Effectiveness of a computer-tailored print-based physical activity intervention among French Canadians with type 2 diabetes in a real-life setting

Effectiveness of Computer-Tailored Health Communication in Increasing Physical Activity in People With or at Risk of Long-Term Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Regular physical activity (PA) is beneficial for enhancing and sustaining both physical and mental well-being as well as for the management of preexisting conditions. Computer-tailored health communication (CTHC) has been shown to be effective in increasing PA and many other health behavior changes in the general population. However, individuals with or at risk of long-term conditions face unique barriers that may limit the applicability of CTHC interventions to this population. Few studies have focused on this cohort, providing limited evidence for the effectiveness of CTHC in promoting PA.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effectiveness of CTHC in increasing PA in individuals with or at risk of long-term conditions.

METHODS

A systematic review and meta-analysis were conducted to evaluate the effect of CTHC in increasing PA in people with or at risk of long-term conditions. Hedges g was used to calculate the mean effect size. The total effect size was pooled and weighted using inverse variance. When possible, potential moderator variables were synthesized, and their effectiveness was evaluated by subgroups analysis with Q test for between-group heterogeneity Qb. Potential moderator variables included behavior change theories and models providing the fundamental logic for CTHC design, behavior change techniques and tailoring strategies to compose messages, and computer algorithms to achieve tailoring. Several methods were used to examine potential publication bias in the results, including the funnel plot, Egger test, Begg test, fail-safe N test, and trim-and-fill method.

RESULTS

In total, 24 studies were included in the systematic review for qualitative analysis and 18 studies were included in the meta-analysis. Significant small to medium effect size values were found when comparing CTHC to general health information (Hedges g=0.16; P<.001) and to no information sent to participants (Hedges g=0.29; P<.001). Half of the included studies had a low to moderate risk of bias, and the remaining studies had a moderate to high risk of bias. Although the results of the meta-analysis indicated no evidence of publication bias, caution is required when drawing definitive conclusions due to the limited number of studies in each subgroup (N≤10). Message-tailoring strategies, implementation strategies, behavior change theories and models, and behavior change techniques were synthesized from the 24 studies. No strong evidence was found from subgroup analyses on the effectiveness of using particular behavior change theories and models or from using particular message-tailoring and implementation strategies.

CONCLUSIONS

This study demonstrates that CTHC is effective in increasing PA for people with or at risk of long-term conditions, with significant small to medium effects compared with general health information or no information. Further studies are needed to guide design decisions for maximizing the effectiveness of CTHC.

A Web-Based Computer-Tailored Program to Improve Treatment Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial

Background

Adherence to core type 2 diabetes mellitus (T2DM) treatment behaviors is suboptimal, and nonadherence is generally not limited to one treatment behavior. The internet holds promise for programs that aim to improve adherence. We developed a computer-tailored eHealth program for patients with T2DM to improve their treatment adherence, that is, adherence to both a healthy lifestyle and medical behaviors.

Objective

The objective of this study is to examine the effectiveness of the eHealth program in a randomized controlled trial.

Methods

Patients with T2DM were recruited by their health professionals and randomized into either the intervention group, that is, access to the eHealth program for 6 months, or a waiting-list control group. In total, 478 participants completed the baseline questionnaire, of which 234 gained access to the eHealth program. Of the 478 participants, 323 were male and 155 were female, the mean age was 60 years, and the participants had unfavorable BMI and HbA_1c levels on average. Outcome data were collected through web-based assessments on physical activity (PA) levels, caloric intake from unhealthy snacks, and adherence to oral hypoglycemic agents (OHAs) and insulin therapy. Changes to separate behaviors were standardized and summed into a composite change score representing changes in the overall treatment adherence. Further standardization of this composite change score yielded the primary outcome, which can be interpreted as Cohen d (effect size). Standardized change scores observed in separate behaviors acted as secondary outcomes. Mixed linear regression analyses were conducted to examine the effectiveness of the intervention on overall and separate treatment behavior adherence, accommodating relevant covariates and patient nesting.

Results

After the 6-month follow-up assessment, 47.4% (111/234) of participants in the intervention group and 72.5% (177/244) of participants in the control group were retained. The overall treatment adherence improved significantly in the intervention group compared with the control group, reflected by a small effect size (d=0.27; 95% CI 0.032 to 0.509; P=.03). When considering changes in separate treatment behaviors, a significant decrease was observed only in caloric intake from unhealthy snacks in comparison with the control group (d=0.36; 95% CI 0.136 to 0.584; P=.002). For adherence to PA (d=−0.14; 95% CI −0.388 to 0.109; P=.27), OHAs (d=0.27; 95% CI −0.027 to 0.457; P=.08), and insulin therapy (d=0.35; 95% CI −0.066 to 0.773; P=.10), no significant changes were observed. These results from the unadjusted analyses were comparable with the results of the adjusted analyses, the per-protocol analyses, and the sensitivity analyses.

