Effects of Providing Tailored Information About e-Cigarettes in a Web-Based Smoking Cessation Intervention: Protocol for a Randomized Controlled Trial

Background

There is an ongoing debate whether electronic cigarettes (e-cigarettes) should be advocated for smoking cessation. Because of this uncertainty, information about the use of e-cigarettes for smoking cessation is usually not provided in governmental smoking cessation communications. However, there is an information need among smokers because despite this uncertainty, e-cigarettes are used by many smokers to reduce and quit tobacco smoking.

Objective

The aim of this study is to describe the protocol of a randomized controlled trial that assesses the effect of providing tailored information about e-cigarettes compared to not providing this information on determinants of decision making and smoking reduction and abstinence. This information is provided in the context of a digital smoking cessation intervention.

Methods

A randomized controlled trial with a 6-month follow-up period will be conducted among adult smokers motivated to quit smoking within 5 years. Participants will be 1:1 randomized into either the intervention condition or control condition. In this trial, which is grounded on the I-Change model, participants in both conditions will receive tailored feedback on attitude, social influence, preparatory plans, self-efficacy, and coping plans. Information on 6 clusters of smoking cessation methods (face-to-face counselling, eHealth interventions, telephone counselling, group-based programs, nicotine replacement therapy, and prescription medication) will be provided in both conditions. Smokers in the intervention condition will also receive detailed tailored information on e-cigarettes, while smokers in the control condition will not receive this information. The primary outcome measure will be the number of tobacco cigarettes smoked in the past 7 days. Secondary outcome measures will include 7-day point prevalence tobacco abstinence, 7-day point prevalence e-cigarette abstinence, and determinants of decision making (ie, knowledge and attitude regarding e-cigarettes). All outcomes will be self-assessed through web-based questionnaires.

Results

This project is supported by a research grant of the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu). Ethical approval was granted by the Ethics Review Committee Health, Medicine and Life Sciences at Maastricht University (FHML-REC/2019/072). Recruitment began in March 2020 and was completed by July 2020. We enrolled 492 smokers in this study. The results are expected to be published in June 2021.

Conclusions

The experimental design of this study allows conclusions to be formed regarding the effects of tailored information about e-cigarettes on decision making and smoking behavior. Our findings can inform the development of future smoking cessation interventions.

Trial Registration

Dutch Trial Register Trial NL8330; https://www.trialregister.nl/trial/8330

International Registered Report Identifier (IRRID)

DERR1-10.2196/27088

Effectiveness of a web-based computer-tailored intervention promoting physical activity for adults from Quebec City: a randomized controlled trial

Background

The primary objective of this study was to determine the effectiveness of a 3-month web-based computer-tailored intervention on moderate-to-vigorous physical activity (MVPA) in adults.

Methods

A total of 242 Canadian adults aged between 35 and 70 years were randomized to an experimental group receiving the intervention or a waiting list control group. The fully automated web-based computer-tailored physical activity intervention consists of seven 10- to 15-min sessions over an 8-week period. The theoretical underpinning of the intervention is based on the I-Change Model.

Results

A repeated-measures ANOVA using a linear mixed model showed a significant 'group-by-time' interaction favoring the intervention group in self-reported MVPA (p = .02). The MVPA was similar in both groups at baseline (mean ± SD; 176 ± 13 vs. 172 ± 15 min/week, p = .72) and higher in the intervention than in the control group at a 3-month follow-up (259 ± 21 vs. 201 ± 22 min/week, p = .04). This finding was comparable across women and men (group-by-sex, p = .57) and across participants meeting or not physical activity guidelines at baseline (group-by-baseline physical activity, p = .43). Although engagement to the web-based sessions declined over time, participants completing more web sessions achieved higher self-reported MVPA (p < .05).

Conclusion

These findings suggest that this intervention is effective in enhancing self-reported MVPA in this adult population in the short term; however, this needs to be confirmed in a larger trial with better engagement to the web-based sessions.

Optimising Web-Based Computer-Tailored Physical Activity Interventions for Prostate Cancer Survivors: A Randomised Controlled Trial Examining the Impact of Website Architecture on User Engagement

BACKGROUND

Web-based computer-tailored interventions can assist prostate cancer survivors to become more physically active by providing personally relevant behaviour change support. This study aimed to explore how changing the website architecture (free choice vs. tunnelled) impacted engagement within a physical activity computer-tailored intervention targeting prostate cancer survivors.

METHODS

On a 2:2:1 ratio, 71 Australian prostate cancer survivors with local or locally advanced disease (mean age: 66.6 years ± 9.66) were randomised into either a free-choice (N = 27), tunnelled (N = 27) or minimal intervention control arm (N =17). The primary outcome was differences in usage of the physical activity self-monitoring and feedback modules between the two intervention arms. Differences in usage of other website components between the two intervention groups were explored as secondary outcomes. Further, secondary outcomes involving comparisons between all study groups (including the control) included usability, personal relevance, and behaviour change.

RESULTS

The average number of physical activity self-monitoring and feedback modules accessed was higher in the tunnelled arm (M 2.6 SD 1.3) compared to the free-choice arm (M 1.5 SD 1.4), p = 0.01. However, free-choice participants were significantly more likely to have engaged with the social support (p = 0.008) and habit formation (p = 0.003) 'once-off' modules compared to the standard tunnelled arm. There were no other between-group differences found for any other study outcomes.

CONCLUSION

This study indicated that website architecture influences behavioural engagement. Further research is needed to examine the impact of differential usage on mechanisms of action and behaviour change.

Spoken Animated Self-Management Video Messages Aimed at Improving Physical Activity in People With Type 2 Diabetes: Development and Interview Study

Background

Web-based tailored interventions are a promising approach to help people with type 2 diabetes successfully adopt regular physical activity. Spoken animation seems to be effective regardless of the characteristics of the user and may be a relevant strategy to communicate complex health information

Objective

The objectives of our study were to evaluate (1) pretesting communication elements and user appreciation, and (2) the applied behavior change techniques of the previously designed spoken animated video messages in a tailored self-management program for people with type 2 diabetes.

Methods

We conducted semistructured interviews with patients with type 2 diabetes recruited from general practices located in different socioeconomic status urban neighborhoods. Based on the pretesting key communication elements of Salazar’s model, we asked participants about the spoken animated video messages’ attractiveness, comprehensibility, acceptance, believability, involvement, and relevance and to what extent the video messages motivated them to become more physically active. We also assessed participants’ intention to use the spoken animated video messages and to recommend them to others. To evaluate participants’ appreciation of the different applied behavior change techniques, we conducted a post hoc analysis of the qualitative data using the MAXQDA program. Transcripts were coded by 2 coders using iterative qualitative content analysis methods to uncover key health communication issues.

