Using internet and mobile phone technology to deliver an automated physical activity program: randomized controlled trial

Using mobile & personal sensing technologies to support health behavior change in everyday life: lessons learned

Lifestyle modification is a key facet of the prevention and management of chronic diseases. Mobile devices that people already carry provide a promising platform for facilitating these lifestyle changes. This paper describes key lessons learned from the development and evaluation of two mobile systems for encouraging physical activity. We argue that by supporting persistent cognitive activation of health goals, encouraging an extensive range of relevant healthy behaviors, focusing on long-term patterns of activity, and facilitating social support as an optional but not primary motivator, systems can be developed that effectively motivate behavior change and provide support when and where people make decisions that affect their health.

The Benefits of (Automated) Dialogue

The authors compared user evaluation of a text based dialogue system with a simple pick list for the same task. The authors matched the systems in terms of key factors, such as design for Usability, and took into account individual differences between participants that might have influenced their perception, such as Locus of Control, Experience and Personality. They found participants rated the text based dialogue system as being more informative, more credible, less frustrating and more persuasive than the simple pick list system. Participants’ ratings were dependent on their Personality, Locus of Control and reported level of physical activity. Participants did not differentiate between the systems in terms of their ease of use, indicating the other observed differences were not due to a simple difference in Usability. This study demonstrated the benefits of including automated dialogue in a system designed to help people find solutions for their exercise barriers. Further work is required to establish in what other situations dialogue provides a benefit.

Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD

Objective

To determine the feasibility and efficacy of a six-month, cell phone-based exercise persistence intervention for patients with chronic obstructive pulmonary disease (COPD) following pulmonary rehabilitation.

Methods

Participants who completed a two-week run-in were randomly assigned to either MOBILE-Coached (n = 9) or MOBILE-Self-Monitored (n = 8). All participants met with a nurse to develop an individualized exercise plan, were issued a pedometer and exercise booklet, and instructed to continue to log their daily exercise and symptoms. MOBILE-Coached also received weekly reinforcement text messages on their cell phones; reports of worsening symptoms were automatically flagged for follow-up. Usability and satisfaction were assessed. Participants completed incremental cycle and six minute walk (6MW) tests, wore an activity monitor for 14 days, and reported their health-related quality of life (HRQL) at baseline, three, and six months.

Results

The sample had a mean age of 68 ±11 and forced expiratory volume in one second 18% predicted. Participants reported that logging their exercise and symptoms (FEV₁) of 40 ± was easy and that keeping track of their exercise helped them remain active. There were no differences between groups over time in maximal workload, 6MW distance, or HRQL (p > 0.05); however, MOBILE-Self-Monitored increased total steps/day whereas MOBILE-Coached logged fewer steps over six months (p =0.04).

Conclusions

We showed that it is feasible to deliver a cell phone-based exercise persistence intervention to patients with COPD post-rehabilitation and that the addition of coaching appeared to be no better than self-monitoring. The latter finding needs to be interpreted with caution since this was a purely exploratory study.

Trial registration

ClinicalTrials.gov (NCT00373932).

Web-site-based tailored advice to promote strength and balance training: an experimental evaluation

This study evaluated a Web site providing tailored advice to encourage older people to undertake strength and balance training (SBT). Adults age 60-88 (N = 302) were randomized to read either generic advice or advice tailored to their self-perceived balance problems and activity preferences. Between-groups differences in attitudes toward SBT after reading the advice did not quite reach significance (p = .059), but the tailored group reported higher ratings than the generic group that the advice was personally relevant (p = .017) and that the activities would be good for them (p = .047). Within-groups differences in the tailored group showed that completing an action plan increased confidence in undertaking SBT (p = .006). These findings were supported by a meta-analysis that pooled the effect sizes with those of a previous study. Thus, a tailored Web site might be a cost-effective way of encouraging some older people to undertake SBT.

A behavior change model for internet interventions

BACKGROUND

The Internet has become a major component to health care and has important implications for the future of the health care system. One of the most notable aspects of the Web is its ability to provide efficient, interactive, and tailored content to the user. Given the wide reach and extensive capabilities of the Internet, researchers in behavioral medicine have been using it to develop and deliver interactive and comprehensive treatment programs with the ultimate goal of impacting patient behavior and reducing unwanted symptoms. To date, however, many of these interventions have not been grounded in theory or developed from behavior change models, and no overarching model to explain behavior change in Internet interventions has yet been published.

PURPOSE

The purpose of this article is to propose a model to help guide future Internet intervention development and predict and explain behavior changes and symptom improvement produced by Internet interventions.

RESULTS

The model purports that effective Internet interventions produce (and maintain) behavior change and symptom improvement via nine nonlinear steps: the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics. Website use leads to behavior change and symptom improvement through various mechanisms of change. The improvements are sustained via treatment maintenance.

CONCLUSION

By grounding Internet intervention research within a scientific framework, developers can plan feasible, informed, and testable Internet interventions, and this form of treatment will become more firmly established.

Feasibility and effectiveness of online physical activity advice based on a personal activity monitor: randomized controlled trial

Background

Inactive people are often not aware of the fact that they are insufficiently active. Providing insight into their actual physical activity (PA) levels may raise awareness and could, in combination with tailored PA advice, stimulate a physically active lifestyle.

