J.M. de Nooijer

Which Intervention Characteristics are Related to More Exposure to Internet-Delivered Healthy Lifestyle Promotion Interventions? A Systematic Review

Background The Internet has become a popular medium for the delivery of tailored healthy lifestyle promoting interventions. The actual reach of Internet-delivered interventions seems, however, lower than expected, and attrition from interventions is generally high. Characteristics of an intervention, such as personally tailored feedback and goal setting, are thought to be among the important factors related to of use of and exposure to interventions. However, there is no systematic overview of which characteristics of Internet-delivered interventions may be related to more exposure. Objective The present study aims to identify (1) which potentially exposure-promoting methods and strategies are used in existing Internet interventions, (2) which objective outcome measures are used to measure exposure to Internet interventions, and (3) which potentially exposure-promoting methods and strategies are associated with better exposure. Methods A systematic review of the literature was conducted based on the Cochrane guidelines. Papers published between 1995 and 2009 were searched in the PubMed, PsycINFO, and Web of Science databases. In total, 64 studies were included that reported objective exposure measures such as completion of an initial visit, number of log-ins, and time spent on the website. Information about intervention-related characteristics (ie, interactive behavior change strategies, interactive elements for fun, peer or counsel support, email/phone contact, and regular updates of the website) that could potentially contribute to better exposure and objective exposure outcomes were abstracted from the studies and qualitative systematic descriptive analyses were performed. Results The results showed that a large variety of behavior change techniques and other exposure-promoting elements were used in the interventions and that these methods and strategies varied for the various lifestyle behaviors. Feedback, interactive elements, and email/phone contact were used most often. In addition, there was much variety and a lack of consistency in the exposure measures that were reported. Of all the categories of intervention characteristics that may be associated with better exposure, there were indications that peer and counselor support result in a longer website visit and that email/phone contact and updates of the website result in more log-ins. Conclusions Results of this qualitative systematic review indicate that of all intervention characteristics that could potentially enhance exposure, only peer support, counselor support, email/phone contact with visitors, and updates of the intervention website were related to better exposure. The diversity of intervention methods used and the inconsistency in the report of exposure measures prevented us from drawing firmer conclusions. More research is needed to identify whether other characteristics of Internet interventions are associated with greater exposure.

Strategies to Facilitate Exposure to Internet-Delivered Health Behavior Change Interventions Aimed at Adolescents or Young Adults: A Systematic Review

The Internet is considered to be a promising delivery channel of interventions aimed at promoting healthful behaviors, especially for adolescents and young adults. Exposure to these interventions, however, is generally low. A more extensive exploration of methods, strategies, and their effectiveness with regard to facilitating exposure is therefore timely, because this knowledge is crucial to improve the use of such interventions and, subsequently, to increase behavioral change. Therefore, a systematic review of the literature was conducted, resulting in 838 studies based on title selection, of which 26 studies met the eligibility criteria. The systematic review resulted in an overview of methods and strategies that have been used to facilitate exposure. Patterns of effective strategies could be observed, such as the combination of tailored communication and the use of reminders and incentives. Nevertheless, exposure-specific theories need to be developed and objective exposure measures should be tracked and reported in future studies.

An Exploration of Factors Related to Dissemination of and Exposure to Internet-Delivered Behavior Change Interventions Aimed at Adults: A Delphi Study Approach

