Program completion of a web-based tailored lifestyle intervention for adults: differences between a sequential and a simultaneous approach

Use and Appreciation of a Web-Based, Computer-Tailored Diet and Physical Activity Intervention Based on the Self-determination Theory: Evaluation Study of Process and Predictors

Background

eHealth is a promising tool for promoting lifestyle behaviors such as a healthy diet and physical activity (PA). However, making people use interventions is a crucial and challenging problem in eHealth. More insight into use patterns and predicting factors is needed to improve future interventions.

Objective

This study aims to examine the use, predictors of use, and appreciation of a web-based, computer-tailored, dietary and PA promotion intervention, MyLifestyleCoach, which is based on the self-determination theory. First, we depict the participants’ flow in the intervention and identify moments when they are likely to discontinue use. Second, we investigate whether demographic, motivational, and program-related characteristics predict the use of several intervention elements. Finally, we report the appreciation scores for the intervention and the participant and program characteristics associated with these scores.

Methods

This study was based on data from web-based self-report questionnaires. Here, objectively assessed intervention use data were analyzed from participants randomized to the intervention condition. Multiple stepwise (logistic) regression analyses were conducted to examine the predictors of intervention use and evaluation scores.

Results

Our findings indicate a low full completion rate for the intervention among those who chose and completed the diet module (49/146, 33.6%), the PA module (2/12, 17%), and both modules (58/273, 21.2%). Several points in the intervention where participants were likely to stop using the intervention were identified. Autonomous and intrinsic motivation toward diet were related to the completion of the initial sessions of the intervention (ie, the opening session in which participants could choose which module to follow and the first session of the diet module). In contrast, controlled motivation was linked to the completion of both modules (initial and follow-up sessions). Appreciation scores were somewhat positive. Appreciation was predicted by several motivational constructs, such as amotivation and basic psychological needs (eg, competence) and program-related features (eg, number of completed sessions).

Conclusions

This study adds meaningful information on the use and appreciation of a web-based, computer-tailored dietary and PA intervention, MyLifestyleCoach. The results indicate that different types of motivations, such as extrinsic and intrinsic motivation, are at play at the points when people are likely to stop using the intervention. The intervention was appreciated fairly well, and several motivational constructs and fulfillment of basic psychological needs were associated with appreciation. Practical implications of these findings have been provided in this study.

Self-regulatory behaviour change techniques in interventions to promote healthy eating, physical activity, or weight loss: a meta-review

Poor quality diet, physical inactivity, and obesity are prevalent, covariant risk factors for chronic disease, suggesting that behaviour change techniques (BCTs) that effectively change one risk factor might also improve the others. To examine that question, registered meta-review CRD42019128444 synthesised evidence from 30 meta-analyses published between 2007 and 2017 aggregating data from 409,185 participants to evaluate whether inclusion of 14 self-regulatory BCTs in health promotion interventions was associated with greater improvements in outcomes. Study populations and review quality varied, with minimal overlap among summarised studies. AMSTAR-2 ratings averaged 37.31% (SD = 16.21%; range 8.33-75%). All BCTs were examined in at least one meta-analysis; goal setting and self-monitoring were evaluated in 18 and 20 reviews, respectively. No BCT was consistently related to improved outcomes. Although results might indicate that BCTs fail to benefit diet and activity self-regulation, we suggest that a Type 3 error occurred, whereby the meta-analytic research design implemented to analyse effects of multi-component intervention trials designed for a different purpose was mismatched to the question of how BCTs affect health outcomes. An understanding of independent and interactive effects of individual BCTs on different health outcomes and populations is needed urgently to ground a cumulative science of behaviour change.

Large-scale systematic analysis of exposure to multiple cancer risk factors and the associations between exposure patterns and cancer incidence

Exposures to cancer risk factors such as smoking and alcohol are not mutually independent. We aimed to identify risk factor exposure patterns and their associations with sociodemographic characteristics and cancer incidence. We considered 120,771 female and, separately, 100,891 male participants of the Australian prospective cohort 45 and Up Study. Factor analysis grouped 36 self-reported variables into 8 combined factors each for females (largely representing 'smoking', 'alcohol', 'vigorous exercise', 'age at childbirth', 'Menopausal Hormone Therapy', 'parity and breastfeeding', 'standing/sitting', 'fruit and vegetables') and males (largely representing 'smoking', 'alcohol', 'vigorous exercise', 'urology and health', 'moderate exercise', 'standing/sitting', 'fruit and vegetables', 'meat and BMI'). Associations with cancer incidence were investigated using multivariable logistic regression (4-8 years follow-up: 6193 females, 8749 males diagnosed with cancer). After multiple-testing correction, we identified 10 associations between combined factors and cancer incidence for females and 6 for males, of which 14 represent well-known relationships (e.g. bowel cancer: females 'smoking' factor Odds Ratio (OR) 1.16 (95% Confidence Interval (CI) 1.08-1.25), males 'smoking' factor OR 1.15 (95% CI 1.07-1.23)), providing evidence for the validity of this approach. The catalogue of associations between exposure patterns, sociodemographic characteristics, and cancer incidence can help inform design of future studies and targeted prevention programmes.

Predictors of Self-Determined Module Choice in a Web-Based Computer-Tailored Diet and Physical Activity Intervention: Secondary Analysis of Data From a Randomized Controlled Trial

Background

Tailoring an online intervention to participant preferences (eg, by giving participants a choice which modules to follow) may increase engagement in the intervention, motivation for behavioral change, and possibly intervention effects. So far, little is known about what characteristics predict these module choices. Filling this knowledge gap is useful for optimizing program engagement.

Objective

We investigated participant choice for a dietary and/or physical activity (PA) promotion module in our web-based computer-tailored intervention based on self-determination theory (SDT) and motivational interviewing (MI). Furthermore, we investigated which demographic characteristics, current behavior, psychosocial constructs and constructs from SDT and MI, and program-related variables such as advice on which module to follow were associated with these choices.

Methods

Observational data were used from the randomized controlled trial MyLifestyleCoach of participants who were randomized into the intervention condition, completed the baseline questionnaire, and made a module choice in the opening session of the intervention. Here, they received advice on their own dietary and PA behavior. At the session’s end, they chose which lifestyle modules they would like to follow (both, diet, PA, or no module). Measurements included demographic information; self-reported diet and PA; and several psychosocial, SDT, and MI constructs. In total, data from 619 Dutch adults (59.6% women; mean age was 51.9 [SD 13.5] years) were analyzed. A stepwise multinomial logistic regression analysis was conducted to investigate which characteristics are related to module choice; the diet module served as reference category as almost everyone was advised to follow this module.

Results

Of this sample, 54.8% (339/619) chose to do both the diet and PA module, 25.4% (157/619) chose to follow the diet module, 17.8% (110/619) preferred to follow no module, and 2.1% (13/619) chose to do the PA module only. Furthermore, it was found that older people, those who consumed more fruit, and those who scored lower on importance to change their current diet were more likely to choose no module compared to the diet module. People who had more motivation to change their current PA and those who received strong advice compared with slight advice to follow the diet module were more likely to choose both modules compared with the diet module only.

Conclusions

The results show that more than half of the sample was interested in following both the diet and PA module in this online lifestyle intervention. Several characteristics were found to be related to module choice. A future challenge is to examine how this knowledge can be used to improve future interventions, such as tailoring (messages or content) on specific groups or examining where and how MI could be used to motivate people to make a certain module choice.