Results

Of 23 patients who expressed an interest in participating, 17 met the inclusion criteria and 15 took part in the interviews. The positive appreciation of the comprehensibility, believability, and personalization was supported by participants’ statements on behavior change techniques and other communication elements. Reinforcement of and feedback on participants’ answers were positively evaluated as was the simplicity and concreteness of the spoken animated video messages. Most participants indicated reasons for not feeling motivated to increase their physical activity level, including being already sufficiently physically active and the presence of other impeding health factors.

Conclusions

Spoken animated video messages should be simple, short, concrete, and without the use of medical terminology. Providing positive reinforcement, feedback on participants’ answers, examples that match user characteristics, and the possibility to identify with the animation figures will enhance involvement in the health message. To connect more with patients’ needs and thereby increase the perceived relevance of and motivation to use an animated video program, we suggest offering the program soon after diabetes mellitus is diagnosed. We recommend piloting behavior change techniques to identify potential resistance.

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

How recommender systems could support and enhance computer-tailored digital health programs: A scoping review

Objective

Tailored digital health programs can promote positive health-related lifestyle changes and have been shown to be (cost) effective in trials. However, such programs are used suboptimally. New approaches are needed to optimise the use of these programs. This paper illustrates the potential of recommender systems to support and enhance computer-tailored digital health interventions. The aim is threefold, to explore: (1) how recommender systems provide health recommendations, (2) to what extent recommender systems incorporate theoretical models and (3) how the use of recommender systems may enhance the usage of computer-tailored interventions.

Methods

A scoping review was conducted, using MEDLINE and ScienceDirect, to identify health recommender systems reported in studies between January 2007 and December 2017. Information was subsequently extracted to understand the potential benefits of recommender systems for computer-tailored digital health programs. Titles and abstracts of 1184 studies were screened for the full-text screening, in which two reviewers independently selected articles and systematically extracted data using a predefined extraction form.

Results

A total of 26 articles were included for data extraction. General characteristics were reported, with eight studies reporting hybrid filtering. A description of how each recommender system provides a recommendation is described; the majority of recommender systems used messages as recommendation. We identified the potential effects of recommender systems on efficiency, effectiveness, trustworthiness and enjoyment of the digital health program.

Conclusions

Incorporating a collaborative method with demographic filtering as a second step to knowledge-based filtering could potentially add value to traditional tailoring with regard to enhancing the user experience. This study illustrates how recommender systems, especially hybrid programs, may have the potential to bring tailored digital health forward.

Efficacy of a Web-Based Tailored Intervention to Reduce Cannabis Use Among Young People Attending Adult Education Centers in Quebec

BACKGROUND

Cannabis use is common among young adults. Web-based interventions are an increasingly popular way to reach this population. The aim of this study was to evaluate the efficacy of a Web-based tailored intervention, developed on theoretical and empirical grounds, to reduce cannabis use among young people by promoting a more positive intention to abstain.

METHODS

An experimental design was employed to evaluate the efficacy of the intervention in reducing cannabis use (primary outcome) by bolstering intention (secondary outcome) to abstain from use. Participants were randomly assigned either to an experimental group that received the Web-based tailored intervention or to a control group that did not.

RESULTS

Of 588 young adults (18-24 years of age) recruited, 295 were randomly assigned to the experimental group and 293 to the control group. At baseline, 343 reported using cannabis at least once in the past year. An intention-to-treat analysis showed that, at postintervention, a higher proportion of participants in the experimental group had reduced their cannabis use compared with the control group [10.8% vs. 5.1%, χ²(2) = 9.89, p = 0.007]. A mixed model for repeated measures revealed a statistically significant difference in terms of change in intention to abstain from cannabis use in the coming month [Group × Time interaction, F(1,474) = 8.03, p = 0.005]: intention increased for the experimental group (5.07 ± 2.07 to 5.45 ± 1.88; p < 0.001), but stayed stable for the control group (5.32 ± 2.03 to 5.36 ± 1.99; p = 0.779).

CONCLUSION

This study shows that the intervention can be efficacious in reducing cannabis use among young people attending adult education centers.

A Lifestyle Intervention via Email in Minority Breast Cancer Survivors: Randomized Parallel-Group Feasibility Study

BACKGROUND

Our data have indicated that minority breast cancer survivors are receptive to participating in lifestyle interventions delivered via email or the Web, yet few Web-based studies exist in this population.

OBJECTIVE

The aim of this study was to examine the feasibility and preliminary results of an email-delivered diet and activity intervention program, "A Lifestyle Intervention Via Email (ALIVE)," delivered to a sample of racial and ethnic minority breast cancer survivors.

METHODS

Survivors (mean age: 52 years, 83% [59/71] African American) were recruited and randomized to receive either the ALIVE program's 3-month physical activity track or its 3-month dietary track. The fully automated system provided tools for self-monitoring and goal setting, tailored content, and automated phone calls. Descriptive statistics and mixed-effects models were computed to examine the outcomes of the study.

RESULTS

Upon completion, 44 of 71 survivors completed the study. Our "intention-to-treat" analysis revealed that participants in the physical activity track made greater improvements in moderate to vigorous activity than those in the dietary track (+97 vs. +49 min/week, P<.001). Similarly, reductions in total sedentary time among those in the physical activity track (-304 vs. -59 min/week, P<.001) was nearly 5 times greater than that for participants in the dietary track. Our completers case analysis indicated that participants in the dietary track made improvements in the intake of fiber (+4.4 g/day), fruits and vegetables (+1.0 cup equivalents/day), and reductions in saturated fat (-2.3 g/day) and trans fat (-0.3 g/day) (all P<.05). However, these improvements in dietary intake were not significantly different from the changes observed by participants in the physical activity track (all P>.05). Process evaluation data indicated that most survivors would recommend ALIVE to other cancer survivors (97%), were satisfied with ALIVE (82%), and felt that ALIVE was effective (73%). However, survivors expressed concerns about the functionality of the interactive emails.

