Willemieke Kroeze

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.

A Systematic Review of Randomized Controlled Trials on the Effectiveness of Computer-Tailored Physical Activity and Dietary Behavior Promotion Programs: an Update

BackgroundA review update is necessary to document evidence regarding the effectiveness of computer-tailored physical activity and nutrition education.PurposeThe purpose of this study was to summarize the latest evidence on the effectiveness of computer-tailored physical activity and nutrition education, and to compare the results to the 2006 review.MethodsDatabases were searched for randomized controlled trials evaluating computer-tailored physical activity and nutrition education aimed at primary prevention in adults, published from September 2004 through June 2011.ResultsCompared to the findings in 2006, a larger proportion of studies found positive effects for computer-tailored programs compared to generic or no information, including those for physical activity promotion. Effect sizes were small and generally at short- or medium-term follow-up.ConclusionsThe results of the 2006 review were confirmed and reinforced. Future interventions should focus on establishing larger effect sizes and sustained effects and include more generic health education control groups and objective measurements of dietary behavior.

The internet and nutrition education: challenges and opportunities.

Objective:To review the possibilities of using the Internet and especially the World Wide Web (WWW) in nutrition education.Results:A healthy existence is partly dependent on dietary behaviours. One way to promote health-promoting dietary habits is nutrition education. In the last decades several potentially important new channels for health communication and nutrition education have emerged, with the Internet and its WWW as the most striking example. The introduction and growth of the WWW has enabled swift and inexpensive distribution of nutrition education expertise and materials. Furthermore, the WWW has also been used for tailoring nutrition education to the personal characteristics of the user. Only few studies have investigated the effects of generic web-based nutrition education, while web-based computer-tailored nutrition education has been studied in randomised controlled trials, with promising but mixed results. Two important challenges for web-based nutrition education interventions are to realise sufficient exposure and to ensure sufficient source reliability and credibility.Conclusions:Next to the great opportunities, there are many challenges for web-based nutrition education. Some evidence for effects of web-based computer-tailored nutrition education has been reported, but more research is needed to obtain evidence for the effectiveness in real-life situations.Sponsorship:The contribution of WK was made possible by a grant from ZonMw, The Netherlands Organisation for Health Research and Development; the contribution of AO was made possible by a grant from the Netherlands Heart Foundation.

Saturated fat consumption and the Theory of Planned Behaviour: exploring additive and interactive effects of habit strength

The additive and interactive effects of habit strength in the explanation of saturated fat intake were explored within the framework of the Theory of Planned Behaviour (TPB). Cross-sectional data were gathered in a Dutch adult sample (n=764) using self-administered questionnaires and analyzed using hierarchical regression analyses and simple slope analyses. Results showed that habit strength was a significant correlate of fat intake (beta=-0.11) and significantly increased the amount of explained variance in fat intake (R(2-change)=0.01). Furthermore, based on a significant interaction effect (beta=0.11), simple slope analyses revealed that intention was a significant correlate of fat intake for low levels (beta=-0.29) and medium levels (beta=-0.19) of habit strength, but a weaker and non-significant correlate for high levels (beta=-0.07) of habit strength. Higher habit strength may thus make limiting fat intake a non-intentional behaviour. Implications for information and motivation-based interventions are discussed.

The efficacy of Web-based and print-delivered computer-tailored interventions to reduce fat intake: results of a randomized, controlled trial

OBJECTIVE To test and compare the efficacy of interactive- and print-delivered computer-tailored nutrition education targeting saturated fat intake reduction. DESIGN A 3-group randomized, controlled trial (2003-2005) with posttests at 1 and 6 months post-intervention. SETTING Worksites and 2 neighborhoods in the urban area of Rotterdam. PARTICIPANTS A convenience sample of healthy Dutch adults (n = 442). INTERVENTIONS An interactive, computer-tailored intervention delivered on a CD-ROM (interactive-tailored condition); a print-delivered, computer-tailored intervention (print-tailored condition); and print-delivered, generic information. MAIN OUTCOME MEASURES Total and saturated fat intake (grams/day and percentage-energy) and energy intake per day assessed with validated food frequency questionnaires at 1 and 6 months post-intervention. ANALYSIS Multilevel linear regression analyses. RESULTS Mean total fat, saturated fat, and energy intakes were significantly lower in both tailored conditions compared to the generic condition at 1-month follow-up. These differences were still significant for the print-tailored condition at 6-months follow-up. Effects were most pronounced among participants with unfavorable fat intakes at baseline. There were no significant differences between the 2 tailoring conditions. CONCLUSIONS AND IMPLICATIONS The results indicate that interactive and print-delivered computer-tailored interventions can have similar short-term effects on fat intake and that the effects of the print-delivered tailored feedback are maintained in the longer term.