Trial Registration

Netherlands Trial Register NL7333; https://www.trialregister.nl/trial/7333

A Web-Based, Computer-Tailored Intervention to Reduce Alcohol Consumption and Binge Drinking Among Spanish Adolescents: Cluster Randomized Controlled Trial

Background

Alcohol consumption, including binge drinking (BD) and heavy episodic drinking (HED), is one of the leading risk factors among Spanish adolescents leading to significant social, health, and economic consequences. Reduction of BD and HED in adolescents can be achieved using Web-based, computer-tailored (CT) interventions, providing highly personalized feedback that is adapted to a person’s individual characteristics and needs. Randomized controlled trials assessing the effects of tailored BD reduction programs among Spanish adolescents are scarce.

Objective

The aim of this study was to test the effectiveness of the Web-based, CT intervention Alerta Alcohol, aimed at the prevention of BD in Spanish adolescents. As a secondary outcome, effects on HED, weekly consumption, and any consumption were also assessed. The adherence and process evaluation were assessed.

Methods

A cluster randomized controlled trial conducted among 15 Spanish schools was developed. Each school was randomized into either an experimental condition (EC) (N=742) or a control condition (CC) (N=505). Finally, 351 participants for the EC and 261 for the CC were included in the analysis (N=612). Baseline assessment took place in January and February 2017. Demographic variables and alcohol use were assessed at baseline. Follow-up assessment of alcohol use took place 4 months later in May and June 2017. Participants were compared according to their randomization group (EC versus CC). After the baseline assessment, participants in the EC started the intervention, which consisted of short stories about BD, in which CT feedback was based on the I-Change Model for behavior change. Participants in the CC group only received the baseline questionnaire. Effects of the intervention were assessed using a three-level mixed logistic regression analysis for BD, HED, and any consumption, and a three-level mixed linear regression analysis for weekly consumption.

Results

In total, 1247 adolescents participated in the baseline assessment and 612 participated in the follow-up assessment; the attrition rate was 50.92%. The intervention was effective in reducing HED among adolescents; the odds of HED in the CC was nine times that in the experimental condition (P=.04). No effects were found for BD, weekly consumption, and any consumption. Process evaluations revealed that the adolescents were satisfied with the program (68.8%), would use the program again (52.9%), and would recommend it to someone else (62.8%). Females and non-binge drinkers showed better responses in the process evaluation.

Conclusions

Our intervention was effective regarding HED but not regarding BD, weekly consumption, and any consumption. It may be that limiting alcohol consumption to prevent HED was easier in the Spanish context than it was to carry out further steps, such as reducing other patterns of alcohol consumption. Hence, additional actions are needed to accomplish these latter goals, including community approaches and policy actions aimed at denormalizing alcohol consumption among Spanish adolescents.

Trial Registration

ClinicalTrials.gov NCT03288896; https://clinicaltrials.gov/ct2/show/NCT03288896

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-018-5346-4

Health information overload among health consumers: A scoping review

OBJECTIVE

To examine and identify the scope of research addressing health information overload in consumers.

METHODS

In accordance with a published protocol, six electronic databases (PubMed, CINAHL, ERIC, PsycINFO, Embase, and Scopus), reference lists of included articles, and grey literature (Google Advanced Search and WorldCat) were searched. Articles in English were included, without any limit on the date of publication.

RESULTS

Of the 69 records included for final analysis, 22 studies specifically examined health information overload, whereas the remainder peripherally discussed the concept alongside other concepts. The 22 studies focused on one or more of the following: 1) ways to measure health information overload (multi-item/single-item scales); 2) predictors of health information overload - these included low education level, health literacy, and socioeconomic status; and 3) interventions to address information overload, such as videotaped consultations or written materials. Cancer information overload was a popular topic amongst studies that focused on information overload.

CONCLUSION

Based on the identified studies, there is a clear need for future studies that investigate health information overload in consumers with chronic medical conditions other than cancer.

PRACTICE IMPLICATIONS

This review is the initial step in facilitating future efforts to create health information that do not overload consumers.

Recruitment and retention of WIC participants in a longitudinal dietary intervention trial

BACKGROUND

This paper describes strategies and outcomes of techniques to recruit and retain low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in a longitudinal dietary intervention trial.

METHODS

Community engagement strategies, methods to recruit and retain participants, and recruitment and retention rates are reported. Demographic and lifestyle predictors of loss to follow-up, contacts required to reach participants at each data collection point, participant reactions to the recruitment and retention strategies used, and reasons for drop out (assessed among those who discontinued their study involvement) also were examined.

RESULTS

Of 1281 eligible women, 744 were enrolled (58% recruitment rate); retention rates were 87%, 70%, and 55%, respectively, 2 weeks and 3 and 6 months post-intervention. Being unmarried, younger, and having low baseline vegetable intake predicted loss to follow-up. Between 4 and 5 contact attempts and 1 and 2 completed contacts were required to reach participants at each data collection point. Participants endorsed recruiting women while waiting for WIC appointments (as they were accessible, perceived the information provided as informative, and wanted to pass the time) and by word of mouth. Lacking time and loss of interest were commonly reported reasons for not completing assessments and dropout. To improve retention, shortening telephone assessments, conducting the assessments in person, and increasing the amount of incentives were recommended.

CONCLUSION

Despite using recommended strategies, recruitment and retention rates were modest. Research is needed to identify and test approaches to effectively engage WIC-enrolled adults in health intervention trials.

Learning to health yourself: a randomized, tailored self-regulation intervention among custodial employees

This intervention sought to bring about a dietary behavior change among individuals who are vulnerable to negative health outcomes and behaviors. Using a randomized controlled trial, we examined the efficacy of a six-week Education + Self-Regulation intervention against an Education Only condition in reducing saturated fat intake among custodial workers (N = 54). Assessments were made at baseline, 4 weeks, 6 weeks and 6 months. The intervention group reported lower saturated fat intake and greater self-regulation than the Education Only control group throughout the intervention period and higher self-efficacy at week 6. Despite a fading of intervention effect at 6 months, Education + Self-Regulation participants continued to report lower saturated fat intake relative to their baseline. Supplementing health education with self-regulatory skills is an effective strategy for positive health behavior change. The authors provide recommendations for engaging non-clinical health psychologists in community-level chronic disease prevention and health promotion efforts.

Promoting Healthy Eating and Physical Activity Behaviors: A Systematic Review of Multiple Health Behavior Change Interventions Among Cancer Survivors

Multiple health behavior change (MHBC) interventions have great potential for enhancing health and well-being following cancer diagnosis and treatment. However, the characteristics and effects of MHBC interventions remain elusive for cancer survivors. The main purpose of this study was to evaluate the effectiveness of MHBC interventions on healthy eating and physical activity behaviors among cancer survivors. A secondary aim was to examine the effect of using a simultaneous and sequential design approach to MHBC (ie, changing both behaviors at the same time or one after the other). Randomized controlled trials reporting the impact of a MHBC intervention on both healthy eating and physical activity behaviors among cancer survivors were retrieved from MEDLINE, Cochrane Library, and PsycINFO. A total of 27 MHBC interventions were identified; most (92.6%) were designed to promote simultaneous change in both behaviors and assessed end-of-treatment effect among breast cancer survivors. MHBC interventions led by nurses or multidisciplinary teams showed the most compelling evidence for small to moderate improvement in both behaviors, with interventions that lasted ≥17 weeks more likely to improve both behaviors. This study identifies research priorities and provides preliminary evidence for clinical decision making and advancements in MHBC intervention design and delivery for clinical oncology.