Objective

This study evaluated the feasibility and effectiveness of a 3-month intervention in which Dutch office workers were provided with a personal activity monitor (PAM) coupled to simple and concise Web-based tailored PA advice (PAM COACH).

Method

Participants were randomly assigned to the 3-month PAM intervention (n = 51) or received a single written information brochure with brief general PA recommendations (n = 51). Study outcome measures were changes in PA (recall of minutes per week spent on PA, as measured by the Activity Questionnaire for Adolescents and Adults), determinants of PA, aerobic fitness, and body composition. Follow-up measurements were performed immediately after the 3-month intervention and at 8-months, 5 months after the end of the 3-month intervention period.

Results

A total of 102 workers, 23 to 39 years old, completed the baseline measurement at the worksite. 48 completed the 3-month follow up and 38 the 8-month follow-up in the intervention group, 50 completed the 3-month follow up and 42 the 8-month follow up in the control group. 35 out of 48 (73%) participants in the PAM intervention group reported wearing the PAM regularly, and the PAM COACH was used almost once a week; 24 out of 46 (52%) PAM users set a personal goal, and 33 (72%) entered their favorite activities on the website. Main reasons for not using these items were lack of interest or not being able to find the item on the website. The majority of PAM users (34 out of 46, 74%) read the advice, of whom 14 (39%) found it unappealing. After the 3-month intervention, no significant intervention effect was observed (adjusted difference in min/week) for sedentary behavior (β = 10, 95% CI = −435 to 455), light-intensity PA (β = −129, 95% CI = −337 to 79), moderate-intensity PA (β = −13, 95% CI = −89 to 63), vigorous-intensity PA (β= −6, 95% CI = −75 to 62), and moderate- to vigorous-intensity PA (β = −23, 95% CI = −121 to 76). No significant intervention effect was observed in the PA outcomes at the 8-month follow-up. For the determinants of PA, aerobic fitness, and body composition, no statistically significant intervention effect was observed in the total study population immediately after the 3-month intervention or the 8-month follow-up.

Conclusions

The intervention appeared to be easily applicable to real-life settings. The intervention was ineffective in improving PA behavior or its determinants in healthy office workers. More attention should have been given to the quality and appropriateness of the tailored advice.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 93896459; http://www.controlled-trials.com/ISRCTN93896459/ (Archived by WebCite at http://www.webcitation.org/5iR3mf7ex)

Effectiveness of active-online, an individually tailored physical activity intervention, in a real-life setting: randomized controlled trial

Background

Effective interventions are needed to reduce the chronic disease epidemic. The Internet has the potential to provide large populations with individual advice at relatively low cost.

Objective

The focus of the study was the Web-based tailored physical activity intervention Active-online. The main research questions were (1) How effective is Active-online, compared to a nontailored website, in increasing self-reported and objectively measured physical activity levels in the general population when delivered in a real-life setting? (2) Do respondents recruited for the randomized study differ from spontaneous users of Active-online, and how does effectiveness differ between these groups? (3) What is the impact of frequency and duration of use of Active-online on changes in physical activity behavior?

Methods

Volunteers recruited via different media channels completed a Web-based baseline survey and were randomized to Active-online (intervention group) or a nontailored website (control group). In addition, spontaneous users were recruited directly from the Active-online website. In a subgroup of participants, physical activity was measured objectively using accelerometers. Follow-up assessments took place 6 weeks (FU1), 6 months (FU2), and 13 months (FU3) after baseline.

Results

A total of 1531 respondents completed the baseline questionnaire (intervention group n = 681, control group n = 688, spontaneous users n = 162); 133 individuals had valid accelerometer data at baseline. Mean age of the total sample was 43.7 years, and 1146 (74.9%) were women. Mixed linear models (adjusted for sex, age, BMI category, and stage of change) showed a significant increase in self-reported mean minutes spent in moderate- and vigorous-intensity activity from baseline to FU1 (coefficient = 0.14, P = .001) and to FU3 (coefficient = 0.19, P < .001) in all participants with no significant differences between groups. A significant increase in the proportion of individuals meeting the HEPA recommendations (self-reported) was observed in all participants between baseline and FU3 (OR = 1.47, P = .03), with a higher increase in spontaneous users compared to the randomized groups (interaction between FU3 and spontaneous users, OR = 2.95, P = .02). There were no increases in physical activity over time in any group for objectively measured physical activity. A significant relation was found between time spent on the tailored intervention and changes in self-reported physical activity between baseline and FU3 (coefficient = 1.13, P = .03, intervention group and spontaneous users combined). However, this association was no longer significant when adjusting for stage of change.

Conclusions

In a real-life setting, Active-online was not more effective than a nontailored website in increasing physical activity levels in volunteers from the general population. Further research may investigate ways of integrating Web-based physical activity interventions in a wider context, for example, primary care or workplace health promotion.

