Lee M. Ritterband

A Behavior Change Model for Internet Interventions

BackgroundThe Internet has become a major component to health care and has important implications for the future of the health care system. One of the most notable aspects of the Web is its ability to provide efficient, interactive, and tailored content to the user. Given the wide reach and extensive capabilities of the Internet, researchers in behavioral medicine have been using it to develop and deliver interactive and comprehensive treatment programs with the ultimate goal of impacting patient behavior and reducing unwanted symptoms. To date, however, many of these interventions have not been grounded in theory or developed from behavior change models, and no overarching model to explain behavior change in Internet interventions has yet been published.PurposeThe purpose of this article is to propose a model to help guide future Internet intervention development and predict and explain behavior changes and symptom improvement produced by Internet interventions.ResultsThe model purports that effective Internet interventions produce (and maintain) behavior change and symptom improvement via nine nonlinear steps: the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics. Website use leads to behavior change and symptom improvement through various mechanisms of change. The improvements are sustained via treatment maintenance.ConclusionBy grounding Internet intervention research within a scientific framework, developers can plan feasible, informed, and testable Internet interventions, and this form of treatment will become more firmly established.

Internet Interventions: In Review, In Use, and Into the Future

The provision of health care over the Internet is a rapidly evolving and potentially beneficial means of delivering treatment otherwise unsought or unobtainable. Internet interventions are typically behavioral treatments operationalized and transformed for Web delivery with the goal of symptom improvement. The literature on the feasibility and utility of Internet interventions is limited, and there are even fewer outcome study findings. This article reviews empirically tested Internet interventions and provides an overview of the issues in developing and/or using them in clinical practice. Future directions and implications are also addressed. Although Internet interventions will not likely replace face-to-face care, there is little doubt that they will grow in importance as a powerful component of successful psychobehavioral treatment. With the advancement of computer technologies over the past 20 years, a flood of new ways to communicate, provide, and deliver psychological treatments has emerged. The Internet has the ability to reach people all over the world and provide highly specialized psychological interventions otherwise not sought or obtainable. There is a new but growing literature on the use of the Internet as a means of delivering treatment. These Internet treatments are typically focused on behavioral issues, with the goal of instituting behavior change and subsequent symptom improvement. They are usually self-paced, interactive, and tailored to the user, and they make use of the multimedia format offered by the Internet. Individuals with computer and Internet access who use these treatments may also overcome many of the barriers to obtaining traditional care because they can seek such treatments at any time, any place, and often at significantly reduced cost. Clearly, people are using computers and the Internet in greater frequency and with the specific purpose of obtaining mental health information (see Crutsinger, 2000; Employment Policy Foundation, 2001; Pew Research Center, 2002; Rabasca, 2000). This new field of Internet interventions is only going to grow and expand. The benefits are vast, as there is the potential for greater numbers of people to receive more services than ever before. However, to meet this potential, Internet interventions, like any other treatment, must first demonstrate feasibility and efficacy through rigorous scientific testing. In this article we present a critical examination of the current state of the available literature focused on the development and testing of these types of interventions. In addition, issues that should be addressed when constructing Internet interventions are enumerated, followed by a discussion of possible future directions and implications for research and clinical practice.

Efficacy of an Internet-Based Behavioral Intervention for Adults with Insomnia

CONTEXT Insomnia is a major health problem with significant psychological, health, and economic consequences. However, availability of one of the most effective insomnia treatments, cognitive behavioral therapy, is significantly limited. The Internet may be a key conduit for delivering this intervention. OBJECTIVE To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia. DESIGN, SETTING, AND PARTICIPANTS Forty-five adults were randomly assigned to an Internet intervention (n = 22) or wait-list control group (n = 23). Forty-four eligible participants (mean [SD] age, 44.86 [11.03] years; 34 women) who had a history of sleep difficulties longer than 10 years on average (mean [SD], 10.59 [8.89] years) were included in the analyses. INTERVENTION The Internet intervention is based on well-established face-to-face cognitive behavioral therapy incorporating the primary components of sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and relapse prevention. MAIN OUTCOME MEASURES The Insomnia Severity Index and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset and sleep efficiency. RESULTS Intention-to-treat analyses showed that scores on the Insomnia Severity Index significantly improved from 15.73 (95% confidence interval [CI], 14.07 to 17.39) to 6.59 (95% CI, 4.73 to 8.45) for the Internet group but did not change for the control group (16.27 [95% CI, 14.61 to 17.94] to 15.50 [95% CI, 13.64 to 17.36]) (F(1,42) = 29.64; P < .001). The Internet group maintained their gains at the 6-month follow-up. Internet participants also achieved significant decreases in wake after sleep onset (55% [95% CI, 34% to 76%]) and increases in sleep efficiency (16% [95% CI, 9% to 22%]) compared with the nonsignificant control group changes of wake after sleep onset (8% [95% CI, -17% to 33%) and sleep efficiency (3%; 95% CI, -4% to 9%). CONCLUSIONS Participants who received the Internet intervention for insomnia significantly improved their sleep, whereas the control group did not have a significant change. The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00328250.

Diabetes and behavioral medicine: the second decade.

Diabetes management depends almost entirely on behavioral self-regulation. Behavioral scientists have continued a collaboration with other health systems researchers to develop a holistic approach to this disease. The authors summarized the literature in 4 major areas: self-management of diabetes, psychosocial adjustment and quality of life, neuropsychological impact, and psychobehavioral intervention development. Progress made in each of these areas over the past decade is highlighted, as are important issues that have not yet received sufficient scientific attention. Emerging areas likely to become central in behavioral research, such as diabetes prevention, are introduced. The future of behavioral medicine in diabetes is also discussed, including topics such as the changing role of psychologists in diabetes care, the urgent need for more and better intervention research, the growing importance of incorporating a health system-public health perspective, and obstacles to the integration of psychobehavioral approaches into routine health care delivery.

Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia

Objective: Insomnia is a common complaint among cancer survivors. Fortunately, cognitive‐behavioral therapy for insomnia (CBT‐I) has been shown to be an effective treatment in this population. However, it is rarely implemented given its limited availability. To address this barrier, we examined the ability of an easily accessible online CBT‐I program to improve insomnia symptoms in cancer survivors.

An Internet Intervention as Adjunctive Therapy for Pediatric Encopresis

This study evaluated the benefits of enhanced toilet training delivered through the Internet for children with encopresis. Twenty-four children with encopresis were randomly assigned to the Internet intervention group (Web) or no Internet intervention group (No-Web). All participants continued to receive routine care from their primary care physician. The Web participants demonstrated greater improvements in terms of reduced fecal soiling, increased defecation in the toilet, and increased unprompted trips to the toilet (ps<.02). Both groups demonstrated similar improvements in knowledge and toileting behaviors. Internet interventions may be an effective way of delivering sophisticated behavioral interventions to a large and dispersed population in a convenient format.

Establishing guidelines for executing and reporting internet intervention research

The field of Internet interventions is growing rapidly. New programs are continually being developed to facilitate health and mental health promotion, disease and emotional distress prevention, risk factor management, treatment, and relapse prevention. However, a clear definition of Internet interventions, guidelines for research, and evidence of effectiveness have been slower to follow. This article focuses on the quality standardization of research on Internet-delivered psychological and behavioural interventions. Although the science underpinning Internet interventions is just starting to be established, across research studies there are often conceptual and methodological difficulties. The authors argue that this situation is due to the lack of universally accepted operational guidelines and evaluation methods. Following a critical appraisal of existing codes of conduct and guidelines for Internet-assisted psychological and health interventions, the authors developed a framework of guidelines for Internet intervention research utilizing aspects of facet theory (Guttman & Greenbaum, 1998). The framework of facets, elements, and guidelines of best practice in reporting Internet intervention research was then sent to several leading researchers in the field for their comment and input, so that a consensus framework could be agreed on. The authors outline 12 key facets to be considered when evaluating and reporting Internet intervention studies. Each facet consists of a range of recommended elements, designed as the minimum features for reporting Internet intervention studies. The authors propose that this framework be utilized when designing and reporting Internet intervention research, so results across studies can be replicated, extended, compared, and contrasted with greater ease and clarity.

Efficacy of internet-delivered cognitive-behavioral therapy for insomnia – A systematic review and meta-analysis of randomized controlled trials

Cognitive-behavioral therapy for insomnia (CBT-I) has been shown efficacious, but the challenge remains to make it available and accessible in order to meet population needs. Delivering CBT-I over the internet (eCBT-I) may be one method to overcome this challenge. The objective of this meta-analysis was to evaluate the efficacy of eCBT-I and the moderating influence of various study characteristics. Two researchers independently searched key electronic databases (1991 to June 2015), selected eligible publications, extracted data, and evaluated methodological quality. Eleven randomized controlled trials examining a total of 1460 participants were included. Results showed that eCBT-I improved insomnia severity, sleep efficiency, subjective sleep quality, wake after sleep onset, sleep onset latency, total sleep time, and number of nocturnal awakenings at post-treatment, with effect sizes (Hedgess g) ranging from 0.21 to 1.09. The effects were comparable to those found for face-to-face CBT-I, and were generally maintained at 4-48 wk follow-up. Moderator analyses showed that longer treatment duration and higher degree of personal clinical support were associated with larger effect sizes, and that larger study dropout in the intervention group was associated with smaller effect sizes. In conclusion, internet-delivered CBT-I appears efficacious and can be considered a viable option in the treatment of insomnia.

Cognitive Function Is Disrupted by Both Hypo- and Hyperglycemia in School-Aged Children With Type 1 Diabetes: A Field Study

OBJECTIVE We developed a field procedure using personal digital assistant (PDA) technology to test the hypothesis that naturally occurring episodes of hypo- and hyperglycemia are associated with deterioration in cognitive function in children with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 61 children aged 6–11 years with type 1 diabetes received a PDA programmed with two brief cognitive tests (mental math and choice reaction time), which they completed just before home glucose readings. The computer recorded time to complete each test and number of correct responses. Children completed several trials per day over 4–6 weeks for a total of 70 trials. Performance variables were compared across glucose ranges. Individual impairment scores (IISs) were also computed for each child by calculating the SD between performance during euglycemia and that during glucose extremes. RESULTS Time to complete both mental math and reaction time was significantly longer during hypoglycemia. During hyperglycemia, time to complete math was significantly longer and reaction time was marginally significant (P = 0.053). There were no differences on task accuracy. Decline in mental math performance was equivalent at glucose levels <3.0 and >22.2 mmol/l. IISs varied greatly across children, with no age or sex differences. CONCLUSIONS A decrease in mental efficiency occurs with naturally occurring hypo- and hyperglycemic glucose fluctuations in children with type 1 diabetes, and this effect can be detected with a field procedure using PDA technology. With blood glucose levels >22.2 mmol/l, cognitive deterioration equals that associated with significant hypoglycemia.

Predictors of fear of hypoglycemia in adolescents with type 1 diabetes and their parents

Objectives:  This study tested the hypothesis that both trait anxiety and hypoglycemic history contribute to fear of hypoglycemia (FOH) both in adolescents with type 1 diabetes mellitus (T1DM) and in their parents, and relationships between FOH and other variables including metabolic control, symptom perception, and use of insulin pump therapy.