A longitudinal study on how implicit attitudes and explicit cognitions synergistically influence physical activity intention and behavior

Background

Strategies to promote physical activity (PA) focus mainly on changing or fostering explicit cognitions and are only modestly effective. Contemporary studies suggest that, as well as explicit cognitions, implicit cognitions influence health behavior, such as PA, and that implicit processes interact with the intention to be active. Relatively little is known about whether implicit processes interact with other explicit cognitions which determine PA intention and behavior, i.e. self-efficacy. The aim of the current study was to investigate the direct effects of explicit cognitions and implicit attitudes on PA behavior as well as interactions between them regarding intention and behavior prediction.

Methods

In a longitudinal study, participants (N = 340) completed self-report measures of explicit cognitions (perceived pros, perceived cons, social norms, social modeling, self-efficacy, intention) and activity levels, as well as a Single-Category Implicit Association Task to measure implicit attitudes towards PA at baseline (T0), and at one (T1) and 3 months thereafter (T2).

Results

Hierarchical multiple regressions revealed that T0-positive implicit attitudes moderated the relationship between T0 self-efficacy and T1 PA. Similarly, T0-neutral implicit attitudes were associated with the relationship between T0 intention and T1 PA. Negative implicit attitudes strengthened the negative relationship between perceived cons and intention at baseline; neutral or positive implicit attitudes strengthened the positive relationship between self-efficacy and intention. At the follow-ups, the relationship between social modeling and intention was strengthened by negative implicit attitudes.

Conclusion

This study revealed important insights into how implicit attitudes and explicit cognitions synergistically predict PA intention and behavior. As well as targeting explicit cognitions, steering a person’s implicit attitude towards a more positive one, i.e. by implicit cognitive trainings, could help to increase both PA intention and behavior.

Electronic supplementary material

The online version of this article (10.1186/s40359-018-0229-0) contains supplementary material, which is available to authorized users.

Promoting Engagement With a Digital Health Intervention (HeLP-Diabetes) Using Email and Text Message Prompts: Mixed-Methods Study

Background

Engagement with digital health interventions (DHIs) may be regarded as a prerequisite for the intervention to achieve positive health or behavior change outcomes. One method employed to promote engagement is the use of prompts such as emails and text messages. However, little is known about the characteristics of prompts that promote engagement. This study explored the association between the content and delivery mode of prompts and the users’ engagement with HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a DHI that aimed to promote self-management in adults with type 2 diabetes.

Objective

The objective of this study was to identify the characteristics of prompts, specifically the content and delivery mode, which were associated with increased engagement.

Methods

This was a mixed-methods study. Email and text message prompts were sent to the registered users of HeLP-Diabetes. Use of the intervention was recorded and examined to identify which email and text message prompts were associated with subsequent visits to the DHI. Characteristics of prompts that were identified as particularly effective or ineffective were explored through think-aloud interviews with the participants.

Results

Of a total of 39 email prompts, 49% (19/39) prompts showed a significant association with subsequent visits to the DHI. However, none of the text message prompts were associated with subsequent visits to the DHI. Furthermore, think-aloud interviews were carried out with 6 experienced participants with type 2 diabetes. The findings suggest that these participants preferred email prompts that were clear, relatively short, and empowering; used nondirective advice; included health professional references; were visually appealing; and contained news and updates.

Conclusions

The findings of this study contribute to the existing evidence supporting the role of email prompts in promoting and maintaining engagement with DHIs. This study described the content of prompts that may be engaging. However, the results should be interpreted with caution, as prompts may be context-specific interventions and the results may not be generalizable across other DHIs or other types of interventions targeting self-management of type 2 diabetes.

Web-Based Intervention for Physical Activity and Fruit and Vegetable Intake Among Chinese University Students: A Randomized Controlled Trial

Background

Ample evidence demonstrates that university students are at high risk for sedentary behaviors and inadequate fruit and vegetable intake (FVI). Internet-based interventions for multiple health behavior appear to be promising in changing such unhealthy habits. Limited randomized controlled trials have tested this assumption among Chinese university students.

Objective

Our objective was to test the efficacy of an 8-week Web-based intervention compared with a control group condition to improve physical activity (PA) and FVI in Chinese university students. The intervention content was based on the health action process approach, and developed on the basis of previous evidence from the Western hemisphere. We evaluated self-reported data including PA and FVI, stages of change for PA and FVI, and motivational (risk perception, outcome expectancies, self-efficacy), volitional (action planning, coping planning, social support), and distal (intention, habit) indicators for PA and FVI, as well as perceived mental health outcomes (quality of life, depression).

Methods

In a randomized controlled trial, we recruited 566 university students from one university in the central region of China during their general physical education class. After random allocation and exclusion of unsuitable participants, we assigned 493 students to 1 of 2 groups: (1) intervention group: first 4 weeks on PA and subsequent 4 weeks on FVI, (2) control group. We conducted 3 Web-based assessments: at the beginning of the intervention (T1, n=493), at the end of the 8-week intervention (T2, n=337), and at a 1-month follow-up after the intervention (T3, n=142). The entire study was conducted throughout the fall semester of 2015.

Results

Significant time ⨯ group interactions revealed superior intervention effects on FVI; motivational, volitional, and distal indicators of FVI; and PA behavior changes, with an effect size (η²) ranging from .08 to .20. In addition, the overall intervention effects were significant for stage progression to the action group from T1 to T2 in PA (χ²₁=11.75, P=.001) and FVI (χ²₁=15.64, P=.03). Furthermore, the intervention effect was seen in the improvement of quality of life (F_3,492=1.23, η²=.03, P=.02).

Conclusions

This study provides evidence for the efficacy of a Web-based multiple health behavior intervention among Chinese university students tested with different outcome variables. Future research should address the high dropout rate and optimize the most effective components of this intervention.

Trial Registration

Clinicaltrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/6pHV1A0G1)

Improving Health and Reducing Comorbidity Associated with HIV: The Development of TAVIE en santé, a Web-Based Tailored Intervention to Support the Adoption of Health Promoting Behaviors among People Living with HIV

Background. In the domain of health behavior change, the deployment and utilization of information and communications technologies as a way to deliver interventions appear to be promising. This article describes the development of a web-based tailored intervention, TAVIE en santé, to support people living with HIV in the adoption of healthy behaviors. Methods. This intervention was developed through an Intervention Mapping (IM) framework and is based on the theory of planned behavior. Results. Crucial steps of IM are the selection of key determinants of behavior and the selection of useful theory-based intervention methods to change the targeted determinants (active ingredients). The content and the sequence of the intervention are then created based on these parameters. TAVIE en santé is composed of 7 interactive web sessions hosted by a virtual nurse. It aims to develop and strengthen skills required for behavior change. Based on an algorithm using individual cognitive data (attitude, perceived behavioral control, and intention), the number of sessions, theory-based intervention methods, and messages contents are tailored to each user. Conclusion. TAVIE en santé is currently being evaluated. The use of IM allows developing intervention with a systematic approach based on theory, empirical evidence, and clinical and experiential knowledge.

Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals

Background

Since the emergence of social media in 2004, a growing percentage of patients use this technology for health related reasons. To reflect on the alleged beneficial and potentially harmful effects of social media use by patients, the aim of this paper is to provide an overview of the extant literature on the effects of social media use for health related reasons on patients and their relationship with healthcare professionals.

Methods

We conducted a systematic literature review on empirical research regarding the effects of social media use by patients for health related reasons. The papers we included met the following selection criteria: (1) published in a peer-reviewed journal, (2) written in English, (3) full text available to the researcher, (4) contain primary empirical data, (5) the users of social media are patients, (6) the effects of patients using social media are clearly stated, (7) satisfy established quality criteria.