Healthcare via cell phones: a systematic review

Regular care and informational support are helpful in improving disease-related health outcomes. Communication technologies can help in providing such care and support. The purpose of this study was to evaluate the empirical evidence related to the role of cell phones and text messaging interventions in improving health outcomes and processes of care. Scientific literature was searched to identify controlled studies evaluating cell phone voice and text message interventions to provide care and disease management support. Searches identified 25 studies that evaluated cell phone voice and text messaging interventions, with 20 randomized controlled trials and 5 controlled studies. Nineteen studies assessed outcomes of care and six assessed processes of care. Selected studies included 38,060 participants with 10,374 adults and 27,686 children. They covered 12 clinical areas and took place in 13 countries. Frequency of message delivery ranged from 5 times per day for diabetes and smoking cessation support to once a week for advice on how to overcome barriers and maintain regular physical activity. Significant improvements were noted in compliance with medicine taking, asthma symptoms, HbA1C, stress levels, smoking quit rates, and self-efficacy. Process improvements were reported in lower failed appointments, quicker diagnosis and treatment, and improved teaching and training. Cost per text message was provided by two studies. The findings that enhancing standard care with reminders, disease monitoring and management, and education through cell phone voice and short message service can help improve health outcomes and care processes have implications for both patients and providers.

The Effectiveness of Lifestyle Physical Activity Interventions to Reduce Cardiovascular Disease

Lifestyle interventions have evolved from proof of concept pilot studies to efficacy and effectiveness studies and have now moved toward translation and dissemination studies because of their demonstrated ability to improve cardiovascular diseases (CVD) outcomes including blood pressure. When combined with diet, they also have demonstrated the ability to normalize blood glucose and help to regulate weight. This review highlights the converging lines of evidence that led to lifestyle physical activity interventions beginning with early epidemiology studies and provides evidence for the efficacy and effectiveness of lifestyle interventions. However, if lifestyle interventions are to play a role in preventing CVD and improving CVD outcomes, their use must be more widespread. This will require translational and dissemination research in order to understand how to move into real world settings. Successful examples of translational studies will be highlighted and issues related to theoretical and practical issues as well as capacity building will be discussed. Building bridges between research and practice must be done if lifestyle interventions are to deliver on their public health promise.

Eight-month follow-up of physical activity and central adiposity: results from an Internet-delivered randomized control trial intervention

BACKGROUND

Less than half of U.S. adults engage in the recommended amount of physical activity (PA). Internet-delivered PA programs increase short-term PA but long-term adherence is largely equivocal.

PURPOSE

To determine whether increased PA following the 16-week Internet-delivered Active Living Every Day (ALED-I) program is maintained 8 months later in sedentary and overweight rural adults.

METHODS

In our previous randomized controlled trial (N = 32; 18 intent-to-treat controls, 14 ALED-I interventions), the ALED-I group increased PA (+1384 steps/day; E.S. = 0.95) and reduced central adiposity. Nine original intervention participants and ten delayed intent-to-treat control participants completed ALED-I and an 8-month followup. Pedometer-measured PA, anthropometric variables, and cardiometabolic disease risk factors were assessed at baseline, postintervention, and at 8 months.

RESULTS

Control crossover participants increased PA (+1337 steps/ day; P = .04). Eight months following completion of ALED-I (N = 19), PA levels relapsed (-1340 steps/day) and were similar to levels before the intervention (6850 +/- 471 steps/day vs. 6755 +/- 543 steps/day; P = .89). Total cholesterol and triglycerides improved, -9.9% and -18.2%, respectively, and reductions in central adiposity were maintained (97.1 +/- 2.2 cm vs. 97.2 +/- 2.2 cm; P = .66).

CONCLUSIONS

The ALED-I intervention was efficacious in the short-term but did not produce longer-term adherence to PA. Future theory-based internet-delivered interventions that produce habituation of increased PA are warranted.

Computer-tailored physical activity behavior change interventions targeting adults: a systematic review

BACKGROUND

Increasing physical activity is important in the promotion of better health. Computer-tailored behavior change programs have shown promise in changing lifestyle risk factors.

PURPOSE

To provide a narrative systematic review describing the range of evidence on 'second' and 'third' generation computer-tailored primary prevention interventions for physical activity, to determine their effectiveness and key characteristics of success. Unlike previous reviews, this review used specific criteria to measure the external validity of studies, was exclusive to primary prevention interventions in which tailoring was generated through an expert system, and excluded first generation computer-tailored interventions.

METHODS

Computer-tailored intervention studies published from January 1996-2008 were identified through a search of five databases: Medline; Embase; PsycINFO; CINAHL; and All EBM Reviews and by examining reference lists of relevant articles.

RESULTS

Seventeen articles were included, describing the evaluation of 16 interventions, ten of which found significant positive effects of the computer-tailored interventions on physical activity or weight reduction outcomes.

CONCLUSION

The evidence of effectiveness for computer-tailored physical activity interventions is inconclusive. They have potential to reach large groups of people however there is uncertainty whether reported effects are generalizable and sustained.