CONCLUSIONS

ALIVE appears to be feasible for racial and ethnic minority cancer survivors and showed promising results for larger implementation. Although survivors favored the educational content, a mobile phone app and interactive emails that work on multiple email domains may help to boost adherence rates and to improve satisfaction with the Web-based platform.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02722850; https://clinicaltrials.gov/ct2/show/NCT02722850 (Archived by WebCite at http://www.webcitation.org/6tHN9VsPh).

A Web-Based and Print-Based Computer-Tailored Physical Activity Intervention for Prostate and Colorectal Cancer Survivors: A Comparison of User Characteristics and Intervention Use

Background

Physical activity (PA) is beneficial in improving negative physical and psychological effects of cancer. The rapidly increasing number of cancer survivors, resulting from aging and improved cancer care, emphasizes the importance to develop and provide low cost, easy accessible PA programs. Such programs could be provided through the Internet, but that could result in the exclusion of cancer survivors not familiar with the Internet. Therefore, we developed a computer-tailored PA intervention for prostate and colorectal cancer survivors in which both Web-based and print materials are provided, and participants can choose their own preferred delivery mode.

Objective

The aim of this study was to assess participants’ characteristics related to delivery mode and use of intervention materials.

Methods

We studied characteristics of participants using Web-based and printed intervention materials in a randomized controlled trial (RCT). Prostate and colorectal cancer survivors recruited from hospitals were randomized to OncoActive (computer-tailored PA intervention) or a usual-care control group. OncoActive participants received both Web-based and printed materials. Participants were classified into initial print- or Web-based participants based on their preferred mode of completion of the first questionnaire, which was needed for the computer-tailored PA advice. Intervention material use during the remainder of the intervention was compared for initial print- or Web-based participants. Additionally, participants were classified into those using only print materials and those using Web-based materials. Differences in participant characteristics and intervention material use were studied through analysis of variance (ANOVAs), chi-square tests, and logistic regressions.

Results

The majority of the participants in the intervention group were classified as initial Web-based participants (170/249, 68.3%), and 84.9% (191/249) used Web-based intervention materials. Dropout was low (15/249, 6.0%) and differed between initial Web-based (4/170, 2.4%) and print-based (11/79, 14%) participants. Participants were less likely to start Web-based with higher age (odds ratio [OR]=0.93), longer time since last treatment (OR=0.87), and higher fatigue (OR=0.96), and more likely with higher education (OR=4.08) and having completed treatments (OR=5.58). Those who were older (OR=0.93) and post treatment for a longer time (OR=0.86) were less likely to use Web-based intervention materials. Initial print-based participants predominantly used print-based materials, whereas initial Web-based participants used both print- and Web-based materials.

Conclusions

To our knowledge, this is one of the first studies that assessed participant characteristics related to delivery mode in an intervention in which participants had a free choice of delivery modes. Use of print-based materials among the initial Web-based participants was substantial, indicating the importance of print-based materials. According to our findings, it may be important to offer Web- and print-based materials alongside each other. Providing Web-based materials only may exclude older, less educated, more fatigued, or currently treated participants; these groups are especially more vulnerable and could benefit most from PA interventions.

The Impact of Participant Characteristics on Use and Satisfaction of a Web-Based Computer-Tailored Chronic Obstructive Pulmonary Disease Self-Management Intervention: A Process Evaluation

BACKGROUND

A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results.

OBJECTIVES

The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction.

METHODS

Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention.

RESULTS

The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (P<.001). Application use was low. Of all participants in the intervention group, 52.9% (348/658) initiated use of one or both modules, 36.0% (237/658) completed an intervention component (prolonged use), and 16.6% (109/658) revisited one of the modules after completing an intervention component (sustained use). Older age, established diagnosis of COPD, or experiencing breathlessness predicted sustained use. Participant satisfaction with the 2 modules was 6.7 (SD 1.6) on a scale from 0 to 10. The interviews revealed that a computer application was believed not to be sufficient and the help of a health care professional was necessary. Participants with a greater intention to change were more satisfied with the application.

CONCLUSIONS

The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with the intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider.

The Impact of Participant Characteristics on Use and Satisfaction of a Web-Based Computer-Tailored Chronic Obstructive Pulmonary Disease Self-Management Intervention: A Process Evaluation

BACKGROUND

A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results.

OBJECTIVES

The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction.

METHODS

Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention.

RESULTS

The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (P<.001). Application use was low. Of all participants in the intervention group, 52.9% (348/658) initiated use of one or both modules, 36.0% (237/658) completed an intervention component (prolonged use), and 16.6% (109/658) revisited one of the modules after completing an intervention component (sustained use). Older age, established diagnosis of COPD, or experiencing breathlessness predicted sustained use. Participant satisfaction with the 2 modules was 6.7 (SD 1.6) on a scale from 0 to 10. The interviews revealed that a computer application was believed not to be sufficient and the help of a health care professional was necessary. Participants with a greater intention to change were more satisfied with the application.

CONCLUSIONS

The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with the intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider.

Impact of a Collective Intelligence Tailored Messaging System on Smoking Cessation: The Perspect Randomized Experiment

Background

Outside health care, content tailoring is driven algorithmically using machine learning compared to the rule-based approach used in current implementations of computer-tailored health communication (CTHC) systems. A special class of machine learning systems (“recommender systems”) are used to select messages by combining the collective intelligence of their users (ie, the observed and inferred preferences of users as they interact with the system) and their user profiles. However, this approach has not been adequately tested for CTHC.

Objective

Our aim was to compare, in a randomized experiment, a standard, evidence-based, rule-based CTHC (standard CTHC) to a novel machine learning CTHC: Patient Experience Recommender System for Persuasive Communication Tailoring (PERSPeCT). We hypothesized that PERSPeCT will select messages of higher influence than our standard CTHC system. This standard CTHC was proven effective in motivating smoking cessation in a prior randomized trial of 900 smokers (OR 1.70, 95% CI 1.03-2.81).

Methods

PERSPeCT is an innovative hybrid machine learning recommender system that selects and sends motivational messages using algorithms that learn from message ratings from 846 previous participants (explicit feedback), and the prior explicit ratings of each individual participant. Current smokers (N=120) aged 18 years or older, English speaking, with Internet access were eligible to participate. These smokers were randomized to receive either PERSPeCT (intervention, n=74) or standard CTHC tailored messages (n=46). The study was conducted between October 2014 and January 2015. By randomization, we compared daily message ratings (mean of smoker ratings each day). At 30 days, we assessed the intervention’s perceived influence, 30-day cessation, and changes in readiness to quit from baseline.