Results

Initially, a total of 1,743 articles were identified from which 22 were included in the study. From these articles six categories of patients’ use of social media were identified, namely: emotional, information, esteem, network support, social comparison and emotional expression. The types of use were found to lead to seven identified types of effects on patients, namely improved self-management and control, enhanced psychological well-being, and enhanced subjective well-being, diminished subjective well-being, addiction to social media, loss of privacy, and being targeted for promotion. Social media use by patients was found to affect the healthcare professional and patient relationship, by leading to more equal communication between the patient and healthcare professional, increased switching of doctors, harmonious relationships, and suboptimal interaction between the patient and healthcare professional.

Conclusions

Our review provides insights into the emerging utilization of social media in healthcare. In particular, it identifies types of use by patients as well as the effects of such use, which may differ between patients and doctors. Accordingly, our results framework and propositions can serve to guide future research, and they also have practical implications for healthcare providers and policy makers.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1691-0) contains supplementary material, which is available to authorized users.

Use and Appreciation of a Tailored Self-Management eHealth Intervention for Early Cancer Survivors: Process Evaluation of a Randomized Controlled Trial

BACKGROUND

A fully automated computer-tailored Web-based self-management intervention, Kanker Nazorg Wijzer (KNW [Cancer Aftercare Guide]), was developed to support early cancer survivors to adequately cope with psychosocial complaints and to promote a healthy lifestyle. The KNW self-management training modules target the following topics: return to work, fatigue, anxiety and depression, relationships, physical activity, diet, and smoking cessation. Participants were guided to relevant modules by personalized module referral advice that was based on participants’ current complaints and identified needs.

OBJECTIVE

The aim of this study was to evaluate the adherence to the module referral advice, examine the KNW module use and its predictors, and describe the appreciation of the KNW and its predictors. Additionally, we explored predictors of personal relevance.

METHODS

This process evaluation was conducted as part of a randomized controlled trial. Early cancer survivors with various types of cancer were recruited from 21 Dutch hospitals. Data from online self-report questionnaires and logging data were analyzed from participants allocated to the intervention condition. Chi-square tests were applied to assess the adherence to the module referral advice, negative binominal regression analysis was used to identify predictors of module use, multiple linear regression analysis was applied to identify predictors of the appreciation, and ordered logistic regression analysis was conducted to explore possible predictors of perceived personal relevance.

RESULTS

From the respondents (N=231; mean age 55.6, SD 11.5; 79.2% female [183/231]), 98.3% (227/231) were referred to one or more KNW modules (mean 2.9, SD 1.5), and 85.7% (198/231) of participants visited at least one module (mean 2.1, SD 1.6). Significant positive associations were found between the referral to specific modules (range 1-7) and the use of corresponding modules. The likelihoods of visiting modules were higher when respondents were referred to those modules by the module referral advice. Predictors of visiting a higher number of modules were a higher number of referrals by the module referral advice (β=.136, P=.009), and having a partner was significantly related with a lower number of modules used (β=-.256, P=.044). Overall appreciation was high (mean 7.5, SD 1.2; scale 1-10) and was significantly predicted by a higher perceived personal relevance (β=.623, P=.000). None of the demographic and cancer-related characteristics significantly predicted the perceived personal relevance.

CONCLUSIONS

The KNW in general and more specifically the KNW modules were well used and highly appreciated by early cancer survivors. Indications were found that the module referral advice might be a meaningful intervention component to guide the users in following a preferred selection of modules. These results indicate that the fully automated Web-based KNW provides personal relevant and valuable information and support for early cancer survivors. Therefore, this intervention can complement usual cancer aftercare and may serve as a first step in a stepped-care approach.

TRIAL REGISTRATION

Nederlands Trial Register: NTR3375; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3375 (Archived by WebCite at http://www.webcitation.org/6jo4jO7kb).

The Effect of Tailored Web-Based Feedback and Optional Telephone Coaching on Health Improvements: A Randomized Intervention Among Employees in the Transport Service Industry

Background

Lifestyle-related health problems are an important health concern in the transport service industry. Web- and telephone-based interventions could be suitable for this target group requiring tailored approaches.

Objective

To evaluate the effect of tailored Web-based health feedback and optional telephone coaching to improve lifestyle factors (body mass index—BMI, dietary intake, physical activity, stress, sleep, tobacco and alcohol consumption, disease history, self-perceived health, and motivation to change health habits), in comparison to no health feedback or telephone coaching.

Methods

Overall, 3,876 employees in the Swedish transport services were emailed a Web-based questionnaire. They were randomized into: control group (group A, 498 of 1238 answered, 40.23%), or intervention Web (group B, 482 of 1305 answered, 36.93%), or intervention Web + telephone (group C, 493 of 1333 answered, 36.98%). All groups received an identical questionnaire, only the interventions differed. Group B received tailored Web-based health feedback, and group C received tailored Web-based health feedback + optional telephone coaching if the participants’ reported health habits did not meet the national guidelines, or if they expressed motivation to change health habits. The Web-based feedback was fully automated. Telephone coaching was performed by trained health counselors. Nine months later, all participants received a follow-up questionnaire and intervention Web + telephone. Descriptive statistics, the chi-square test, analysis of variance, and generalized estimating equation (GEE) models were used.

Results

Overall, 981 of 1473 (66.60%) employees participated at baseline (men: 66.7%, mean age: 44 years, mean BMI: 26.4 kg/m²) and follow-up. No significant differences were found in reported health habits between the 3 groups over time. However, significant changes were found in motivation to change. The intervention groups reported higher motivation to improve dietary habits (144 of 301 participants, 47.8%, and 165 of 324 participants, 50.9%, for groups B and C, respectively) and physical activity habits (181 of 301 participants, 60.1%, and 207 of 324 participants, 63.9%, for B and C, respectively) compared with the control group A (122 of 356 participants, 34.3%, for diet and 177 of 356 participants, 49.7%, for physical activity). At follow-up, the intervention groups had significantly decreased motivation (group B: P<.001 for change in diet; P<.001 for change in physical activity; group C: P=.007 for change in diet; P<.001 for change in physical activity), whereas the control group reported significantly increased motivation to change diet and physical activity (P<.001 for change in diet; P<.001 for change in physical activity).

Conclusion

Tailored Web-based health feedback and the offering of optional telephone coaching did not have a positive health effect on employees in the transport services. However, our findings suggest an increased short-term motivation to change health behaviors related to diet and physical activity among those receiving tailored Web-based health feedback.

Comparative efficacy of simultaneous versus sequential multiple health behavior change interventions among adults: A systematic review of randomised trials

BACKGROUND

Growing evidence points to the benefits of addressing multiple health behaviors rather than single behaviors.

PURPOSE

This review evaluates the relative effectiveness of simultaneous and sequentially delivered multiple health behavior change (MHBC) interventions. Secondary aims were to identify: a) the most effective spacing of sequentially delivered components; b) differences in efficacy of MHBC interventions for adoption/cessation behaviors and lifestyle/addictive behaviors, and; c) differences in trial retention between simultaneously and sequentially delivered interventions.

METHODS

MHBC intervention trials published up to October 2015 were identified through a systematic search. Eligible trials were randomised controlled trials that directly compared simultaneous and sequential delivery of a MHBC intervention. A narrative synthesis was undertaken.

RESULTS

Six trials met the inclusion criteria and across these trials the behaviors targeted were smoking, diet, physical activity, and alcohol consumption. Three trials reported a difference in intervention effect between a sequential and simultaneous approach in at least one behavioral outcome. Of these, two trials favoured a sequential approach on smoking. One trial favoured a simultaneous approach on fat intake. There was no difference in retention between sequential and simultaneous approaches.