Designing and testing a web-based interface for self-monitoring of exercise and symptoms for older adults with chronic obstructive pulmonary disease

The use of information and communication technologies to support collaborative management of chronic obstructive pulmonary disease and associated symptoms is particularly appealing since most people with chronic obstructive pulmonary disease continue to experience dyspnea despite optimal medical therapy and therefore must engage in the long-term tasks of self-management. Exercise is an effective therapy to reduce dyspnea in patients with chronic obstructive pulmonary disease. The purpose of this article was to describe our process of developing a set of integrated tools to support collaborative symptom and exercise monitoring for patients with chronic obstructive pulmonary disease. This process could be followed by other researchers and clinicians interested in developing collaborative management tools for other chronic conditions. User-centered design principles guided the 4-phase development process of a set of integrated tools for self-symptom management. The usability challenges uncovered during the field testing were mostly minor and were easily corrected. Patients had a strong preference for a calendar-like display of completed exercise coupled with simultaneous goal viewing. Field usability testing showed that the integrated set of tools was relatively easy to learn, efficient to use, and with minimal errors and has a high level of user satisfaction. An iterative, multimodal process is essential to successful development of acceptable Web-based tools for self-management in chronic obstructive pulmonary disease.

Healthy living with persuasive technologies: framework, issues, and challenges

While our Y2K worries about old computers "retiring" at midnight captured the television and news media attention, a more significant "old age" phenomenon snuck onto the scene with hardly a headline: the dawn of the age of the aged. (1) The over burdened health care system will face a worldwide wave of retirees who will live longer, cost more to treat, and demand new goods and services to help them stay healthy, active, and independent. Research in persuasive technologies and the associated usage of a computing system, device, or application intentionally designed to change a person's attitude or behavior in a predetermined way is showing the potential to assist in improving healthy living, reduce the costs on the health care system, and allow the aged to maintain a more independent life. This article gives a deeper insight into the evolution of persuasive technologies and presents a framework that can guide a researcher or practitioner in comprehending more effectively the work being done in this novel research field. It also provides categories of domains within health care in which these technologies are used and surveys exemplars from published literature. The article's goal is to provide greater understanding by addressing the challenges that lie ahead for all key stakeholders that design and/or use persuasive technologies in health care.

Behavior change interventions delivered by mobile telephone short-message service

CONTEXT

The expansion and adoption of new methods of communication provide new opportunities for delivering health behavior change interventions. This paper reviews the current research examining mobile telephone short-message service (SMS) for delivering health behavior change interventions via text messages. This service has wide population reach, can be individually tailored, and allows instant delivery with asynchronous receipt, suggesting potential as a delivery channel for health behavior interventions.

EVIDENCE ACQUISITION

An electronic database search was conducted for studies published between January 1990 and March 2008. Studies were included in the review if they (1) evaluated an intervention delivered primarily via SMS, (2) assessed change in health behavior using pre-post assessment, and (3) were published in English in a peer-reviewed scientific journal.

EVIDENCE SYNTHESIS

Of 33 studies identified, 14 met the inclusion criteria. Four of the 14 studies reviewed targeted preventive health behaviors (e.g., smoking cessation), and ten focused on clinical care (e.g., diabetes self-management). Positive behavior change outcomes were observed in 13 of the 14 reviewed studies. Intervention initiation (researcher or participant), SMS dialogue initiation, tailoring of SMS content, and interactivity were found to be important features of SMS-delivered interventions. Methodologic issues with current SMS research were also identified.

CONCLUSIONS

This review suggests that SMS-delivered interventions have positive short-term behavioral outcomes. Further research is required to evaluate interventions for preventive health behaviors that incorporate features found to affect behavioral outcomes and participant acceptance. The quality of studies in this emerging field of research needs to improve to allow the full potential of this medium to be explored.

Randomized trial of a neighborhood environment-focused physical activity website intervention

OBJECTIVE

To evaluate the use of a local neighborhood environment-focused physical activity website and its effects on walking and overall physical activity in middle-aged adults.

METHOD

One-hundred and six (72% women) inactive adults aged 52+/-4.6 years were randomly allocated to receive access to a neighborhood environment-focused website, (Neighborhood group, n=52) or a motivational-information website (Comparison group n=54). Participants also received eleven emails over the 26 weeks. Study outcomes were objectively-monitored website use, and self-reported total walking (min/wk), total physical activity (min/wk) and neighborhood walking (min/wk) collected at baseline, 12 and 26 weeks. The study was conducted between August 2005 and February 2006 in Brisbane, Australia.

RESULTS

Website use was significantly greater among Neighborhood participants (p=0.01). Statistically significant increases in walking and total physical activity were observed in both groups. There was also a statistically significant interaction effect for total physical activity, with Neighborhood group participants maintaining more of their initial increase in physical activity at week-26 (p<0.05). Further, those in the Neighborhood group who used the website more often reported significantly more walking along the community trail at week-26 (p=0.05) compared with those who did not.

CONCLUSIONS

A local neighborhood-environment focused physical activity website was more effective at engaging participants than a motivational-information website. Moreover, its use resulted in meaningful increases in physical activity relative to the comparison website.

Consumer health informatics: from genomics to population health

Innovations in health information technology have ushered in a new era of health care. The use of emerging information and communication technology to improve or enable health and health care is the central focus of consumer health informatics (CHI). Traditionally, CHI interventions to promote health and well-being have targeted the individual or family. Advances in genomic health and the emergence of public health informatics call for broadening the scope of CHI. The authors discuss CHI from the point-of-view of the consumer (e.g., from individuals to policy makers) and the level of health data from the subcellular (e.g., genetic or protein structures) to population (e.g., geographically-referenced information).