Conclusions

Our multibehavior program significantly improved the overall treatment adherence compared with the control group. To further enhance the impact of the intervention in the personal, societal, and economic areas, a wide-scale implementation of our eHealth intervention is suggested.

Trial Registration

Netherlands Trial Register NL664; https://www.trialregister.nl/trial/6664

A web-based program to improve treatment adherence in patients with type 2 diabetes: Development and study protocol

BACKGROUND

Many patients with type 2 diabetes mellitus (T2DM) sub-optimally adhere to core treatment recommendations, such as healthy diets, sufficient physical activity and pharmacological support. This paper describes the development of the web-based computer-tailored program My Diabetes Profile (MDP), incorporating identified success factors of web-based interventions, and the protocol for testing the effectiveness of this program in a randomized multicentre trial.

METHODS

Formative research - including the input of a program committee, qualitative and quantitative studies with patients and health professionals and a literature search - yielded input for the development of the MDP program. MDP provides video and text tailored advice, based on determinants and salient beliefs derived from the I-Change Model, on decreasing unhealthy snack intake, increasing physical activity, and improving adherence to both oral blood glucose lowering drugs and self-administered insulin therapy. Patients with T2DM recruited by practice nurses and diabetes nurses across the Netherlands fill in online questionnaires at baseline and six-months follow-up. Participants are randomized on patient level to the intervention group (access to the MDP program) or control group (receiving care as usual).

DISCUSSION

The formative research using co-creation principles proved essential in the development of the MDP program and involved various disciplines in T2DM management including target group representatives. Co-creation revealed clearly that patients needed short and attractive messages. Consequently, a mix of video and short text messages were chosen for the ultimate program format. Pilot testing was useful to further shape the program to needs of patients and professionals.

TRIAL REGISTRATION

Dutch Trial Register NTR6840; Archived program website: http://www.webcitation.org/6xXz01S7X.

Effectiveness of Computer Tailoring Versus Peer Support Web-Based Interventions in Promoting Physical Activity Among Insufficiently Active Canadian Adults With Type 2 Diabetes: Protocol for a Randomized Controlled Trial

BACKGROUND

Type 2 diabetes is a major challenge for Canadian public health authorities, and regular physical activity is a key factor in the management of this disease. Given that less than half of people with type 2 diabetes in Canada are sufficiently active to meet the Canadian Diabetes Association's guidelines, effective programs targeting the adoption of regular physical activity are in demand for this population. Many researchers have argued that Web-based interventions targeting physical activity are a promising avenue for insufficiently active populations; however, it remains unclear if this type of intervention is effective among people with type 2 diabetes.

OBJECTIVE

This research project aims to evaluate the effectiveness of two Web-based interventions targeting the adoption of regular aerobic physical activity among insufficiently active adult Canadian Francophones with type 2 diabetes.

METHODS

A 3-arm, parallel randomized controlled trial with 2 experimental groups and 1 control group was conducted in the province of Quebec, Canada. A total of 234 participants were randomized at a 1:1:1 ratio to receive an 8-week, fully automated, computer-tailored, Web-based intervention (experimental group 1); an 8-week peer support (ie, Facebook group) Web-based intervention (experimental group 2); or no intervention (control group) during the study period.

RESULTS

The primary outcome of this study is self-reported physical activity level (total min/week of moderate-intensity aerobic physical activity). Secondary outcomes are attitude, social influence, self-efficacy, type of motivation, and intention. All outcomes are assessed at baseline and 3 and 9 months after baseline with a self-reported questionnaire filled directly on the study websites.

CONCLUSIONS

By evaluating and comparing the effectiveness of 2 Web-based interventions characterized by different behavior change perspectives, findings of this study will contribute to advances in the field of physical activity promotion in adult populations with type 2 diabetes.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): ISRCTN15747108; http://www.isrctn.com/ISRCTN15747108 (Archived by WebCite at http://www.webcitation.org/6eJTi0m3r).

Predicting intentions and behaviours in populations with or at-risk of diabetes: A systematic review

Purpose

To systematically review the Theory of Planned Behaviour studies predicting self-care intentions and behaviours in populations with and at-risk of diabetes.