Results

The proportion of days when smokers agreed/strongly agreed (daily rating ≥4) that the messages influenced them to quit was significantly higher for PERSPeCT (73%, 23/30) than standard CTHC (44%, 14/30, P=.02). Among less educated smokers (n=49), this difference was even more pronounced for days strongly agree (intervention: 77%, 23/30; comparison: 23%, 7/30, P<.001). There was no significant difference in the frequency which PERSPeCT randomized smokers agreed or strongly agreed that the intervention influenced them to quit smoking (P=.07) and use nicotine replacement therapy (P=.09). Among those who completed follow-up, 36% (20/55) of PERSPeCT smokers and 32% (11/34) of the standard CTHC group stopped smoking for one day or longer (P=.70).

Conclusions

Compared to standard CTHC with proven effectiveness, PERSPeCT outperformed in terms of influence ratings and resulted in similar cessation rates.

ClinicalTrial

Clinicaltrials.gov NCT02200432; https://clinicaltrials.gov/ct2/show/NCT02200432 (Archived by WebCite at http://www.webcitation.org/6lEJY1KEd)

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 Effectiveness of a Web-Based Computer-Tailored Intervention on Workplace Sitting: A Randomized Controlled Trial

Background

Effective interventions to influence workplace sitting are needed, as office-based workers demonstrate high levels of continued sitting, and sitting too much is associated with adverse health effects. Therefore, we developed a theory-driven, Web-based, interactive, computer-tailored intervention aimed at reducing and interrupting sitting at work.

Objective

The objective of our study was to investigate the effects of this intervention on objectively measured sitting time, standing time, and breaks from sitting, as well as self-reported context-specific sitting among Flemish employees in a field-based approach.

Methods

Employees (n=213) participated in a 3-group randomized controlled trial that assessed outcomes at baseline, 1-month follow-up, and 3-month follow-up through self-reports. A subsample (n=122) were willing to wear an activity monitor (activPAL) from Monday to Friday. The tailored group received an automated Web-based, computer-tailored intervention including personalized feedback and tips on how to reduce or interrupt workplace sitting. The generic group received an automated Web-based generic advice with tips. The control group was a wait-list control condition, initially receiving no intervention. Intervention effects were tested with repeated-measures multivariate analysis of variance.

Results

The tailored intervention was successful in decreasing self-reported total workday sitting (time × group: P<.001), sitting at work (time × group: P<.001), and leisure time sitting (time × group: P=.03), and in increasing objectively measured breaks at work (time × group: P=.07); this was not the case in the other conditions. The changes in self-reported total nonworkday sitting, sitting during transport, television viewing, and personal computer use, objectively measured total sitting time, and sitting and standing time at work did not differ between conditions.

Conclusions

Our results point out the significance of computer tailoring for sedentary behavior and its potential use in public health promotion, as the effects of the tailored condition were superior to the generic and control conditions.

Trial Registration

Clinicaltrials.gov NCT02672215; http://clinicaltrials.gov/ct2/show/NCT02672215 (Archived by WebCite at http://www.webcitation.org/6glPFBLWv)

A Web-Based Computer-Tailored Alcohol Prevention Program for Adolescents: Cost-Effectiveness and Intersectoral Costs and Benefits

Background

Preventing excessive alcohol use among adolescents is important not only to foster individual and public health, but also to reduce alcohol-related costs inside and outside the health care sector. Computer tailoring can be both effective and cost-effective for working with many lifestyle behaviors, yet the available information on the cost-effectiveness of computer tailoring for reducing alcohol use by adolescents is limited as is information on the costs and benefits pertaining to sectors outside the health care sector, also known as intersectoral costs and benefits (ICBs).

Objective

The aim was to assess the cost-effectiveness of a Web-based computer-tailored intervention for reducing alcohol use and binge drinking by adolescents from a health care perspective (excluding ICBs) and from a societal perspective (including ICBs).

Methods

Data used were from the Alcoholic Alert study, a cluster randomized controlled trial with randomization at the level of schools into two conditions. Participants either played a game with tailored feedback on alcohol awareness after the baseline assessment (intervention condition) or received care as usual (CAU), meaning that they had the opportunity to play the game subsequent to the final measurement (waiting list control condition). Data were recorded at baseline (T0=January/February 2014) and after 4 months (T1=May/June 2014) and were used to calculate incremental cost-effectiveness ratios (ICERs), both from a health care perspective and a societal perspective. Stochastic uncertainty in the data was dealt with by using nonparametric bootstraps (5000 simulated replications). Additional sensitivity analyses were conducted based on excluding cost outliers. Subgroup cost-effectiveness analyses were conducted based on several background variables, including gender, age, educational level, religion, and ethnicity.

Results

From both the health care perspective and the societal perspective for both outcome measures, the intervention was more costly and more effective in comparison with CAU. ICERs differed for both perspectives, namely €40 and €79 from the health care perspective to €62 and €144 for the societal perspective per incremental reduction of one glass of alcohol per week and one binge drinking occasion per 30 days, respectively. Subgroup analyses showed, from both perspectives and for both outcome measures, that the intervention was cost-effective for older adolescents (aged 17-19 years) and those at a lower educational level and, from a health care perspective, the male and nonreligious adolescent subgroups.

Conclusions

Computer-tailored feedback could be a cost-effective way to target alcohol use and binge drinking among adolescents. Including ICBs in the economic evaluation had an impact on the cost-effectiveness results of the analysis. It could be worthwhile to aim the intervention specifically at specific subgroups.

Trial Registration

Nederlands Trial Register: NTR4048; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4048 (Archived by Webcite at http://www.webcitation.org/6c7omN8wG)

Effectiveness of a Web-Based Computer-Tailored Multiple-Lifestyle Intervention for People Interested in Reducing their Cardiovascular Risk: A Randomized Controlled Trial

Background

Web-based computer-tailored interventions for multiple health behaviors can improve the strength of behavior habits in people who want to reduce their cardiovascular risk. Nonetheless, few randomized controlled trials have tested this assumption to date.

Objective

The study aim was to test an 8-week Web-based computer-tailored intervention designed to improve habit strength for physical activity and fruit and vegetable consumption among people who want to reduce their cardiovascular risk. In a randomized controlled design, self-reported changes in perceived habit strength, self-efficacy, and planning across different domains of physical activity as well as fruit and vegetable consumption were evaluated.