A text message-based intervention for weight loss: randomized controlled trial

Background

To our knowledge, no studies have evaluated whether weight loss can be promoted in overweight adults through the use of an intervention that is largely based on daily SMS (Short Message Service: text) and MMS (Multimedia Message Service: small picture) messages transmitted via mobile phones.

Objective

This paper describes the development and evaluation of a text message–based intervention designed to help individuals lose or maintain weight over 4 months.

Methods

The study was a randomized controlled trial, with participants being exposed to one of the following two conditions, lasting 16 weeks: (1) receipt of monthly printed materials about weight control; (2) an intervention that included personalized SMS and MMS messages sent two to five times daily, printed materials, and brief monthly phone calls from a health counselor. The primary outcome was weight at the end of the intervention. A mixed-model repeated-measures analysis compared the effect of the intervention group to the comparison group on weight status over the 4-month intervention period. Analysis of covariance (ANCOVA) models examined weight change between baseline and 4 months after adjusting for baseline weight, sex, and age.

Results

A total of 75 overweight men and women were randomized into one of the two groups, and 65 signed the consent form, completed the baseline questionnaire, and were included in the analysis. At the end of 4 months, the intervention group (n = 33) lost more weight than the comparison group (−1.97 kg difference, 95% CI −0.34 to −3.60 kg, P = .02) after adjusting for sex and age. Intervention participants’ adjusted average weight loss was 2.88 kg (3.16%). At the end of the study, 22 of 24 (92%) intervention participants stated that they would recommend the intervention for weight control to friends and family.

Conclusions

Text messages might prove to be a productive channel of communication to promote behaviors that support weight loss in overweight adults.

Trial Registration

Clinicaltrials.gov NCT00415870; http://clinicaltrials.gov/ct2/show/NCT00415870 (Archived by WebCite at http://www.webcitation.org/5dnolbkFt)

Rates and determinants of uptake and use of an internet physical activity and weight management program in office and manufacturing work sites in England: cohort study

BACKGROUND

Internet-based physical activity (PA) and weight management programs have the potential to improve employees' health in large occupational health settings. To be successful, the program must engage a wide range of employees, especially those at risk of weight gain or ill health.

OBJECTIVE

The aim of the study was to assess the use and nonuse (user attrition) of a Web-based and monitoring device-based PA and weight management program in a range of employees and to determine if engagement with the program was related to the employees' baseline characteristics or measured outcomes.

METHODS

Longitudinal observational study of a cohort of employees having access to the MiLife Web-based automated behavior change system. Employees were recruited from manufacturing and office sites in the North West and the South of England. Baseline health data were collected, and participants were given devices to monitor their weight and PA via data upload to the website. Website use, PA, and weight data were collected throughout the 12-week program.

RESULTS

Overall, 12% of employees at the four sites (265/2302) agreed to participate in the program, with 130 men (49%) and 135 women (51%), and of these, 233 went on to start the program. During the program, the dropout rate was 5% (11/233). Of the remaining 222 Web program users, 173 (78%) were using the program at the end of the 12 weeks, with 69% (153/222) continuing after this period. Engagement with the program varied by site but was not significantly different between the office and factory sites. During the first 2 weeks, participants used the website, on average, 6 times per week, suggesting an initial learning period after which the frequency of website log-in was typically 2 visits per week and 7 minutes per visit. Employees who uploaded weight data had a significant reduction in weight (-2.6 kg, SD 3.2, P< .001). The reduction in weight was largest for employees using the program's weight loss mode (-3.4 kg, SD 3.5). Mean PA level recorded throughout the program was 173 minutes (SE 12.8) of moderate/high intensity PA per week. Website interaction time was higher and attrition rates were lower (OR 1.38, P= .03) in those individuals with the greatest weight loss.

CONCLUSIONS

This Web-based PA and weight management program showed high levels of engagement across a wide range of employees, including overweight or obese workers, shift workers, and those who do not work with computers. Weight loss was observed at both office and manufacturing sites. The use of monitoring devices to capture and send data to the automated Web-based coaching program may have influenced the high levels of engagement observed in this study. When combined with objective monitoring devices for PA and weight, both use of the website and outcomes can be tracked, allowing the online coaching program to become more personalized to the individual.

A robust automated system elucidates mouse home cage behavioral structure

Patterns of behavior exhibited by mice in their home cages reflect the function and interaction of numerous behavioral and physiological systems. Detailed assessment of these patterns thus has the potential to provide a powerful tool for understanding basic aspects of behavioral regulation and their perturbation by disease processes. However, the capacity to identify and examine these patterns in terms of their discrete levels of organization across diverse behaviors has been difficult to achieve and automate. Here, we describe an automated approach for the quantitative characterization of fundamental behavioral elements and their patterns in the freely behaving mouse. We demonstrate the utility of this approach by identifying unique features of home cage behavioral structure and changes in distinct levels of behavioral organization in mice with single gene mutations altering energy balance. The robust, automated, reproducible quantification of mouse home cage behavioral structure detailed here should have wide applicability for the study of mammalian physiology, behavior, and disease.

Using a website to build community and enhance outcomes in a group, multi-component intervention promoting healthy diet and exercise in adolescents

OBJECTIVE

This article describes website use and behavioral outcomes in a multi-component lifestyle intervention promoting healthy diet and exercise.