Methods

A systematic review using six electronic databases was conducted in 2013. A standardised protocol was used for appraisal. Studies eligibility included a measure of behaviour for healthy eating, physical activity, glucose monitoring, medication use (ii) the TPB variables (iii) the TPB tested in populations with diabetes or at-risk.

Results

Sixteen studies were appraised for testing the utility of the TPB. Studies included cross-sectional (n = 7); prospective (n = 5) and randomised control trials (n = 4). Intention (18%–76%) was the most predictive construct for all behaviours. Explained variance for intentions was similar across cross-sectional (28–76%); prospective (28–73%); and RCT studies (18–63%). RCTs (18–43%) provided slightly stronger evidence for predicting behaviour.

Conclusions

Few studies tested predictability of the TPB in populations with or at-risk of diabetes. This review highlighted differences in the predictive utility of the TPB suggesting that the model is behaviour and population specific. Findings on key determinants of specific behaviours contribute to a better understanding of mechanisms of behaviour change and are useful in designing targeted behavioural interventions for different diabetes populations.

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Intention was the most predictive construct for diabetes self-care behaviours (18% – 76% of explained variance).

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Studies included cross-sectional (n = 7); prospective (n = 5) and randomised control trials (n = 4).

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Explained variance for intentions were similar across the study designs and RCTs provided slightly stronger evidence for predicting diabetes-related behaviour.

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The predictive utility of the TPB is behaviour specific and depends largely on the target population.

Psychenet.de: Development and process evaluation of an e-mental health portal

BACKGROUND

E-mental health interventions can have a positive impact on patient-reported and clinical outcomes. The purpose of this project was to develop a user-centered e-mental health portal.

METHODS

The development of the portal www.psychenet.de included mixed-methods techniques for needs assessment to identify user-relevant content. Furthermore, user-centered design techniques were applied by utilizing individual usability testing with cognitive task analysis. First, a basic version of the portal was created and introduced to the public by means of a media campaign. After the development of module-specific content, exposure and use of the portal was investigated as part of a process evaluation.

RESULTS

Relevant content identified by needs assessment covered both, overarching and diagnosis-specific topics. Results of the process evaluation showed a highly accessed website. During the first 18 months, 119,423 visits were tracked. The portal was predominantly accessed by Google searches (73.9%), while 17.6% of visits were related to direct traffic.

DISCUSSION

Serving as a complement to face-to-face consultations, www.psychenet.de attempts to inform about mental disorders, and engage patients in the course of their treatment. Results of the process evaluation confirm the high relevance and potential of the portal and can be used for further improvements and extensions in the future.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.

A tailored, interactive health communication application for patients with type 2 diabetes: study protocol of a randomised controlled trial

BACKGROUND

Type 2 diabetes is an increasingly common chronic condition whose prognosis can be improved by patient involvement and self-management. Patient involvement can be fostered by web-based Interactive Health Communication Applications (IHCAs) combining health information with decision support, social support and/or behaviour change support. They reach great numbers of patients at low cost and provide high-quality information and support at the time, place and learning speed patients prefer. Still, online tools often suffer from high attrition. Tailoring content and tone of IHCAs to the individual patient´s needs might improve their effectiveness. This study aims to test the effectiveness and usage of a tailored IHCA combining health information with decision support and behaviour change support for patients with type 2 diabetes.

METHODS/DESIGN

The effectiveness and usage of the tailored IHCA will be tested against a standard website with identical content in a single-blinded randomized trial with a parallel design. The content covers information on type 2 diabetes, its complications and sequelae, and its treatment options including health behaviour. In the intervention group the content is delivered in dialogue form, tailored to relevant patient characteristics (health literacy, attitudes towards self-care, and barriers to insulin treatment). In the control group the different sections are presented in a content tree, without any tailoring. Participants are blinded to group assignment. Eligibility criteria are age ≥ 18 years, self-reported type 2 diabetes, and Internet access. The study aims to include 414 participants in order to detect the expected small effect (Cohen's d=0.2), with measurements at baseline, directly after the first visit, and at 3-month follow-up. The primary hypothesis is that the tailored IHCA has larger effects on diabetes knowledge and patient empowerment (primary outcomes) than the standard website. Secondary outcomes are website usage as well as decisional conflict and preparation for decision making. All measurements are online self-report questionnaires.

DISCUSSION

IHCAs are a promising way to foster diabetes knowledge and self-management competencies. The present trial tries to increase the knowledge on how to develop more effective IHCAs for patients with type 2 diabetes.

TRIAL REGISTRATION

International Clinical Trials Registry DRKS00003322.

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.