Methods

This study was a randomized controlled trial involving an intervention group (n=403) and a waiting control group (n=387). Web-based data collection was performed in Germany and the Netherlands during 2013-2015. The intervention content was based on the Health Action Process Approach and involved personalized feedback on lifestyle behaviors, which indicated whether participants complied with behavioral guidelines for physical activity and fruit and vegetable consumption. There were three Web-based assessments: baseline (T0, N=790), a posttest 8 weeks after the baseline (T1, n=206), and a follow-up 3 months after the baseline (T2, n=121). Data analysis was conducted by analyzing variances and structural equation analysis.

Results

Significant group by time interactions revealed superior treatment effects for the intervention group, with substantially higher increases in self-reported habit strength for physical activity (F1,199=7.71, P=.006, Cohen’s d=0.37) and fruit and vegetable consumption (F1,199=7.71, P=.006, Cohen’s d=0.30) at posttest T1 for the intervention group. Mediation analyses yielded behavior-specific sequential mediator effects for T1 planning and T1 self-efficacy between the intervention and habit strength at follow-up T2 (fruit and vegetable consumption: beta=0.12, 95% CI 0.09-0.16, P<.001; physical activity: beta=0.04, 95% CI 0.02-0.06, P<.001).

Conclusions

Our findings indicate the general effectiveness and practicality of Web-based computer-tailored interventions in terms of increasing self-reported habit strength for physical activity and fruit and vegetable consumption. Self-efficacy and planning may play major roles in the mechanisms that facilitate the habit strength of these behaviors; therefore, they should be actively promoted in Web-based interventions. Although the results need to take into account the high dropout rates and medium effect sizes, a large number of people were reached and changes in habit strength were achieved after 3 months.

Trial Registration

Clinicaltrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/6g5F0qoft) and Nederlands Trial Register NTR3706 http://www.trialregister.nl/ trialreg/admin/rctview.asp?TC=3706 (Archived by WebCite at http://www.webcitation.org/6g5F5HMLX)

Short-term effectiveness of a web-based tailored intervention for cancer survivors on quality of life, anxiety, depression, and fatigue: randomized controlled trial

BACKGROUND

The aim of this study was to evaluate the short-term effectiveness of the web-based computer-tailored intervention Kanker Nazorg Wijzer (Cancer Aftercare Guide). The intervention aims to support cancer survivors with managing psychosocial and lifestyle-related issues. In this study, the impact on quality of life, anxiety, depression, and fatigue were evaluated.

METHODS

Cancer survivors were recruited through 21 Dutch hospitals (November 2013-June 2014). Outcome measures included quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30), anxiety and depression (Hospital Anxiety and Depression Scale), and fatigue (Checklist Individual Strength). In a randomized controlled trial with an intervention group (n = 231) and a waiting list control group (n = 231), the short-term effectiveness was evaluated through multilevel linear regression analyses, controlling for selective dropout, baseline differences, and several demographic and disease-related characteristics.

RESULTS

In total, 188 participants of the intervention group and 221 of the control group completed the 6-month measurement (dropout = 11.5%). The intervention was effective in reducing depression (B = -0.63, p = 0.007, f²  = 0.019, d = 0.21) and fatigue (B = -4.36, p = 0.020, f²  = 0.013, d = 0.21). In addition, effects were found for emotional (B = 3.47, p = 0.022, f²  = 0.013, d = 0.15) and social functioning (B = 3.95, p = 0.011, f²  = 0.017, d = 0.15), although this evidence was less strong. There were indications that the effects of fatigue and social functioning were influenced by module use.

CONCLUSIONS

While effect sizes were small, they can be considered as clinically relevant. With the Cancer Aftercare Guide being an effective, low-intensive, and easy accessible intervention, it could serve as a first step in stepped care for needs assessment and initial support for psychosocial problems that are present after cancer treatment. Copyright © 2016 John Wiley & Sons, Ltd.

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).

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)

Impact of Educational Level on Study Attrition and Evaluation of Web-Based Computer-Tailored Interventions: Results From Seven Randomized Controlled Trials

Background

Web-based computer-tailored interventions have shown to be effective in improving health behavior; however, high dropout attrition is a major issue in these interventions.

Objective

The aim of this study is to assess whether people with a lower educational level drop out from studies more frequently compared to people with a higher educational level and to what extent this depends on evaluation of these interventions.

Methods

Data from 7 randomized controlled trials of Web-based computer-tailored interventions were used to investigate dropout rates among participants with different educational levels. To be able to compare higher and lower educated participants, intervention evaluation was assessed by pooling data from these studies. Logistic regression analysis was used to assess whether intervention evaluation predicted dropout at follow-up measurements.

Results

In 3 studies, we found a higher study dropout attrition rate among participants with a lower educational level, whereas in 2 studies we found that middle educated participants had a higher dropout attrition rate compared to highly educated participants. In 4 studies, no such significant difference was found. Three of 7 studies showed that participants with a lower or middle educational level evaluated the interventions significantly better than highly educated participants (“Alcohol-Everything within the Limit”: F_2,376=5.97, P=.003; “My Healthy Behavior”: F_2,359=5.52, P=.004; “Master Your Breath”: F_2,317=3.17, P=.04). One study found lower intervention evaluation by lower educated participants compared to participants with a middle educational level (“Weight in Balance”: F_2,37=3.17, P=.05). Low evaluation of the interventions was not a significant predictor of dropout at a later follow-up measurement in any of the studies.

Conclusions

Dropout attrition rates were higher among participants with a lower or middle educational level compared with highly educated participants. Although lower educated participants evaluated the interventions better in approximately half of the studies, evaluation did not predict dropout attrition. Further research is needed to find other explanations for high dropout rates among lower educated participants.

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)

Development of Motivate4Change Using the Intervention Mapping Protocol: An Interactive Technology Physical Activity and Medication Adherence Promotion Program for Hospitalized Heart Failure Patients

Background

It is important that heart failure (HF) patients adhere to their medication regimen and engage in physical activity. Evidence shows that adherence to these HF self-management behaviors can be improved with appropriate interventions.

Objective

To further promote medication adherence and physical activity among HF patients, we developed an intervention for hospitalized HF patients.

Methods

The intervention mapping protocol was applied in the development of the intervention. This entailed performing a needs assessment, defining change objectives, selecting determinants and strategies, and developing the materials.