CONCLUSIONS

There is limited evidence regarding the relative effectiveness of sequential and simultaneous approaches. Given only three of the six trials observed a difference in intervention effectiveness for one health behavior outcome, and the relatively consistent finding that the sequential and simultaneous approaches were more effective than a usual/minimal care control condition, it appears that both approaches should be considered equally efficacious. PROSPERO registration number: CRD42015027876.

Generating and predicting high quality action plans to facilitate physical activity and fruit and vegetable consumption: results from an experimental arm of a randomised controlled trial

Background

In order to improve the transition from an intention to a change in health behaviour, action planning is a frequently used behavioural change method. The quality of action plans in terms of instrumentality and specificity is important in terms of supporting a successful change in health behaviour. Until now, little has been known about the predictors of action plan generation and the predictors of high quality action plans and, therefore, the current study investigates these predictors.

Method

A randomised controlled trial was conducted to improve physical activity (PA) and fruit and vegetable (FV) consumption using a web-based computer tailored intervention. During the 8-week intervention period, participants in the intervention arm (n = 346) were guided (step-by-step) to generate their own action plans to improve their health behaviours. Demographic characteristics, social cognitions, and health behaviour were assessed at baseline by means of self-reporting. Whether participants generated action plans was tracked by means of server registrations within two modules of the intervention.

Results

The action planning component of the intervention regarding physical activity and fruit and vegetable consumption was used by 40.9 and 20.7 % of the participants, respectively. We found that participants who were physically active at baseline were less likely to generate action plans concerning physical activity. With regards to generating fruit and vegetable action plans, participants with a high risk perception and a strong intention to eat fruit and vegetables on a daily basis made more use of the action planning component for this behaviour. Finally, the large majority of the action plans for physical activity (96.6 %) and fruit and vegetable consumption (100 %) were instrumental and about half of the action plans were found to be highly specific (PA = 69.6 %/FV = 59.7 %). The specificity of the action plans is associated with having a relationship and low levels of negative outcome expectancies.

Conclusion

Risk perception and intention are predictors of using the application of action planning. Increasing the motivation to change behaviour should be prioritised in interventions concerning changes in health behaviour before participants are asked to generate action plans. This would also make the intervention suitable for unmotivated people. For those participants who already perform the desired health behaviour prior to the intervention, action plans might be less relevant. Nevertheless, using a guided step-by-step approach to generate action plans resulted in highly instrumental and specific action plans and might be integrated into other interventions concerning changes in health behaviour.

Trial Registration

Netherlands Trial Register: NTR 3706, ClinicalTrials.gov: NCT01909349.

Web-based interventions in multiple sclerosis: the potential of tele-rehabilitation

The World Wide Web is increasingly used in therapeutic settings. In this regard, internet-based interventions have proven effective in ameliorating several health behaviors, amongst them physical activity behavior. Internet-delivered interventions have shown positive effects on physical activity and physical function in persons with MS (pwMS). In this review we give an overview on several online exercise programs for pwMS and discuss the advantages and drawbacks of web-based interventions. Although participants of online exercise programs reported a high acceptance and satisfaction with the intervention, decreasing compliance was a major issue. A possible remedy might be the implementation of game-design elements to increase compliance and long-term adherence to internet-delivered interventions. In addition we believe that the integration of social networks seems to be a promising strategy.

What You Don't Know: Improving Family Health History Knowledge among Multigenerational Families of Mexican Origin

BACKGROUND

This study investigated diabetes and heart disease family health history (FHH) knowledge and changes after providing personalized disease risk feedback.

METHODS

A total of 497 adults from 162 families of Mexican origin were randomized by household to conditions based on feedback recipient and content. Each provided personal and relatives' diabetes and heart disease diagnoses and received feedback materials following baseline assessment. Multivariate models were fitted to identify factors associated with the rate of 'don't know' FHH responses.

RESULTS

At baseline, US nativity was associated with a higher 'don't know' response rate (p = 0.002). Though confounded by country of birth, younger age showed a trend toward higher 'don't know' response rates. Overall, average 'don't know' response rates dropped from 20 to 15% following receipt of feedback (p < 0.001). An intervention effect was noted, as 'don't know' response rates decreased more in households where one family member (vs. all) received supplementary risk assessments (without behavioral recommendations; p = 0.011).

CONCLUSIONS

Limited FHH knowledge was noted among those born in the US and younger participants, representing a key population to reach with intervention efforts. The intervention effect suggests that 'less is more', indicating the potential for too much information to limit health education program effectiveness.

Effects of a Web-Based Computer-Tailored Game to Reduce Binge Drinking Among Dutch Adolescents: A Cluster Randomized Controlled Trial

Background

Binge drinking among Dutch adolescents is among the highest in Europe. Few interventions so far have focused on adolescents aged 15 to 19 years. Because binge drinking increases significantly during those years, it is important to develop binge drinking prevention programs for this group. Web-based computer-tailored interventions can be an effective tool for reducing this behavior in adolescents. Embedding the computer-tailored intervention in a serious game may make it more attractive to adolescents.

Objective

The aim was to assess whether a Web-based computer-tailored intervention is effective in reducing binge drinking in Dutch adolescents aged 15 to 19 years. Secondary outcomes were reduction in excessive drinking and overall consumption during the previous week. Personal characteristics associated with program adherence were also investigated.

Methods

A cluster randomized controlled trial was conducted among 34 Dutch schools. Each school was randomized into either an experimental (n=1622) or a control (n=1027) condition. Baseline assessment took place in January and February 2014. At baseline, demographic variables and alcohol use were assessed. Follow-up assessment of alcohol use took place 4 months later (May and June 2014). After the baseline assessment, participants in the experimental condition started with the intervention consisting of a game about alcohol in which computer-tailored feedback regarding motivational characteristics was embedded. Participants in the control condition only received the baseline questionnaire. Both groups received the 4-month follow-up questionnaire. Effects of the intervention were assessed using logistic regression mixed models analyses for binge and excessive drinking and linear regression mixed models analyses for weekly consumption. Factors associated with intervention adherence in the experimental condition were explored by means of a linear regression model.

Results

In total, 2649 adolescents participated in the baseline assessment. At follow-up, 824 (31.11%) adolescents returned. The intervention was effective in reducing binge drinking among adolescents aged 15 years (P=.03) and those aged 16 years when they participated in at least 2 intervention sessions (P=.04). Interaction effects between excessive drinking and educational level (P=.08) and between weekly consumption and age (P=.09) were found; however, in-depth analyses revealed no significant subgroup effects for both interaction effects. Additional analyses revealed that prolonged use of the intervention was associated with stronger effects for binge drinking. Yet, overall adherence to the intervention was low. Analyses revealed that being Protestant, female, younger, a nonbinge drinker, and having a higher educational background were associated with adherence.

Conclusions

The intervention was effective for adolescents aged 15 and 16 years concerning binge drinking. Prevention messages may be more effective for those at the start of their drinking career, whereas other methods may be needed for those with a longer history of alcohol consumption. Despite using game elements, intervention completion was low.

Trial Registration

Dutch Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by WebCite® at http://www.webcitation.org/6eSJD3FiY)

Use and Effectiveness of a Video- and Text-Driven Web-Based Computer-Tailored Intervention: Randomized Controlled Trial

Background

Many Web-based computer-tailored interventions are characterized by high dropout rates, which limit their potential impact.