Towards the integration and development of a cross-European research network and infrastructure: the DEterminants of DIet and Physical ACtivity (DEDIPAC) Knowledge Hub

To address major societal challenges and enhance cooperation in research across Europe, the European Commission has initiated and facilitated `joint programming’. Joint programming is a process by which Member States engage in defining, developing and implementing a common strategic research agenda, based on a shared vision of how to address major societal challenges that no Member State is capable of resolving independently. Setting up a Joint Programming Initiative (JPI) should also contribute to avoiding unnecessary overlap and repetition of research, and enable and enhance the development and use of standardised research methods, procedures and data management. The Determinants of Diet and Physical Activity (DEDIPAC) Knowledge Hub (KH) is the first act of the European JPI `A Healthy Diet for a Healthy Life’. The objective of DEDIPAC is to contribute to improving understanding of the determinants of dietary, physical activity and sedentary behaviours. DEDIPAC KH is a multi-disciplinary consortium of 46 consortia and organisations supported by joint programming grants from 12 countries across Europe. The work is divided into three thematic areas: (I) assessment and harmonisation of methods for future research, surveillance and monitoring, and for evaluation of interventions and policies; (II) determinants of dietary, physical activity and sedentary behaviours across the life course and in vulnerable groups; and (III) evaluation and benchmarking of public health and policy interventions aimed at improving dietary, physical activity and sedentary behaviours. In the first three years, DEDIPAC KH will organise, develop, share and harmonise expertise, methods, measures, data and other infrastructure. This should further European research and improve the broad multi-disciplinary approach needed to study the interactions between multilevel determinants in influencing dietary, physical activity and sedentary behaviours. Insights will be translated into more effective interventions and policies for the promotion of healthier behaviours and more effective monitoring and evaluation of the impacts of such interventions.

The effects of using a nutrition logo on consumption and product evaluation of a sweet pastry

Nutrition logos have received a great deal of attention to stimulate people to eat a healthier diet. However, very little is known neither about actual consumption behavior related to nutrition logos nor about potential compensatory eating behaviors due to nutrition logos. The aim of this study was to assess the effects of using an existing nutrition logo on consumption and product evaluation of a chocolate mousse cake. A cross-over design was applied with two conditions: a condition with a logo and a condition without a logo. Participants were females recruited in the university community (n = 36, mean age 22.6 ± 6.3). Data on consumption, tastefulness, perceived healthiness, dietary restraint and Body Mass Index were collected. No significant differences between conditions were found on consumption and tastefulness. The cake was rated as significantly less unhealthy in the logo condition. In conclusion, results cannot be extrapolated to other products, especially not to products that are perceived as healthy. In this study, the use of a nutrition logo did not result in an increased consumption and had no effect on the rating of taste of a sweet pastry among females from the university community.

Equity-specific effects of 26 Dutch obesity-related lifestyle interventions

CONTEXT Reducing health inequalities is a policy priority in many developed countries. Little is known about effective strategies to reduce inequalities in obesity and its underlying behaviors. The goal of the study was to investigate differential effectiveness of interventions aimed at obesity prevention, the promotion of physical activity or a healthy diet by SES. EVIDENCE ACQUISITION Subgroup analyses in 2010 and 2011 of 26 Dutch studies funded by The Netherlands Organization for Health Research and Development after 1990 (n=17) or identified by expert contact (n=9). Methodologic quality and differential effects were synthesized in harvest plots, subdivided by setting, age group, intensity, and time to follow-up. EVIDENCE SYNTHESIS Seven lifestyle interventions were rated more effective and four less effective in groups with high SES; for 15 studies no differential effects could be demonstrated. One study in the healthcare setting showed comparable effects in both socioeconomic groups. The only mass media campaign provided modest evidence for higher effectiveness among those with high SES. Individually tailored and workplace interventions were either more effective in higher-SES groups (n=4) or no differential effects were demonstrated (n=9). School-based studies (n=7) showed mixed results. Two of six community studies provided evidence for better effectiveness in lower-SES groups; none were more effective in higher-SES groups. One high-intensity community-based study provided best evidence for higher effectiveness in low-SES groups. CONCLUSIONS Although for the majority of interventions aimed at obesity prevention, the promotion of physical activity, or a healthy diet, no differential effectiveness could be demonstrated, interventions may widen as well as reduce socioeconomic inequalities in these outcomes. Equity-specific subgroup analyses contribute to needed knowledge about what may work to reduce socioeconomic inequalities in obesity and underlying health behaviors.