Background The Internet is an attractive medium for delivering individualized, computer-tailored behavior change interventions to large numbers of people. However, the actual numbers of people reached seem to fall behind the high expectations. Insight into factors that determine use of and exposure to these Internet interventions is important to be able to increase the reach and improve exposure. Objective The aim was to identify potentially important factors that determine whether adults visit an Internet-delivered behavior change intervention, extend their visit, and revisit the intervention. Methods A systematic, three-round Delphi study was conducted among national and international experts from Internet intervention research and practice, e-marketing/e-commerce, Web design, and technical website development. In the first round, 30 experts completed a structured, open-ended online questionnaire assessing factors that were, in their opinion, important for a first visit, an extended visit, a revisit and for effective promotion strategies. Based on the responses in this first questionnaire, a closed-ended online questionnaire was developed for use in the second round. A total of 233 experts were invited to complete this questionnaire. Median and interquartile deviation (IQD) scores were computed to calculate agreement and consensus on the importance of the factors. The factors for which no consensus was obtained (IQD > 1) were included in the third-round questionnaire. Factors with a median score of six or higher and with an IQD ≤ 1 were considered to be important. Results Of the 62 experts invited for the first round, 30 completed the questionnaire (48% response rate); 93/233 experts completed the second-round questionnaire (40% response rate), and 59/88 completed the third round (67% response rate). Being motivated to visit an Internet intervention and perceiving the intervention as personally relevant appeared to be important factors related to a first visit. The provision of tailored feedback, relevant and reliable information, and an easy navigation structure were related to an extended visit. Provision of regular new content and the possibility to monitor personal progress toward behavior change were identified as important factors to encourage a revisit. Primarily traditional promotion strategies, like word-of-mouth by family and friends, a publicity campaign with simultaneous use of various mass media, and recommendation by health professionals, were indicated as effective ways to encourage adults to visit an Internet intervention. Conclusions This systematic study identified important factors related to the dissemination of and exposure to Internet interventions aimed at adults. In order to improve optimal use of and exposure to Internet interventions, potential users may need to be motivated to visit such an intervention and the information provided needs to be personally relevant. Furthermore, several (technical) aspects of the intervention itself need to be taken into account when developing Internet interventions.

A conceptual framework for understanding and improving adolescents' exposure to Internet-delivered interventions

Although exposure is crucial to improve the public health impact of Internet-delivered interventions, it appears that in practice exposure to such interventions is low. Therefore, a conceptual framework, which incorporates elements of user experience of websites, is applied to Internet-delivered health behaviour change interventions aimed at adolescents and results from previous explorative research are incorporated. This framework, described from the point of view of an interventions development team, can be used in practice to optimize user experience and therewith improving exposure rates to Internet-delivered interventions and increasing the number of revisiting users.

Increasing fruit and vegetable intake among children: comparing long-term effects of a free distribution and a multicomponent program

The aim of this study was to evaluate and compare the effectiveness of two primary school-based interventions on childrens fruit and vegetable (F&V) consumption on the long term (2 years after the start of the interventions). Six primary schools were recruited and randomly assigned to (i) a daily free distribution program for the whole school or (ii) a multicomponent program consisting of a classroom curriculum and parental involvement (without free F&V), and six schools served as controls. Follow-up measurements were conducted at the end of the intervention (Follow-up I) and 1 year later (Follow-up II). Random coefficient analyses for longitudinal data showed that the effects of both interventions did not differ between the two follow-up measurements. The results showed similar effects for the free distribution program and the multicomponent program in increasing childrens fruit consumption over time (respectively, 7.2 and 15.2 g day(-1)). The distribution program also increased childrens vegetable consumption over time (3.25 g day(-1)), even after repeating the analyses using a pessimistic scenario. Despite the large dropout and its consequences for generalizability of our results, the distribution program is considered as the preferred intervention of the two, and implementation on a larger scale should be investigated.

Effectiveness of online word of mouth on exposure to an Internet-delivered intervention

The use of online word of mouth (WOM) seems a promising strategy to motivate young people to visit Internet-delivered interventions. An Internet-delivered intervention aimed at changing implicit attitudes related to alcohol was used in two experiments to test effectiveness of e-mail invitations on a first visit to the intervention. The results of the first experiment (N = 196) showed that an invitation by e-mail from a friend was more effective to attract young adults (aged 18–24 years) to the intervention website than an invitation from an institution. A 2 × 2 design was used in the second experiment (N = 236) to test manipulations of argument strength and the use of peripheral cues in invitations. Results showed that weak arguments were more effective to attract young adults to the intervention website when an incentive was withheld. These results need to be taken into account when using online WOM as a strategy to improve exposure to Internet-delivered interventions.

Passive cancer detection and medical help seeking for cancer symptoms: (in)adequate behavior and psychosocial determinants.