Objective

This study had 4 aims: (1) examining if the use of a Web-based computer-tailored obesity prevention intervention can be increased by using videos as the delivery format, (2) examining if the delivery of intervention content via participants’ preferred delivery format can increase intervention use, (3) examining if intervention effects are moderated by intervention use and matching or mismatching intervention delivery format preference, (4) and identifying which sociodemographic factors and intervention appreciation variables predict intervention use.

Methods

Data were used from a randomized controlled study into the efficacy of a video and text version of a Web-based computer-tailored obesity prevention intervention consisting of a baseline measurement and a 6-month follow-up measurement. The intervention consisted of 6 weekly sessions and could be used for 3 months. ANCOVAs were conducted to assess differences in use between the video and text version and between participants allocated to a matching and mismatching intervention delivery format. Potential moderation by intervention use and matching/mismatching delivery format on self-reported body mass index (BMI), physical activity, and energy intake was examined using regression analyses with interaction terms. Finally, regression analysis was performed to assess determinants of intervention use.

Results

In total, 1419 participants completed the baseline questionnaire (follow-up response=71.53%, 1015/1419). Intervention use declined rapidly over time; the first 2 intervention sessions were completed by approximately half of the participants and only 10.9% (104/956) of the study population completed all 6 sessions of the intervention. There were no significant differences in use between the video and text version. Intervention use was significantly higher among participants who were allocated to an intervention condition that matched their preferred intervention delivery format. There were no significant interaction terms for any of the outcome variables; a match and more intervention use did not result in better intervention effects. Participants with a high BMI and participants who felt involved and supported by the intervention were more likely to use the intervention more often.

Conclusions

Video delivery of tailored feedback does not increase the use of Web-based computer-tailored interventions. However, intervention use can potentially be increased by delivering intervention content via participants’ preferred intervention delivery format and creating feelings of relatedness. Because more intervention use was not associated with better intervention outcomes, more research is needed to examine the optimum number of intervention sessions in terms of maximizing use and effects.

Trial Registration

Nederlands Trial Register: NTR3501; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3501 (Archived by WebCite at http://www.webcitation.org/6b2tsH8Pk)

Who Follows eHealth Interventions as Recommended? A Study of Participants' Personal Characteristics From the Experimental Arm of a Randomized Controlled Trial

BACKGROUND

Computer-tailored eHealth interventions to improve health behavior have been demonstrated to be effective and cost-effective if they are used as recommended. However, different subgroups may use the Internet differently, which might also affect intervention use and effectiveness. To date, there is little research available depicting whether adherence to intervention recommendations differs according to personal characteristics.

OBJECTIVE

The aim was to assess which personal characteristics are associated with using an eHealth intervention as recommended.

METHODS

A randomized controlled trial was conducted among a sample of the adult Dutch population (N=1638) testing an intervention aimed at improving 5 healthy lifestyle behaviors: increasing fruit and vegetable consumption, increasing physical activity, reducing alcohol intake, and promoting smoking cessation. Participants were asked to participate in those specific online modules for which they did not meet the national guideline(s) for the respective behavior(s). Participants who started with fewer than the recommended number of modules of the intervention were defined as users who did not follow the intervention recommendation.

RESULTS

The fewer modules recommended to participants, the better participants adhered to the intervention modules. Following the intervention recommendation increased when participants were older (χ(2)1=39.8, P<.001), female (χ(2)1=15.8, P<.001), unemployed (χ(2)1=7.9, P=.003), ill (χ(2)1=4.5, P=.02), or in a relationship (χ(2)1=7.8, P=.003). No significant relevant differences were found between groups with different levels of education, incomes, or quality of life.

CONCLUSION

Our findings indicate that eHealth interventions were used differently by subgroups. The more frequent as-recommended intervention use by unemployed, older, and ill participants may be an indication that these eHealth interventions are attractive to people with a greater need for health care information. Further research is necessary to make intervention use more attractive for people with unhealthy lifestyle patterns.

Tailored eHealth Lifestyle Promotion: Which Behavioral Modules Do Users Prefer?

Health risk behaviors are widespread among adults and often co-occur. eHealth computer-tailored technology provides individuals with personalized feedback regarding multiple lifestyle behaviors. First, the authors investigated individuals' preferences for particular lifestyle modules and hypothesised that health preventive behavior modules would be preferred over addictive behavior modules. Second, characteristics associated with these choices were examined. A web-based questionnaire assessed demographics, health status, and five lifestyle behaviors (i.e., physical activity, fruit consumption, vegetable consumption, alcohol intake and tobacco use) among adults (N = 1,828). Responses were translated into a health risk appraisal outlining whether respondents adhered to the national guidelines for these behaviors. Next, respondents could select one of the lifestyle modules providing personalized advice. More than 60% of the participants failed to meet the guidelines for more than one lifestyle behavior. The physical activity module was the most popular, followed by the smoking and fruit modules. Young adults tended to prefer the physical activity and fruit modules, whereas the vegetable module was more popular among older adults. No consistent pattern was identified for the alcohol and smoking modules. The results support the authors' hypothesis that health preventive behaviors-in particular, physical activity-would be preferred. Although this could imply that physical activity could serve as a gateway behavior when aiming at multiple behavior changes, it is also conceivable that other mechanisms, such as the actual success of behavior change, or the fact that people can choose, may increase chances of multiple behavior change. Hence, mechanisms leading to multiple behavior change need to be further explored.

Cross-behavior associations and multiple health behavior change: A longitudinal study on physical activity and fruit and vegetable intake

This study aimed to examine the interrelation of physical activity and fruit and vegetable intake. The influence of stage congruence between physical activity and fruit and vegetable intake on multiple behavior change was also investigated. Health behaviors, social-cognitions, and stages of change were assessed in 2693 adults at two points in time. Physical activity and fruit and vegetable intake were assessed 4 weeks after the baseline.

Social-cognitions, stages as well as stage transitions across behavior domains were positively interrelated. Stage congruence was not related to changes in physical activity and fruit and vegetable intake. Physical activity and nutrition appear to facilitate rather than hinder each other. Having intentions to change both behaviors simultaneously does not seem to overburden individuals.

Fostering multiple healthy lifestyle behaviors for primary prevention of cancer

The odds of developing cancer are increased by specific lifestyle behaviors (tobacco use, excess energy and alcohol intakes, low fruit and vegetable intake, physical inactivity, risky sexual behaviors, and inadequate sun protection) that are established risk factors for developing cancer. These behaviors are largely absent in childhood, emerge and tend to cluster over the life span, and show an increased prevalence among those disadvantaged by low education, low income, or minority status. Even though these risk behaviors are modifiable, few are diminishing in the population over time. We review the prevalence and population distribution of these behaviors and apply an ecological model to describe effective or promising healthy lifestyle interventions targeted to the individual, the sociocultural context, or environmental and policy influences. We suggest that implementing multiple health behavior change interventions across these levels could substantially reduce the prevalence of cancer and the burden it places on the public and the health care system. We note important still-unresolved questions about which behaviors can be intervened upon simultaneously in order to maximize positive behavioral synergies, minimize negative ones, and effectively engage underserved populations. We conclude that interprofessional collaboration is needed to appropriately determine and convey the value of primary prevention of cancer and other chronic diseases.

Can an evidence-based book club intervention delivered via a tablet computer improve physical activity in middle-aged women?

BACKGROUND

Fewer than 50% of middle-aged women participate in regular physical activity (PA). Innovative approaches that engage women who may not otherwise participate in PA programs are warranted. The purpose of this study was to explore the acceptability and feasibility of a 12-week tablet-based book club for improving middle-aged women's PA.