Results

The resulting intervention, Motivate4Change, makes use of interactive technology and provides HF patients with personalized feedback and advice. Specific change objectives were defined. The relevant behavioral determinants for the physical activity program were practical knowledge on physical activity performance and self-efficacy for, and perceived benefits of, physical activity. For medication-taking, the selected determinants were practical knowledge on medication-taking, perceived barriers to medication-taking, beliefs about the necessity and harm regarding the medication prescribed, and beliefs about overprescribing and harm of medication in general. The change objectives and behavior change determinants were translated in feedback and advice strategies in an interactive technology program that included tailored feedback and advice, and role models in videos in which the behaviors and overcoming barriers were demonstrated. Relevant stakeholders were involved in the interventions development process. The intervention was pretested among HF patients and adjustments were made accordingly.

Conclusions

The interactive technology physical activity and medication adherence promotion program for hospitalized HF patients was systematically developed using the intervention mapping protocol and was based on the available theory and evidence regarding HF self-management behavior change. The intervention’s efficacy is yet to be determined in evaluation research.

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.

Effectiveness of a web-based, computer-tailored, pedometer-based physical activity intervention for adults: a cluster randomized controlled trial

BACKGROUND

Computer-tailored physical activity (PA) interventions delivered through the Internet represent a promising and appealing method to promote PA at a population level. However, personalized advice is mostly provided based on subjectively measured PA, which is not very accurate and might result in the delivery of advice that is not credible or effective. Therefore, an innovative computer-tailored PA advice was developed, based on objectively pedometer-measured PA.

OBJECTIVE

The study aim was to evaluate the effectiveness of a computer-tailored, pedometer-based PA intervention in working adults.

METHODS

Participants (≥18 years) were recruited between May and December 2012 from eight Flemish workplaces. These workplaces were allocated randomly to an intervention or control group. Intervention group participants (n=137) received (1) a booklet with information on how to increase their steps, (2) a non-blinded pedometer, and (3) an Internet link to request computer-tailored step advice. Control group participants (n=137) did not receive any of the intervention components. Self-reported and pedometer-based PA were assessed at baseline (T0), and 1 month (T1) and 3 months (T2) months post baseline. Repeated measures analyses of covariance were used to examine intervention effects for both the total sample and the at-risk sample (ie, adults not reaching 10,000 steps a day at baseline).

RESULTS

The recruitment process resulted in 274 respondents (response rate of 15.1%) who agreed to participate, of whom 190 (69.3%) belonged to the at-risk sample. Between T0 and T1 (1-month post baseline), significant intervention effects were found for participants' daily step counts in both the total sample (P=.004) and the at-risk sample (P=.001). In the at-risk sample, the intervention effects showed a daily step count increase of 1056 steps in the intervention group, compared to a decrease of 258 steps in the control group. Comparison of participants' self-reported PA revealed a significant intervention effect for time spent walking in the at-risk sample (P=.02). Intervention effects were still significant 3 months post baseline for participants' daily step counts in both the total sample (P=.03) and the at-risk sample (P=.02); however, self-reported PA differences were no longer significant.

CONCLUSIONS

A computer-tailored, pedometer-based PA intervention was effective in increasing both pedometer-based and self-reported PA levels, mainly in the at-risk participants. However, more effort should be devoted to recruit and retain participants in order to improve the public health impact of the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02080585; https://clinicaltrials.gov/ct2/show/NCT02080585 (Archived by WebCite at http://www.webcitation.org/6VvQnRQSy).

What do general practitioners think about an online self-regulation programme for health promotion? Focus group interviews

BACKGROUND

Chronic diseases may be prevented through programmes that promote physical activity and healthy nutrition. Computer-tailoring programmes are effective in changing behaviour in the short- and long-term. An important issue is the implementation of these programmes in general practice. However, there are several barriers that hinder the adoption of eHealth programmes in general practice. This study explored the feasibility of an eHealth programme that was designed, using self-regulation principles.

METHODS

Seven focus group interviews (a total of 62 GPs) were organized to explore GPs' opinions about the feasibility of the eHealth programme for prevention in general practice. At the beginning of each focus group, GPs were informed about the principles of the self-regulation programme 'My Plan'. Open-ended questions were used to assess the opinion of GPs about the content and the use of the programme. The focus groups discussions were audio-taped, transcribed and thematically analysed via NVivo software.

RESULTS

The majority of the GPs was positive about the use of self-regulation strategies and about the use of computer-tailored programmes in general practice. There were contradictory results about the delivery mode of the programme. GPs also indicated that the programme might be less suited for patients with a low educational level or for old patients.

CONCLUSIONS

Overall, GPs are positive about the adoption of self-regulation techniques for health promotion in their practice. However, they raised doubts about the adoption in general practice. This barrier may be addressed (1) by offering various ways to deliver the programme, and (2) by allowing flexibility to match different work flow systems. GPs also believed that the acceptability and usability of the programme was low for patients who are old or with low education. The issues raised by GPs will need to be taken into account when developing and implementing an eHealth programme in general practice.

Short- and medium-term efficacy of a Web-based computer-tailored nutrition education intervention for adults including cognitive and environmental feedback: randomized controlled trial

BACKGROUND

Web-based, computer-tailored nutrition education interventions can be effective in modifying self-reported dietary behaviors. Traditional computer-tailored programs primarily targeted individual cognitions (knowledge, awareness, attitude, self-efficacy). Tailoring on additional variables such as self-regulation processes and environmental-level factors (the home food environment arrangement and perception of availability and prices of healthy food products in supermarkets) may improve efficacy and effect sizes (ES) of Web-based computer-tailored nutrition education interventions.

OBJECTIVE

This study evaluated the short- and medium-term efficacy and educational differences in efficacy of a cognitive and environmental feedback version of a Web-based computer-tailored nutrition education intervention on self-reported fruit, vegetable, high-energy snack, and saturated fat intake compared to generic nutrition information in the total sample and among participants who did not comply with dietary guidelines (the risk groups).

METHODS

A randomized controlled trial was conducted with a basic (tailored intervention targeting individual cognition and self-regulation processes; n=456), plus (basic intervention additionally targeting environmental-level factors; n=459), and control (generic nutrition information; n=434) group. Participants were recruited from the general population and randomly assigned to a study group. Self-reported fruit, vegetable, high-energy snack, and saturated fat intake were assessed at baseline and at 1- (T1) and 4-months (T2) postintervention using online questionnaires. Linear mixed model analyses examined group differences in change over time. Educational differences were examined with group×time×education interaction terms.

