W. Brouwer

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.

Internet-delivered interventions aimed at adolescents: a Delphi study on dissemination and exposure

It appears that in practice exposure to Internet-delivered behaviour change interventions, encouraging a healthy lifestyle for adolescents with regard to health risk behaviours, is quite low. There is, however, a lack of evidence-based insight into how to disseminate such interventions and how to reach optimal exposure. A more extensive exploration is therefore timely since this knowledge is crucial to improve the public health impact of such interventions. By means of a three-round Delphi study factors associated with dissemination of and exposure (first visit, stay long enough and revisit) to Internet-delivered interventions aimed at adolescents had been identified, as well as the extent to which experts agree on the importance of these factors. Results showed that there was a high rate of consensus among experts from several disciplines with regard to the importance of factors like word of mouth recommendation, the interface of the intervention and utilization of all features provided by the Internet. Experts do not agree, however, on a gold standard for successful dissemination. Overall, the results of this exploration serve as a handle for the formation of further research questions to be tested and answered in research among adolescents.

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.

Demographic, behavioral, and psychosocial correlates of using the website component of a worksite physical activity and healthy nutrition promotion program: a longitudinal study.

Background Internet-delivered behavior change programs have the potential to reach a large population. However, low participation levels and high levels of attrition are often observed. The worksite could be a setting suitable for reaching and retaining large numbers of people, but little is known about reach and use of Internet-delivered health promotion programs in the worksite setting. Objective This study aimed (1) to gain more insight in the use of the website component of a worksite behavior change intervention and (2) to identify demographic, behavioral, and psychosocial factors associated with website use. Methods The study was an observational study among participants from 5 workplaces in a cluster randomized controlled trial. At baseline, all participants visited a study website to fill out the baseline questionnaire. Then a physical health check was done followed by face-to-face advice. After this contact, all participants received an email to promote visiting the website to view their health check results and the personal advice based on the baseline questionnaire. In the subsequent period, only participants in the intervention group received monthly email messages to promote website visits and were offered additional Web-based tools (self-monitors and a food frequency questionnaire [FFQ] assessing saturated fat intake) to support their behavior change. Website use was monitored by website statistics registering website access. Complete data were available for 726 employees. Logistic regression analyses were conducted to identify characteristics of employees who visited and used the website. Results In total, 43% of the participants visited the website after the email to promote website visits. Participants who were insufficiently physically active were less likely to visit the website (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.45-0.88), whereas individuals with an elevated total cholesterol level visited the website more often (OR 1.44, 95% CI 1.05-1.98). The monthly emails in the intervention group resulted in higher website use during a 3-month period (18% versus 5% in the reference group, OR 3.96, 95% CI 2.30-6.82). Participants with a positive attitude toward increasing physical activity were less likely to visit the website (OR 0.54, 95% CI 0.31-0.93) or to use the self-monitor and FFQ (OR 0.50, 95% CI 0.25-0.99). Female workers visited the website more often to monitor their behavior and to receive advice on fat intake (OR 2.36, 95% CI 1.14-4.90). Conclusions Almost half of the participants used the website component of a worksite behavior change program. Monthly emails were a prompt to visit the website, but website use remained low. More women than men used the website to obtain personalized advice for behavior change. No consistently higher participation was found among those with healthier behaviors. This health promotion program did not provide an indication that healthier subjects are more susceptible to health promotion. Trial Registration ISRCTN52854353; http://www.controlled-trials.com/ISRCTN52854353 (Archived by WebCite at http://www.webcitation.org/5smxIncB1)

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.

Qualitative assessment of adolescents' views about improving exposure to internet‐delivered interventions

– The purpose of this paper is to gain first insight into factors which might be associated with exposure to internet‐delivered interventions., – Semi‐structured focus group interviews were conducted with five groups of Dutch adolescents (n=54), aged 12‐17 years. Several aspects of exposure: a first visit; staying long enough actually to use and process the information; and revisiting the intervention, were explored., – Several factors that are likely to improve exposure to internet‐delivered interventions were identified, such as the use of “word of mouth” marketing, comparison of own behaviour with friends and the use of reminders., – Focus group interviews are only a first step in the generation of ideas and opinions. A next step would be to conduct observational, experimental and longitudinal studies to test if and how these factors improve exposure to internet‐delivered interventions., – This paper is a useful source for those developing internet‐delivered interventions who want to improve exposure rates to their interventions., – The results of this exploration serve as an important first step to gain more insight into factors that improve exposure to internet‐delivered interventions.