METHODS

A 2-year randomized clinical trial to improve bone density in 228 adolescent girls, the intervention included a website designed to enhance intervention adherence, retention of participants, and behavioral outcomes. Measures included diet and exercise recalls, surveys, and web-usage data.

RESULTS

Website use was associated with increases in calcium intake (ss = 69.72, p =.01, ES = 0.15) and high-impact activity (ss = 10.93, p =.04, ES =.13). Use of web pages related to behavioral feedback and communications was not significantly associated with behavioral outcomes. The most visited website pages had content related to incentive points, caption contests, and fun facts.

CONCLUSIONS

Web elements of a multi-component intervention may promote retention and engagement in target behaviors. Such websites may be most acceptable to adolescent participants if they blend fun and behavioral elements, rather than exclusively focusing on behavioral changes.

Using electronic/computer interventions to promote physical activity

The internet has been used as a method to deliver various health interventions (eg, weight management, smoking cessation, increasing physical activity). An electronic search (ie, PubMed, PsycInfo, Web of Science) for internet-based physical activity interventions among adults yields fewer than 25 studies. Although many have considered physical activity as one element of a multifactorial behavioural intervention, few have focused exclusively on changing sedentary behaviour. Overall, current results are encouraging and it appears that response to an internet-based physical activity intervention is similar to response to other more established, effective interventions. Given that primary care referrals for physical activity are successful in changing sedentary behaviour to some extent, there is an urgent need for investigations into the effect of using an internet-based physical activity programme within the context of primary care. Although no studies that have combined an established internet-based physical activity programme with primary care were found, there is evidence that significant progress would probably be made by providing clinicians with information on internet-based physical activity programmes.

Development of Alive! (A Lifestyle Intervention Via Email), and its effect on health-related quality of life, presenteeism, and other behavioral outcomes: randomized controlled trial

BACKGROUND

Cost-effective interventions to improve diet and physical activity are a public health priority. Alive! is an email-based intervention to increase physical activity, reduce saturated and trans fats and added sugars, and increase fruit and vegetable consumption. It was shown to improve these behaviors in a large randomized controlled trial.

OBJECTIVE

(1) To describe the components and behavioral principles underlying Alive!, and (2) to report effects of the intervention on the secondary outcomes: health-related quality of life, presenteeism, self-efficacy, and stage of change.

METHODS

The Alive! behavior change model is designed to elicit healthy behaviors and promote their maintenance. Behavioral strategies include assessments followed by individualized feedback, weekly goal-setting, individually tailored goals and tips, reminders, and promotion of social support. Alive! was tested among non-medical employees of Kaiser Permanente of Northern California, who were randomized to either the intervention group or the wait-list control group. After randomization, intervention group participants chose one topic to undertake for the intervention period: increasing physical activity, increasing fruits and vegetables, or decreasing saturated and trans fats and added sugars. Pre-post questionnaires assessed changes in SF-8 health-related quality of life, presenteeism, self-efficacy, and stage of change. Mixed effects multiple linear regression and ordinal logistic regression models were used, with department as a random effect factor. Analyses were by intention to treat: the 30% (238/787) who did not respond to the follow-up questionnaires were assigned change scores of zero.

RESULTS

Participants were 19 to 65 years (mean 44.0 +/- 10.6), and 74.3% (585/787) were female. Mean SF-8 Physical quality of life score increased significantly more in the intervention group than in the control group, 1.84 (95% CI 0.96-2.72) vs 0.72 (95% CI -0.15-1.58) respectively, P = .02. SF8 Mental score also improved significantly more in the intervention group than in the control group (P = .02). The odds ratio for improvement in self-assessed health status was 1.57 (95% CI 1.21-2.04, P < .001) for the intervention group compared to the control group. The odds ratio for having a reduction in difficulty accomplishing work tasks because of physical or emotional problems, a measure of presenteeism, was 1.47 (95% CI 1.05-2.05, P = .02) for the intervention group compared to the control group. The odds of having an improvement in self-efficacy for changing diet was 2.05 (95% CI 1.44-2.93) for the intervention vs the control group (P < .001). Greater improvement in stage of change for physical activity (P = .05), fats (P = .06), and fruits/vegetables (P = .006) was seen in the intervention group compared to the control group. Significant effects on diet and physical activity behavior change are reported elsewhere.

CONCLUSIONS

Cost-effective methods that can reach large populations with science-based interventions are urgently needed. Alive! is a fully automated low-cost intervention shown to effect significant improvements in important health parameters.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00607009; http://clinicaltrials.gov/ct2/show/NCT00607009 (Archived by WebCite at http://www.webcitation.org/5cLpCWcT6).

User attitudes towards physical activity websites in a randomized controlled trial

OBJECTIVE

To better understand the mixed findings regarding the efficacy of Internet-based physical activity interventions, we examined the use and usefulness of particular website components that may lead to improvements in intervention efficacy.

METHOD

Participants were sedentary individuals from a 12-month randomized controlled physical activity trial conducted in Providence, Rhode Island and Pittsburgh, Pennsylvania from 2003-2006. The present study included participants from the Tailored Internet arm (n=81; instantaneous web-based tailored feedback to participants) or the Standard Internet arm (n=82; websites currently available to the public). We obtained objective data via the intervention websites and subjective usefulness data via questionnaires.

