accessible tools, exclusion of tools for mobile devices, study quality, and the use of non-validated scales.

Conclusion

Few tools were identified that met our criteria for effectiveness, usefulness, sustainability, and usability. Priority areas include identifying strategies to minimize website attrition and enabling patients and clinicians to make informed decisions about website choice by encouraging reporting of website quality indicators.

Attrition in web-based treatment for problem drinkers

Background

Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs.

Objective

The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program.

Methods

Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis.

Results

The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ²₁ = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention.

Conclusions

The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase.

Trial

International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

Evaluation of a Web-based intervention to promote hand hygiene: exploratory randomized controlled trial

Background

Hand-washing is regarded as a potentially important behavior for preventing transmission of respiratory infection, particularly during a pandemic.

Objective

The objective of our study was to evaluate whether a Web-based intervention can encourage more frequent hand-washing in the home, and to examine potential mediators and moderators of outcomes, as a necessary first step before testing effects of the intervention on infection rates in the PRIMIT trial (PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory infection Transmission).

Methods

In a parallel-group pragmatic exploratory trial design, 517 nonblinded adults recruited through primary care were automatically randomly assigned to a fully automated intervention comprising 4 sessions of tailored motivational messages and self-regulation support (n = 324) or to a no-intervention control group (n = 179; ratio 2:1). Hand-washing frequency and theory of planned behavior cognitions relating to hand-washing were assessed by online questionnaires at baseline (in only half of the control participants, to permit evaluation of effects of baseline assessment on effect sizes), at 4 weeks (postintervention; all participants), and at 12 weeks.

Results

Hand-washing rates in the intervention group were higher at 4 weeks than in the control group (mean 4.40, n = 285 and mean 4.04, n = 157, respectively; P < .001, Cohen d = 0.42) and remained higher at 12 weeks (mean 4.45, n = 282 and mean 4.12, n = 154, respectively; P < .001, Cohen d = 0.34). Hand-washing intentions and positive attitudes toward hand-washing increased more from baseline to 4 weeks in the intervention group than in the control group. Mediation analyses revealed positive indirect effects of the intervention on change in hand-washing via intentions (coefficient = .15, 95% confidence interval [CI], .08–.26) and attitudes (coefficient = 0.16, 95% CI, .09–.26). Moderator analyses confirmed that the intervention was similarly effective for men and women, those of higher and lower socioeconomic status, and those with higher and lower levels of perceived risk.

Conclusions

This study provides promising evidence that Web-based interventions could potentially provide an effective method of promoting hand hygiene in the home. Data were collected during the 2010 influenza pandemic, when participants in both groups had already been exposed to extensive publicity about the need for hand hygiene, suggesting that our intervention could add to existing public health campaigns. However, further research is required to determine the effects of the intervention on actual infection rates.

Trial

International Standard Randomized Controlled Trial Number (ISRCTN): 75058295; http://www.controlled-trials.com/ISRCTN75058295 (Archived by WebCite at http://www.webcitation.org/62KSbkNmm)

Health promotion in the workplace: assessing stress and lifestyle with an intranet tool

BACKGROUND

Chronic noncommunicable conditions, particularly cardiovascular and metabolic diseases, are the major causes of death and morbidity in both industrialized and low- to middle-income countries. Recent epidemiological investigations suggest that management of lifestyle factors, such as stress and lack of physical activity, could have an important value in cardiometabolic conditions, while information technology tools could play a significant facilitatory role.

OBJECTIVES

The objective of our study was to verify the feasibility of using a private website, directed to the workers of a major Italian company, to describe their health profile and lifestyle and work habits using an ad hoc self-administered questionnaire.

METHODS

We administered anonymous multiple choice Web-based questionnaires to 945 participants (683 completed the task) as part of an ongoing health promotion program in a multinational company. Qualitative and quantitative data were synthesized with nonlinear principal component analysis to construct indicators (ie, variables) for stress, control, and lifestyle domains. Considering in addition absenteeism, the Calinski-Harabasz statistic and cluster analysis jointly differentiated seven clusters, which displayed different distributions of standardized classification variables. The final step consisted in assessing the relationship of the resulting seven subject typologies with personal data, illnesses, and metabolic syndrome status, carried out for the most part with descriptive methods.

RESULTS

Statistical analyses singled out two not-overlapping domains of stress and control, as well as three not-overlapping domains of physical activity, smoking, and alcohol habits. The centroids of the seven clusters generated by the procedure were significantly (P < .001) different considering all possible 21 comparisons between couples of groups. Percentage distributions of variables describing personal information (gender, age group, work category, illness status, or metabolic syndrome) within participant typologies show some noteworthy findings: females, workers aged 35-44 years, junior white collar workers, and respondents reporting illness were more prevalent in the stress group than in the overall studied population; preclinical metabolic syndrome status was more prevalent in the group with higher alcohol consumption. Absentees reported more illness.