RESULTS

In the total sample, the basic (T1: ES=-0.30; T2: ES=-0.18) and plus intervention groups (T1: ES=-0.29; T2: ES=-0.27) had larger decreases in high-energy snack intake than the control group. The basic version resulted in a larger decrease in saturated fat intake than the control intervention (T1: ES=-0.19; T2: ES=-0.17). In the risk groups, the basic version caused larger decreases in fat (T1: ES=-0.28; T2: ES=-0.28) and high-energy snack intake (T1: ES=-0.34; T2: ES=-0.20) than the control intervention. The plus version resulted in a larger increase in fruit (T1: ES=0.25; T2: ES=0.37) and a larger decrease in high-energy snack intake (T1: ES=-0.38; T2: ES=-0.32) than the control intervention. For high-energy snack intake, educational differences were found. Stratified analyses showed that the plus version was most effective for high-educated participants.

CONCLUSIONS

Both intervention versions were more effective in improving some of the self-reported dietary behaviors than generic nutrition information, especially in the risk groups, among both higher- and lower-educated participants. For fruit intake, only the plus version was more effective than providing generic nutrition information. Although feasible, incorporating environmental-level information is time-consuming. Therefore, the basic version may be more feasible for further implementation, although inclusion of feedback on the arrangement of the home food environment and on availability and prices may be considered for fruit and, for high-educated people, for high-energy snack intake.

TRIAL REGISTRATION

Netherlands Trial Registry NTR3396; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3396 (Archived by WebCite at http://www.webcitation.org/6VNZbdL6w).

Is Action Planning Helpful for Smoking Cessation? Assessing the Effects of Action Planning in a Web-Based Computer-Tailored Intervention

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the efficacy of a web-assisted computer-tailored smoking cessation intervention, an action planning (AP) intervention in which potential quitters were encouraged to form action plans (e.g., plan a quit date) and execute them (e.g., remove ashtrays). We also investigated whether the AP intervention resulted in more AP and plan execution than a similar, control intervention without the supplementary AP component.

METHODS

In a randomized controlled trial, the AP intervention (N = 977) was compared with the control intervention (N = 1,005) in terms of self-reported continued abstinence (CA) and point prevalence abstinence (PPA) six months after baseline. AP, plan execution, and opinion of the intervention were measured one month after baseline.

RESULTS

Complete-case logistic regression analysis showed that the AP intervention had a significant effect on CA (OR = 2.01; CI 1.08-3.84, p = .02), whereas intention-to-treat analysis showed a borderline significant effect (OR = 1.68; CI .96-2.92, p = .07). Sixteen percent of the experimental group achieved CA compared to 10% of the control group. The AP intervention had no effect on PPA. The experimental group also showed significantly more AP and plan execution at one month. Execution of plans was associated with smoking cessation.

CONCLUSIONS

The effects of the AP intervention on CA, AP, and execution of plans were encouraging. The potential for widespread use of web-based interventions means that even small behavioral effects may have an impact on public health. We recommend that the intervention be intensified and improved.

Randomized controlled trial to assess the short-term effectiveness of tailored web- and text-based facilitation of smoking cessation in primary care (iQuit in practice)

AIMS

To estimate the short-term effectiveness, feasibility and acceptability of a smoking cessation intervention (the iQuit system) that consists of tailored printed and Short Message Service (SMS) text message self-help delivered as an adjunct to cessation support in primary care to inform the design of a definitive trial.

DESIGN

A stratified two parallel-group randomized controlled trial comparing usual care (control) with usual care plus the iQuit system (intervention), delivered by primary care nurses/healthcare assistants who were blinded to the allocation sequence.

SETTING

Thirty-two general practice (GP) surgeries in England, UK.

PARTICIPANTS

A total of 602 smokers initiating smoking cessation support from their local GP surgery were randomized (control n = 303, intervention n = 299).

MEASUREMENTS

Primary outcome was self-reported 2-week point prevalence abstinence at 8 weeks follow-up. Secondary smoking outcomes and feasibility and acceptability measures were collected at 4 weeks after quit date, 8 weeks and 6 months follow-up.

FINDINGS

There were no significant between-group differences in the primary outcome [control 40.3%, iQuit 45.2%; odds ratio (OR) = 1.22, 95% confidence interval (CI) = 0.88-1.69] or in secondary short-term smoking outcomes. Six-month prolonged abstinence was significantly higher in the iQuit arm (control 8.9%, iQuit 15.1%; OR = 1.81, 95% CI = 1.09-3.01). iQuit support took on average 7.7 minutes (standard deviation = 4.0) to deliver and 18.9% (95% CI = 14.8-23.7%) of intervention participants discontinued the text message support during the programme.

CONCLUSIONS

Tailored printed and text message self-help delivered alongside routine smoking cessation support in primary care does not significantly increase short-term abstinence, but may increase long-term abstinence and demonstrated feasibility and acceptability compared with routine cessation support alone.

Efficacy of a Web-based computer-tailored smoking prevention intervention for Dutch adolescents: randomized controlled trial

Background

Preventing smoking initiation among adolescents is crucial to reducing tobacco-caused death and disease. This study focuses on the effectiveness of a Web-based computer-tailored smoking prevention intervention aimed at adolescents.

Objective

The intent of the study was to describe the intervention characteristics and to show the effectiveness and results of a randomized controlled trial. We hypothesized that the intervention would prevent smoking initiation among Dutch secondary school students aged 10-20 years and would have the largest smoking prevention effect among the age cohort of 14-16 years, as smoking uptake in that period is highest.

Methods

The intervention consisted of a questionnaire and fully automated computer-tailored feedback on intention to start smoking and motivational determinants. A total of 89 secondary schools were recruited via postal mail and randomized into either the computer-tailored intervention condition or the control condition. Participants had to complete a Web-based questionnaire at baseline and at 6-month follow-up. Data on smoking initiation were collected from 897 students from these schools. To identify intervention effects, multilevel logistic regression analyses were conducted using multiple imputation.

Results

Smoking initiation among students aged 10-20 years was borderline significantly lower in the experimental condition as compared to the control condition 6 months after baseline (OR 0.25, 95% CI 0.05-1.21, P=.09). Additional analyses of the data for the 14-16 year age group showed a significant effect, with 11.5% (24/209) of the students in the control condition reporting initiation compared to 5.7% (10/176) in the experimental condition (OR 0.22, 95% CI 0.05-1.02, P=.05). No moderation effects were found regarding gender and educational level.