RESULTS

The Tailored Internet arm logged onto their website significantly more times than the Standard Internet arm (median 50 vs. 38; p<.05). Among participants in the Tailored Internet arm, the self-monitoring feature (i.e., logging) followed by goal setting were rated as the most useful website components.

CONCLUSION

Logins in the current study were substantially higher compared to previous studies. Participants endorsed goal setting and self-monitoring as being most useful, which are critical components for health behavior change. Future studies should continue to examine these features and improve the perceived usefulness of other theory-based strategies.

Innovation in practice: mobile phone technology in patient care

Mobile phones are becoming increasingly important in everyday life and now in healthcare. There has been a steady growth of information and communication technologies in health communication and technology is used progressively in telemedicine, wireless monitoring of health outcomes in disease and in the delivery of health interventions. Mobile phones are becoming an important method of encouraging better nurse-patient communication and will undoubtedly increase in application over coming years. This article presents recent developments and applications of mobile technology for health promotion and patient-monitoring in chronic disease.

Diabetes self-management care via cell phone: a systematic review

BACKGROUND

The objective of this study was to evaluate the evidence on the impact of cell phone interventions for persons with diabetes and/or obesity in improving health outcomes and/or processes of care for persons with diabetes and/or obesity.

METHODS

We searched Medline (1966-2007) and reviewed reference lists from included studies and relevant reviews to identify additional studies. We extracted descriptions of the study design, sample size, patient age, duration of study, technology, educational content and delivery environment, intervention and control groups, process and outcome measures, and statistical significance.

RESULTS

In this review, we included 20 articles, representing 18 studies, evaluating the use of a cell phone for health information for persons with diabetes or obesity. Thirteen of 18 studies measured health outcomes and the remaining 5 studies evaluated processes of care. Outcomes were grouped into learning, behavior change, clinical improvement, and improved health status. Nine out of 10 studies that measured hemoglobin A1c reported significant improvement among those receiving education and care support. Cell phone and text message interventions increased patient-provider and parent-child communication and satisfaction with care.

CONCLUSIONS

Providing care and support with cell phones and text message interventions can improve clinically relevant diabetes-related health outcomes by increasing knowledge and self-efficacy to carry out self-management behaviors.

Internet-delivered behavior change program increases physical activity and improves cardiometabolic disease risk factors in sedentary adults: results of a randomized controlled trial

OBJECTIVES

To determine whether the Active Living Every Day (ALED-I) internet-delivered theory-based physical activity (PA) behavior change program increases PA and improves cardiometabolic disease risk factors (CDRF) in sedentary overweight adults.

METHODS

The study was a randomized control trial that took place in southern Wyoming and northern Colorado from 2005-2007. Thirty-two men and women (21-65 years) were randomized to a 16-week ALED-I intervention (n=14; age=41.4+/-3.7 years; BMI=32.3+/-1.3 kg/m(2)) or a delayed intent-to-treat control condition (n=18; age=49.4+/-1.7 years; BMI=30.6+/-0.8 kg/m(2)). At baseline and post-intervention, PA by pedometer and CDRFs were measured.

RESULTS

Both groups had similar baseline PA levels. ALED-I increased PA by an average of 1384 steps/day (p=0.03) compared to 816 steps/day (p=0.14) for the control group. Waist circumference (100.6+/-2.4 vs. 96.6+/-2.7 cm) and Coronary Risk Ratio (5.1+/-0.3 vs. 4.7+/-0.3) decreased in the ALED-I group and did not change in the control group (99.2+/-2.2 vs.99.8+/-2.1 cm) and (3.7+/-0.1 vs. 3.7+/-0.1), respectively.

CONCLUSIONS

The internet-delivered ALED program increased PA and improved some CDRFs in sedentary overweight/obese adults. To our knowledge, this is the first efficacy trial of the internet-delivered ALED program. Further studies are warranted due to the reach and cost-effectiveness of internet-delivered PA programs.

Randomized controlled trial of an internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: pilot study

Background

People with chronic obstructive pulmonary disease (COPD) continue to experience dyspnea with activities of daily living (ADL) despite optimal medical management. Information and communication technologies may facilitate collaborative symptom management and could potentially increase the reach of such interventions to those who are unable to attend face-to-face pulmonary rehabilitation or self-management programs.

Objective

The purpose of this randomized study was to test the efficacy of two 6-month dyspnea self-management programs, Internet-based (eDSMP) and face-to-face (fDSMP), on dyspnea with ADL in people living with COPD.

Methods

We randomly assigned 50 participants with moderate to severe COPD who were current Internet users to either the eDSMP (n = 26) or fDSMP (n = 24) group. The content of the two programs was similar, focusing on education, skills training, and ongoing support for dyspnea self-management, including independent exercise. The only difference was the mode (Internet/personal digital assistant [PDA] or face-to-face) in which the education sessions, reinforcement contacts, and peer interactions took place. Participants returned to one of two academic clinical sites for evaluation at 3 and 6 months. The primary outcome of dyspnea with ADL was measured with the Chronic Respiratory Questionnaire. Secondary outcomes of exercise behavior, exercise performance, COPD exacerbations, and mediators, such as self-efficacy and social support, were also measured. A satisfaction survey was administered and a semistructured exit interview was conducted at the final visit.