CONCLUSIONS

The present Intranet-based study shows the potential of applying diverse statistical techniques to deal jointly with qualitative and quantitative self-reported data. The resulting formal description of subject typologies and their relationship with personal characteristics might provide a convenient tool for supporting health promotion in the work environment.

Engagement in "My Child's Asthma", an interactive web-based pediatric asthma management intervention

PURPOSE

The Internet is a promising tool for delivering health behavior change programs although such interventions raise questions about participant engagement in this medium. In this study we sought to determine the characteristics of parents who engage in an Internet-based health intervention for their children (with asthma) and to distinguish parents who engage at the prescribed intervals versus those who engage less often.

METHODS

N=283 parents with children who had asthma were recruited and randomized to receive a web-based intervention. Participants filled out six surveys over a 6-month period asking them about demographic and clinical characteristics, outcome expectations and self-efficacy beliefs regarding asthma control for their child, and attitudes about computers and the Internet. Descriptive statistics were used to describe the population and analyze associations.

RESULTS

Controller use and being adherent to this medication as well as positive outcome and self efficacy expectations were associated with increased engagement. Parents who logged on only once reported significantly less frequent use of the Internet than parents who logged on to all sessions.

DISCUSSION AND CONCLUSION

The results of this study suggest that it is important to find ways to increase engagement in a web-based intervention for parents who are not yet engaging in the recommended behaviors and/or who report less positive outcome and efficacy expectations around asthma management.

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.

A web-based computerized adaptive testing (CAT) to assess patient perception in hospitalization

BACKGROUND

Many hospitals have adopted mobile nursing carts that can be easily rolled up to a patient's bedside to access charts and help nurses perform their rounds. However, few papers have reported data regarding the use of wireless computers on wheels (COW) at patients' bedsides to collect questionnaire-based information of their perception of hospitalization on discharge from the hospital.

OBJECTIVE

The purpose of this study was to evaluate the relative efficiency of computerized adaptive testing (CAT) and the precision of CAT-based measures of perceptions of hospitalized patients, as compared with those of nonadaptive testing (NAT). An Excel module of our CAT multicategory assessment is provided as an example.

METHOD

A total of 200 patients who were discharged from the hospital responded to the CAT-based 18-item inpatient perception questionnaire on COW. The numbers of question administrated were recorded and the responses were calibrated using the Rasch model. They were compared with those from NAT to show the advantage of CAT over NAT.

RESULTS

Patient measures derived from CAT and NAT were highly correlated (r = 0.98) and their measurement precisions were not statistically different (P = .14). CAT required fewer questions than NAT (an efficiency gain of 42%), suggesting a reduced burden for patients. There were no significant differences between groups in terms of gender and other demographic characteristics.

CONCLUSIONS

CAT-based administration of surveys of patient perception substantially reduced patient burden without compromising the precision of measuring patients' perceptions of hospitalization. The Excel module of animation-CAT on the wireless COW that we developed is recommended for use in hospitals.

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.

Qualitative and quantitative research into the development and feasibility of a video-tailored physical activity intervention

Background

Continued low adherence to physical activity recommendations illustrates the need to refine intervention strategies and increase their effectiveness. The purpose of this study was to conduct formative research related to the development of a next generation of computer-tailored interventions that use online tailored video-messages to increase physical activity.

Methods

Five focus groups (n = 30), aimed at males and females, aged between 35 and 60 years, that do not meet the physical activity recommendation, were conducted to allow in-depth discussion of various elements related to the development of an online video-tailored intervention. In addition, a series of questions were delivered to a random sample (n = 1261) of Australians, using CATI survey technology, to gain more information and add a quantitative assessment of feasibility related to the development of the intervention. Focus group data was transcribed, and summarised using Nvivo software. Descriptive and frequency data of the survey was obtained using SPSS 18.0.

Results

Nearly all of the focus group participants supported the concept of a video-tailored intervention and 35.8% of survey participants indicated that they would prefer a video-based over a text-based intervention. Participants with a slow internet-connection displayed a lower preference for video-based advice (31.9%); however less than 20% of the survey sample indicated that downloading videos would be slow. The majority of focus group and survey participants did not support the idea of using mobile phones to receive this kind of intervention and indicated that video-tailored messages should be shorter than 5 minutes. Video-delivery of content is very rich in information, which increases the challenge to appropriately tailor content to participant characteristics; focus-group outcomes indicated a large diversity in participant preferences. 52.4% of survey participants indicated that the videos should be convincing and motivating.

Conclusions

These results provide valuable information to develop an innovative video-tailored physical activity intervention. The results support the feasibility of such intervention, both in terms of users being ready to participate in it, as well as from a point of view whereby current internet infrastructure is able to cope with the demands of downloading videos. Though promising, a number of specific challenges in the development of these interventions were identified (e.g. the videos need to be short, made professionally, and tailor to a larger number of variables) and will need to be overcome in the development and evaluation of this new type of physical activity intervention.