Determinants of dietary behavior among youth: an umbrella review

BackgroundThe literature on determinants of dietary behavior among youth is extensive and unwieldy. We conducted an umbrella review or review-of-reviews to present a comprehensive overview of the current knowledge.MethodsTherefore, we included systematic reviews identified in four databases (i.e. PubMed, PsycINFO, The Cochrane Library and Web of Science) that summarized determinants of observable child and adolescent dietary behaviors. Data extraction included a judgment of the importance of determinants, strength of evidence and evaluation of the methodological quality of the eligible reviews.ResultsIn total, 17 reviews were considered eligible. Whereas social-cognitive determinants were addressed most intensively towards the end of the 20th century, environmental determinants (particularly social and physical environmental) have been studied most extensively during the past decade, thereby representing a paradigm shift.With regard to environmental determinants, mixed findings were reported. Sedentary behavior and intention were found to be significant determinants of a wide range of dietary behaviors in most reviews with limited suggestive evidence due to the cross-sectional study designs. Other potential determinants such as automaticity, self-regulation and subjective norm have been studied in relatively few studies, but results are promising.ConclusionThe multitude of studies conducted on potential determinants of dietary behavior provides quite convincing evidence of the importance of several determinants (i.e. quite some variables were significantly related to dietary behavior). However, because of the often used weak research designs in the studies covered in the available reviews, the evidence for true determinants is suggestive at best.

Comparison of Use and Appreciation of a Print-Delivered Versus CD-ROM-Delivered, Computer-Tailored Intervention Targeting Saturated Fat Intake: Randomized Controlled Trial

Background Computer-tailored health education, a promising health education technique, is increasingly being delivered interactively, for example, over the Internet. It has been suggested that there may be differences in use and appreciation between print and interactive delivery of computer-tailored interventions, which may influence information processing. This may especially be the case for women, older people, and people of lower socioeconomic status. Knowledge about differences in use and appreciation could help in choosing the appropriate delivery mode for a particular target audience. Objective The study investigates a content-identical, computer-tailored intervention addressing saturated fat intake delivered via print or CD-ROM. We analyzed consumer use and appreciation of the feedback information and explored whether possible differences exist among gender, age, and education subgroups. Methods Healthy Dutch adults (18-65 years), none of whom were under treatment for hypercholesterolemia, were randomly allocated to receive a computer-tailored program on CD-ROM (n = 151) or in print (n = 141). At baseline, data were collected on gender, age, and education level. One month post-intervention, data were collected on the use (feedback information read, saved, discussed) and appreciation (trustworthiness, perceived individualization, perceived personal relevance, and user-friendliness) of the feedback. Statistical analyses on the use and appreciation items were performed using chi-square tests and independent-samples t tests. Results After exclusion of individuals with missing values, a total of 257 and 240 respondents were included in the analyses of the use outcomes of feedback read and saved, respectively. The results indicate that among the total population, the print feedback was read more often than the CD-ROM feedback (95% vs 81%; P = .001) and saved more often than the CD-ROM feedback (97% vs 77%; P < .001). Similar results were found among the gender, age, and education subgroups. After exclusion of individuals who did not read the information and those with missing values, a total of 208-223 respondents were included in the analyses of the use outcome of feedback discussed and the appreciation items. The personal relevance of the print feedback was rated higher than for the CD-ROM-delivered feedback (0.97 vs 0.68; P = .04), but the effect size was small (0.28). These differences in personal relevance were also seen among women (1.06 vs 0.67; P = .04) and respondents aged 35-49 years (1.00 vs 0.58; P = .03), with moderate effect sizes (0.38 and 0.44, respectively). Conclusions Despite the possible advantages of interactive feedback, the present study indicates that interactive-delivered feedback was used less and perceived as less personally relevant compared to the print-delivered feedback. These differences in use and appreciation of delivery modes should be taken into consideration when selecting a delivery mode for a specific subgroup in order to optimize exposure. Trial Registration ISRCTN 01557410; http://www.webcitation.org/5XMylWleH