Conclusions

The findings of this study suggest that computer-tailored smoking prevention programs are a promising way of preventing smoking initiation among adolescents for at least 6 months, in particular among the age cohort of 14-16 years. Further research is needed to focus on long-term effects.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN): 77864351; http://www.controlled-trials.com/ISRCTN77864351 (Archived by WebCite at http://www.webcitation.org/6BSLKSTm5).

Differential effects of the computer-tailored FATaintPHAT programme on dietary behaviours according to sociodemographic, cognitive and home environmental factors

OBJECTIVE

To explore whether the effects on dietary behaviours of a computer-tailored intervention aimed to prevent excessive weight gain among adolescents, FATaintPHAT, were moderated by sociodemographic, cognitive and home environmental factors.

DESIGN

A two-group cluster randomized trial. Potential moderation of the outcome measures (consumption of sugar-sweetened beverages, snacks, fruits and vegetables) was studied by gender, education level, ethnicity, awareness of risk behaviour, intention and home availability.

SETTING

Twenty schools in the Netherlands.

SUBJECTS

Students (n 883) aged 12-13 years.

RESULTS

Of the twenty-four interactions tested, only three were significant. The intervention effect on sugar-sweetened beverages was moderated by level of education (P = 0·009); intervention effects were found only among academic preparatory students. The intervention effects on fruit and vegetable intake were moderated by awareness of fruit intake (P < 0·001) and home availability of vegetables (P = 0·007); an effect on fruit intake was found only among students who were aware of their low fruit intake at baseline and an effect on vegetable consumption was found only among students who reported that vegetables were always available at their home.

CONCLUSIONS

The effects of the intervention generally did not differ between sociodemographic subgroups. The moderation by home availability illustrates that the environment may influence the effects of educational interventions.

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).

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).

Influence of delivery strategy on message-processing mechanisms and future adherence to a Dutch computer-tailored smoking cessation intervention

BACKGROUND

Smoking tobacco is one of the most preventable causes of illness and death. Web-based tailored smoking cessation interventions have shown to be effective. Although these interventions have the potential to reach a large number of smokers, they often face high attrition rates, especially among lower educated smokers. A possible reason for the high attrition rates in the latter group is that computer-tailored smoking cessation interventions may not be attractive enough as they are mainly text-based. Video-based messages might be more effective in attracting attention and stimulating comprehension in people with a lower educational level and could therefore reduce attrition rates.

OBJECTIVE

The objective of the present study was to investigate whether differences exist in message-processing mechanisms (attention, comprehension, self-reference, appreciation, processing) and future adherence (intention to visit/use the website again, recommend the website to others), according to delivery strategy (video or text based messages) and educational level, to a Dutch computer-tailored smoking cessation program.

METHODS

Smokers who were motivated to quit within the following 6 months and who were aged over 16 were included in the program. Participants were randomly assigned to one of two conditions (video/text CT). The sample was stratified into 2 categories: lower and higher educated participants. In total, 139 participants completed the first session of the web-based tailored intervention and were subsequently asked to fill out a questionnaire assessing message-processing mechanisms and future adherence. ANOVAs and regression analyses were conducted to investigate the differences in message-processing mechanisms and future adherence with regard to delivery strategy and education.

RESULTS

No interaction effects were found between delivery strategy (video vs text) and educational level on message-processing mechanisms and future adherence. Delivery strategy had no effect on future adherence and processing mechanisms. However, in both groups results indicated that lower educated participants showed higher attention (F(1,138)=3.97; P=.05) and processing levels (F(1,138)=4.58; P=.04). Results revealed also that lower educated participants were more inclined to visit the computer-tailored intervention website again (F(1,138)=4.43; P=.04).

CONCLUSIONS

Computer-tailored programs have the potential to positively influence lower educated groups as they might be more involved in the computer-tailored intervention than higher educated smokers. Longitudinal studies with a larger sample are needed to gain more insight into the role of delivery strategy in tailored information and to investigate whether the intention to visit the intervention website again results in the ultimate goal of behavior change.

TRIAL REGISTRATION

Netherlands Trial Register (NTR3102).

Usability evaluation of an online, tailored self-management intervention for chronic obstructive pulmonary disease patients incorporating behavior change techniques

BACKGROUND

An eHealth intervention using computer tailored technology including several behavior change techniques was developed to support the self-management of chronic obstructive pulmonary disease patients.

OBJECTIVE

The goal of this study was to evaluate and improve the usability of the eHealth intervention.

METHODS

We conducted a usability evaluation with 8 chronic obstructive pulmonary disease patients, with a mixed methods design. We improved the usability through iterative cycles of evaluation and adaptation. Participants were asked to think aloud during the evaluation sessions. Participants then completed a semi-structured interview. The sessions were observed and recorded. Descriptive statistics and content analysis were used to uncover usability issues.

RESULTS

Areas for improvement were layout, navigation, and content. Most issues could be solved within 3 iterations of improvement. Overall, participants found the program easy to use. The length of the program urged us to further analyze the appreciation of behavior change techniques. Some were perceived as helpful and easy to use, while others evoked frustration.

CONCLUSIONS

The usability study identified several issues for improvement, confirming the need for usability evaluation during the development of eHealth interventions. The uncovered strengths and limitations of behavior change techniques may lead to optimization of eHealth interventions, but further insight is needed.

A community-based participatory approach to personalized, computer-generated nutrition feedback reports: the healthy environments partnership

BACKGROUND

Computer tailoring and personalizing recommendations for dietary health-promoting behaviors are in accordance with community-based participatory research (CBPR) principles, which emphasizes research that benefits the participants and community involved.

OBJECTIVE

To describe the CBPR process utilized to computer-generate and disseminate personalized nutrition feedback reports (NFRs) for Detroit Healthy Environments Partnership (HEP) study participants.

METHODS

The CBPR process included discussion and feedback from HEP partners on several draft personalized reports. The nutrition feedback process included defining the feedback objectives; prioritizing the nutrients; customizing the report design; reviewing and revising the NFR template and readability; producing and disseminating the report; and participant follow-up.

LESSONS LEARNED

Application of CBPR principles in designing the NFR resulted in a reader-friendly product with useful recommendations to promote heart health.

CONCLUSIONS

A CBPR process can enhance computer tailoring of personalized NFRs to address racial and socioeconomic disparities in cardiovascular disease (CVD).