Results

The study was stopped early due to multiple technical challenges with the eDSMP, but follow-up was completed on all enrolled participants. Data were available for 39 participants who completed the study (female: 44%; age: 69.5 ± 8.5 years; percent predicted forced expiratory volume in 1 s: 49.6 ± 17.0%). The fDSMP and eDSMP showed similar clinically meaningful changes in dyspnea with ADL from baseline to 3 months (fDSMP: + 3.3 points; eDSMP: + 3.5 points) and sustained these improvements at 6 months (fDSMP: + 4.0 points; eDSMP: + 2.5 points; time effects P < .001; group by time P = .51). Self-reported endurance exercise time (P = .001), physical functioning (P = .04), and self-efficacy for managing dyspnea (P = .02) also showed positive improvements over time in both groups with no significant differences with respect to program modality. Participants who completed the study reported favorable satisfaction with the programs.

Conclusions

Although there were numerous technical challenges with the eDSMP, both dyspnea self-management programs were effective in reducing dyspnea with ADL in the short term. Our findings will need to be confirmed in a larger randomized trial with more mature Web and personal digital assistant tools, use of a control group, and longer follow-up.

Trial registration

clinicaltrials.gov NCT00102401, http://www.webcitation.org/5X8CX4gLC

Feasibility of a mobile phone-based data service for functional insulin treatment of type 1 diabetes mellitus patients

Background

Patients with type 1 diabetes mellitus (DM1) have to be active participants in their treatment because they are inevitably responsible for their own day-to-day-care. Availability of mobile Internet access is advancing rapidly and mobile phones are now widely available at low cost. Thus, mobile phones have the potential to assist in daily diabetes management and to enable a telemedical interaction between patients and health care professionals.

Objective

The aim of the study was to evaluate the feasibility and user acceptance of a mobile phone–based data service to assist DM1 patients on intensive insulin treatment.

Methods

A software application called Diab-Memory (based on Java 2 Mobile Edition) has been developed to support patients when entering diabetes-related data with synchronization to the remote database at the monitoring center. The data were then processed to generate statistics and trends, which were provided for the patient and his/her health care professional via a Web portal. The system has been evaluated in the course of a clinical before-after pilot trial. Outcome measures focused on patients’ adherence to the therapy, availability of the monitoring system, and the effects on metabolic status. General user acceptance of the system was evaluated using a questionnaire.

Results

Ten patients (four female) with DM1 participated in the trial. Mean age was 36.6 years (± 11.0 years) and prestudy glycated hemoglobin (HbA_1c) was 7.9% (± 1.1%). A total of 3850 log-ins were registered during the 3 months of the study. The total number of received datasets was 13003, which equates to an average of 14 transmitted parameters per patient per day. The service was well accepted by the patients (no dropouts), and data transmission via mobile phone was successful on the first attempt in 96.5% of cases. Upon completion of the study, a statistically significant improvement in metabolic control was observed (HbA_1c: prestudy 7.9% ± 1.1% versus poststudy 7.5% ± 0.9%;P= .02). While there was a slight decrease in average blood glucose level (prestudy 141.8 mg/dL ± 22.5 mg/dL vs poststudy 141.2 mg/dL ± 23.1 mg/dL;P= .69), the difference was not statistically significant.

Conclusion

The results of the clinical pilot trial indicate that this proposed diabetes management system was well accepted by the patients and practical for daily usage. Thus, using the mobile phone as patient terminal seems to provide a ubiquitous, easy-to-use, and cost efficient solution for patient-centered data acquisition in the management of DM1. To confirm the promising results of the pilot trial further research has to be done to study long-term effects on glycemic control and cost-effectiveness.

A review of web-assisted interventions for diabetes management: maximizing the potential for improving health outcomes

Current endeavors in diabetes care focus on helping patients and providers deal successfully with the complexities of the disease by improving the system of care, expanding the reach of interventions, and empowering patients to engage in self-care behaviors. Internet technologies that combine the broad reach of mass media with the interactive capabilities of interpersonal media provide a wide range of advantages over standard modes of delivery. The technical affordances of Web delivery enable individualization or tailoring, appropriately timed reinforcement of educational messages, social support, improved feedback, and increased engagement. In turn, these have been significantly correlated with improved health outcomes.This article is a narrative review of Web-based interventions for managing type 2 diabetes published from 2000 to 2007 that utilize Web sites, Web portals, electronic medical records, videoconference, interactive voice response, and short messaging systems. The most effective systems link medical management and self-management. Patient satisfaction is highest when the Web-based system gives them the ability to track blood glucose, receive electronic reminders, schedule physician visits, email their health care team, and interact with other diabetic patients. However, comprehensive medical and self-management programs have not been implemented widely outside of systems funded by government agencies. The cost of developing and maintaining comprehensive systems continues to be a challenge and is seldom measured in efficacy studies. Lack of reimbursement for Web-based treatments is also a major barrier to implementation. These barriers must be overcome for widespread adoption and realization of subsequent cost savings.