MATERIALS AND METHODS

Thirty women (35-64 years of age) were randomized to the Fit Minded Tablet (n=15) and the Standard Fit Minded (i.e., face-to-face intervention) (n=15) groups. The Fit Minded Tablet was adapted from the Standard Fit Minded, a previously tested, theory-based book club intervention using books as a platform for discussion and group support to help women adopt regular PA. Both interventions met weekly for 3 months, for a total of 12 sessions. Tablet group participants accessed materials (e.g., e-books, workbook, live/recorded videoconferencing) via a tablet computer; Standard group participants received materials (e.g., printed books, workbook, live face-to-face meetings) in person. Feasibility (i.e., implementation and expansion) was assessed using process evaluation, qualitative interviews, satisfaction surveys, and quantitative outcome assessments.

RESULTS

Women in the Tablet group attended fewer meetings (mean, 8.25) than women in the Standard group (mean, 9.9). Videoconferencing, digital literacy, and participant engagement limitations were observed in the Tablet group. Tablet participants enjoyed the e-books but thought technology barriers hindered their engagement during meetings. Women in both groups valued the support they received from other group members. Standard participants cited this support as a key contributor to their PA changes, whereas Tablet participants reported needing in-person contact to feel more connected.

CONCLUSIONS

Given the popularity of tablet computers and the value that middle-aged women place on group interaction to support their PA behaviors, additional research is warranted to determine best strategies for optimizing social support, mitigating technology barriers, and improving engagement in online and mobile health promotion programs targeting middle-aged women.

Process evaluation of the first computer tailored program for smoking cessation among Romanian smokers

The objective of this paper is to present the implementation and process evaluation of the first computer tailored program for smoking cessation among Romanian smokers. The program targeted adult smokers who declared the intention to quit smoking in the next six months. The intervention consisted of a letter tailored to several respondent characteristics: gender, cognitive variables (attitude, social influence, and self-efficacy), intention to quit smoking, goal and relapse prevention strategies (action and coping plans), and smoking behaviour. The first 80 participants entered into the program filled in a process evaluation questionnaire one month after the intervention. The results of our study confirmed that the participants had read and remembered the letter. Moreover, new for Romania, this approach was positively appreciated by the participant and the score received for the tailored letter was high. The opinions of the participants confirmed that the tailored letter provided information that was useful, trustworthy and relevant for the individual. At the same time, the participants appreciated the polite, easy to understand content of the letter. These data underlined the premises for continuing the program and for using the information and communication technologies for healthy lifestyle promotion among Romanian population.

Effects of a web-based tailored multiple-lifestyle intervention for adults: a two-year randomized controlled trial comparing sequential and simultaneous delivery modes

Background

Web-based computer-tailored interventions for multiple health behaviors can have a significant public health impact. Yet, few randomized controlled trials have tested this assumption.

Objective

The objective of this paper was to test the effects of a sequential and simultaneous Web-based tailored intervention on multiple lifestyle behaviors.

Methods

A randomized controlled trial was conducted with 3 tailoring conditions (ie, sequential, simultaneous, and control conditions) in the Netherlands in 2009-2012. Follow-up measurements took place after 12 and 24 months. The intervention content was based on the I-Change model. In a health risk appraisal, all respondents (N=5055) received feedback on their lifestyle behaviors that indicated whether they complied with the Dutch guidelines for physical activity, vegetable consumption, fruit consumption, alcohol intake, and smoking. Participants in the sequential (n=1736) and simultaneous (n=1638) conditions received tailored motivational feedback to change unhealthy behaviors one at a time (sequential) or all at the same time (simultaneous). Mixed model analyses were performed as primary analyses; regression analyses were done as sensitivity analyses. An overall risk score was used as outcome measure, then effects on the 5 individual lifestyle behaviors were assessed and a process evaluation was performed regarding exposure to and appreciation of the intervention.

Results

Both tailoring strategies were associated with small self-reported behavioral changes. The sequential condition had the most significant effects compared to the control condition after 12 months (T1, effect size=0.28). After 24 months (T2), the simultaneous condition was most effective (effect size=0.18). All 5 individual lifestyle behaviors changed over time, but few effects differed significantly between the conditions. At both follow-ups, the sequential condition had significant changes in smoking abstinence compared to the simultaneous condition (T1 effect size=0.31; T2 effect size=0.41). The sequential condition was more effective in decreasing alcohol consumption than the control condition at 24 months (effect size=0.27). Change was predicted by the amount of exposure to the intervention (total visiting time: beta=–.06; P=.01; total number of visits: beta=–.11; P<.001). Both interventions were appreciated well by respondents without significant differences between conditions.

Conclusions

Although evidence was found for the effectiveness of both programs, no simple conclusive finding could be drawn about which intervention mode was more effective. The best kind of intervention may depend on the behavior that is targeted or on personal preferences and motivation. Further research is needed to identify moderators of intervention effectiveness. The results need to be interpreted in view of the high and selective dropout rates, multiple comparisons, and modest effect sizes. However, a large number of people were reached at low cost and behavioral change was achieved after 2 years.

Trial Registration

Nederlands Trial Register: NTR 2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB).

Designing a theory- and evidence-based tailored eHealth rehabilitation aftercare program in Germany and the Netherlands: study protocol

BACKGROUND

Cardiac rehabilitation programs aim to improve health status and to decrease the risk of further cardiac events. Persons undergoing rehabilitation often have difficulties transferring the learned health behaviors into their daily routine after returning home and maybe to work. This includes physical activity as well as fruit and vegetable consumption. Computer-based tailored interventions have been shown to be effective in increasing physical activity as well as fruit and vegetable consumption. The aim of this study is, to support people in transferring these two learned behavior changes and their antecedents into their daily life after cardiac rehabilitation.

METHODS

The study will have a randomized controlled design and will be conducted among German and Dutch people who participated in cardiac rehabilitation. The study will consist of one intervention group which will be compared to a waiting list control group. During the eight week duration of the intervention, participants will be invited to participate in the online after-care program once per week. The intervention encourages participants to define individual health behavior goals as well as action, and coping plans to reach these self-determined goals. The effectiveness of the program will be compared between the intervention condition and the control group in terms of behavior change, antecedents of behavior change (e.g., self-efficacy), ability to return to work and increased well-being. Further, subgroup-differences will be assessed including differences between the two countries, socioeconomic inequalities and across age groups.

DISCUSSION

The present study will make a contribution to understanding how such an online-based tailored interventions enables study participants to adopt and maintain a healthy lifestyle. Implications can include how such an online program could enrich cardiac rehabilitation aftercare further.

TRIAL REGISTRATION

NTR 3706, NCT01909349.

Effects of a Web-based tailored intervention to reduce alcohol consumption in adults: randomized controlled trial

Background

Web-based tailored interventions provide users with information that is adapted to their individual characteristics and needs. Randomized controlled trials assessing the effects of tailored alcohol self-help programs among adults are scarce. Furthermore, it is a challenge to develop programs that can hold respondents’ attention in online interventions.

Objective

To assess whether a 3-session, Web-based tailored intervention is effective in reducing alcohol intake in high-risk adult drinkers and to compare 2 computer-tailoring feedback strategies (alternating vs summative) on behavioral change, dropout, and appreciation of the program.

Methods

A single-blind randomized controlled trial was conducted with an experimental group and a control group (N=448) in Germany in 2010-2011. Follow-up took place after 6 months. Drinking behavior, health status, motivational determinants, and demographics were assessed among participants recruited via an online access panel. The experimental group was divided into 2 subgroups. In the alternating condition (n=132), the tailored feedback was split into a series of messages discussing individual topics offered while the respondent was filling out the program. Participants in the summative condition (n=181) received all advice at once after having answered all questions. The actual texts were identical for both conditions. The control group (n=135) only filled in 3 questionnaires. To identify intervention effects, logistic and linear regression analyses were conducted among complete cases (n=197) and after using multiple imputation.