The present study explored the performance and psychosocial determinants of passive cancer detection behavior, that is, attentiveness to cancer symptoms, and medical help seeking, and investigated potential dependency between these two behaviors. A detailed telephone survey was conducted among 459 respondents, aged 55 years or older. The survey assessed passive detection behavior and appropriately timed medical help seeking, regarding 14 cancer symptoms. Knowledge of cancer symptoms and various other psychosocial determinants were also measured. Knowledge of cancer symptoms and adequate passive detection behavior was low to moderate. Timely medical help-seeking behavior was low to moderate for urgent symptoms but relatively high for prolonged symptoms. Overall, women had higher knowledge levels, paid more attention to cancer symptoms, and performed more timely help seeking than men. Passive detection behavior was positively associated with premotivational awareness factors (knowledge and awareness), female gender, and perceived advantages. Timely medical help seeking was positively related to cognitive motivational factors (perceived advantages, self-efficacy expectations, and intention) and negatively related to educational level and perceived susceptibility to cancer. Furthermore, a strong positive association was found between the performance of passive detection behavior and timely medical help seeking. The suboptimal levels of knowledge and performance of early cancer detection behaviors found in this study emphasize a need for educational efforts in the area of early cancer detection. The effectiveness of these efforts may benefit from considering the distinct sets of determinants of passive detection behavior and medical help seeking.

Breast self-examination: longitudinal predictors of intention and subsequent behaviour

This study analysed in a longitudinal design the relationship between past breast self-examination (BSE) behaviour, determinants, intention and future BSE behaviour in a population of adult Dutch women. Past behaviour and psychosocial determinants were assessed at T1, followed 6 weeks later (T2) with the assessment of the intention to perform BSE monthly. Half a year after the first measurement the current BSE behaviour was assessed by means of a telephone survey (T3) (total end response 78%, n=364). The questionnaires included BSE behaviour, intention, attitude (pros and cons of BSE, anticipated regret, moral obligation), social influence (support, modelling) and self-efficacy. Other background variables assessed were past BSE behaviour, and demographics. Although 81% of the women stated that they performed BSE, only 41% of the women performed BSE correctly. Women who performed BSE correctly differed from women who did not on all psychosocial determinants assessed a half year earlier, with the exception of anticipated regret. Stepwise multiple regression analyses showed that the psychosocial determinants explained 51% of the variance in intention to perform BSE, assessed 6 weeks later; past behaviour accounted for 2% of extra explained variance. Logistic regression analyses showed that past behaviour, the psychosocial determinants and intention were significant predictors of correct BSE behaviour a half year later (Nagelkerkes total explained variance was 47%). It was concluded that misperceptions of correct BSE behaviour was highly prevalent. Both the psychosocial determinants as well as past behaviour were important predictors of intention to perform BSE and subsequent BSE behaviour.

Intervening via chat: an opportunity for adolescents’ mental health promotion?

Mental health problems are highly prevalent among adolescents, but a majority of adolescents is reluctant to seek help at mental health services because of shame and lack of anonymity. Intervening via chat (i.e. offering online support) could be a solution to remove these barriers and to reach adolescents. The dimensions of the RE-AIM model (reach, efficacy, adoption, implementation and maintenance) served as a guiding principle for discussing the potential of offering online support via chat. It appeared that the use of chat may be an appropriate way to reach adolescents and may have a positive impact on outcome measures related to mental health. Additional efforts are needed to stimulate adoption at the individual level (target group, intermediaries) and the organizational level. Future research needs to focus on the dissemination of chat-based interventions, differences between online peer support and online professional support, and the content of conversations via chat about mental health problems.

Using intervention mapping for systematic development of two school‐based interventions aimed at increasing children's fruit and vegetable intake

Purpose – The purpose of this paper is to show how the intervention mapping (IM) protocol could be applied to the development of two school‐based interventions. It provides an extensive description of the development, implementation and evaluation of two interventions which aimed to increase fruit and vegetable (FV applying methods and strategies for behavioural change; creating a program plan; preparing program implementation; and evaluation. An extensive assessment of the perceived health problem was conducted prior to beginning step 1 of IM.Findings – Application of the protocol resulted in two scho...