Results

Among the complete cases (response rate: 197/448, 44.0%) who did not comply with the German national guideline for low-risk drinking at baseline, 21.1% of respondents in the experimental group complied after 6 months compared with 5.8% in the control group (effect size=0.42; OR 2.65, 95% CI 1.14-6.16, P=.02). The experimental group decreased by 3.9 drinks per week compared to 0.4 drinks per week in the control group, but this did not reach statistical significance (effect size=0.26; beta=−0.12, 95% CI −7.96 to 0.03, P=.05). Intention-to-treat analyses also indicated no statistically significant effect. Separate analyses of the 2 experimental subgroups showed no differences in intervention effects. The dropout rate during the first visit to the intervention website was significantly lower in the alternating condition than in the summative condition (OR 0.23, 95% CI 0.08-0.60, P=.003). Program appreciation was comparable for the 2 experimental groups.

Conclusions

Complete case analyses revealed that Web-based tailored feedback can be an effective way to reduce alcohol intake among adults. However, this effect was not confirmed when applying multiple imputations. There was no indication that one of the tailoring strategies was more effective in lowering alcohol intake. Nevertheless, the lower attrition rates we found during the first visit suggest that the version of the intervention with alternating questions and advice may be preferred.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 91623132; http://www.controlled-trials.com/ISRCTN91623132 (Archived by WebCite at http://www.webcitation.org/6J4QdhXeG).

Long-term engagement with a mobile self-management system for people with type 2 diabetes

Background

In a growing number of intervention studies, mobile phones are used to support self-management of people with Type 2 diabetes mellitus (T2DM). However, it is difficult to establish knowledge about factors associated with intervention effects, due to considerable differences in research designs and outcome measures as well as a lack of detailed information about participants’ engagement with the intervention tool.

Objective

To contribute toward accumulating knowledge about factors associated with usage and usability of a mobile self-management application over time through a thorough analysis of multiple types of investigation on each participant’s engagement.

Methods

The Few Touch application is a mobile-phone–based self-management tool for patients with T2DM. Twelve patients with T2DM who have been actively involved in the system design used the Few Touch application in a real-life setting from September 2008 until October 2009. During this period, questionnaires and semistructured interviews were conducted. Recorded data were analyzed to investigate usage trends and patterns. Transcripts from interviews were thematically analyzed, and the results were further analyzed in relation to the questionnaire answers and the usage trends and patterns.

Results

The Few Touch application served as a flexible learning tool for the participants, responsive to their spontaneous needs, as well as supporting regular self-monitoring. A significantly decreasing (P<.05) usage trend was observed among 10 out of the 12 participants, though the magnitude of the decrease varied widely. Having achieved a sense of mastery over diabetes and experiences of problems were identified as reasons for declining motivation to continue using the application. Some of the problems stemmed from difficulties in integrating the use of the application into each participant’s everyday life and needs, although the design concepts were developed in the process where the participants were involved. The following factors were identified as associated with usability and/or usage over time: Integration with everyday life; automation; balance between accuracy and meaningfulness of data with manual entry; intuitive and informative feedback; and rich learning materials, especially about foods.

Conclusion

Many grounded design implications were identified through a thorough analysis of results from multiple types of investigations obtained through a year-long field trial of the Few Touch application. The study showed the importance and value of involving patient-users in a long-term trial of a tool to identify factors influencing usage and usability over time. In addition, the study confirmed the importance of detailed analyses of each participant’s usage of the provided tool for better understanding of participants’ engagement over time.

Web-based intervention to promote physical activity by sedentary older adults: randomized controlled trial

BACKGROUND

Physical activity (PA) for older adults has well-documented physical and cognitive benefits, but most seniors do not meet recommended guidelines for PA, and interventions are lacking.

OBJECTIVES

This study evaluated the efficacy of a 12-week Internet intervention to help sedentary older adults over 55 years of age adopt and maintain an exercise regimen.

METHODS

A total of 368 sedentary men and women (M=60.3; SD 4.9) were recruited, screened, and assessed online. They were randomized into treatment and control groups and assessed at pretest, at 12 weeks, and at 6 months. After treatment group participants rated their fitness level, activity goals, and barriers to exercise, the Internet intervention program helped them select exercise activities in the areas of endurance, flexibility, strengthening, and balance enhancement. They returned to the program weekly for automated video and text support and education, with the option to change or increase their exercise plan. The program also included ongoing problem solving to overcome user-identified barriers to exercise.

RESULTS

The multivariate model indicated significant treatment effects at posttest (P=.001; large effect size) and at 6 months (P=.001; medium effect size). At posttest, intervention participation showed significant improvement on 13 of 14 outcome measures compared to the control participants. At 6 months, treatment participants maintained large gains compared to the control participants on all 14 outcome measures.

CONCLUSIONS

These results suggest that an online PA program has the potential to positively impact the physical activity of sedentary older adult participants. More research is needed to replicate the study results, which were based on self-report measures. Research is also needed on intervention effects with older populations.

Periodic email prompts to re-use an internet-delivered computer-tailored lifestyle program: influence of prompt content and timing

Background

Adherence to Internet-delivered lifestyle interventions using multiple tailoring is suboptimal. Therefore, it is essential to invest in proactive strategies, such as periodic email prompts, to boost re-use of the intervention.

Objective

This study investigated the influence of content and timing of a single email prompt on re-use of an Internet-delivered computer-tailored (CT) lifestyle program.

Methods

A sample of municipality employees was invited to participate in the program. All participants who decided to use the program received an email prompting them to revisit the program. A 2×3 (content × timing) design was used to test manipulations of prompt content and timing. Depending on the study group participants were randomly assigned to, they received either a prompt containing standard content (an invitation to revisit the program), or standard content plus a preview of new content placed on the program website. Participants received this prompt after 2, 4, or 6 weeks. In addition to these 6 experimental conditions, a control condition was included consisting of participants who did not receive an additional email prompt. Clicks on the uniform resource locator (URL) provided in the prompt and log-ins to the CT program were objectively monitored. Logistic regression analyses were conducted to determine whether prompt content and/or prompt timing predicted clicking on the URL and logging in to the CT program.

Results

Of all program users (N=240), 206 participants received a subsequent email prompting them to revisit the program. A total of 53 participants (25.7%) who received a prompt reacted to this prompt by clicking on the URL, and 25 participants (12.1%) actually logged in to the program. There was a main effect of prompt timing; participants receiving an email prompt 2 weeks after their first visit clicked on the URL significantly more often compared with participants that received the prompt after 4 weeks (odds ratio [OR] 3.069, 95% CI 1.392-6.765, P=.005) and after 6 weeks (OR 4.471, 95% CI 1.909-10.471, P=.001). Furthermore, participants who received an email prompt 2 weeks after their first visit logged in to the program significantly more often compared to participants receiving the prompt after 6 weeks (OR 16.356, 95% CI 2.071-129.196, P=.008). A trend was observed with regard to prompt content. Participants receiving a prompt with additional content were more likely to log in to the program compared to participants who received a standard prompt. However, this result was not statistically significant (OR 2.286, 95% CI 0.892-5.856, P=.09).

Conclusions

The key findings suggest that boosting revisits to a CT program benefits most from relatively short prompt timing. Furthermore, a preview of new website content may be added to a standard prompt to further increase its effectiveness in persuading people to log in to the program.