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      Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy

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          Abstract

          Background

          The Internet is increasingly used as a medium for the delivery of interventions designed to promote health behavior change. However, reviews of these interventions to date have not systematically identified intervention characteristics and linked these to effectiveness.

          Objectives

          The present review sought to capitalize on recently published coding frames for assessing use of theory and behavior change techniques to investigate which characteristics of Internet-based interventions best promote health behavior change. In addition, we wanted to develop a novel coding scheme for assessing mode of delivery in Internet-based interventions and also to link different modes to effect sizes.

          Methods

          We conducted a computerized search of the databases indexed by ISI Web of Knowledge (including BIOSIS Previews and Medline) between 2000 and 2008. Studies were included if (1) the primary components of the intervention were delivered via the Internet, (2) participants were randomly assigned to conditions, and (3) a measure of behavior related to health was taken after the intervention.

          Results

          We found 85 studies that satisfied the inclusion criteria, providing a total sample size of 43,236 participants. On average, interventions had a statistically small but significant effect on health-related behavior (d + = 0.16, 95% CI 0.09 to 0.23). More extensive use of theory was associated with increases in effect size ( P = .049), and, in particular, interventions based on the theory of planned behavior tended to have substantial effects on behavior (d + = 0.36, 95% CI 0.15 to 0.56). Interventions that incorporated more behavior change techniques also tended to have larger effects compared to interventions that incorporated fewer techniques ( P < .001). Finally, the effectiveness of Internet-based interventions was enhanced by the use of additional methods of communicating with participants, especially the use of short message service (SMS), or text, messages.

          Conclusions

          The review provides a framework for the development of a science of Internet-based interventions, and our findings provide a rationale for investing in more intensive theory-based interventions that incorporate multiple behavior change techniques and modes of delivery.

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          The Effectiveness of Web-Based vs. Non-Web-Based Interventions: A Meta-Analysis of Behavioral Change Outcomes

          Background A primary focus of self-care interventions for chronic illness is the encouragement of an individual's behavior change necessitating knowledge sharing, education, and understanding of the condition. The use of the Internet to deliver Web-based interventions to patients is increasing rapidly. In a 7-year period (1996 to 2003), there was a 12-fold increase in MEDLINE citations for “Web-based therapies.” The use and effectiveness of Web-based interventions to encourage an individual's change in behavior compared to non-Web-based interventions have not been substantially reviewed. Objective This meta-analysis was undertaken to provide further information on patient/client knowledge and behavioral change outcomes after Web-based interventions as compared to outcomes seen after implementation of non-Web-based interventions. Methods The MEDLINE, CINAHL, Cochrane Library, EMBASE, ERIC, and PSYCHInfo databases were searched for relevant citations between the years 1996 and 2003. Identified articles were retrieved, reviewed, and assessed according to established criteria for quality and inclusion/exclusion in the study. Twenty-two articles were deemed appropriate for the study and selected for analysis. Effect sizes were calculated to ascertain a standardized difference between the intervention (Web-based) and control (non-Web-based) groups by applying the appropriate meta-analytic technique. Homogeneity analysis, forest plot review, and sensitivity analyses were performed to ascertain the comparability of the studies. Results Aggregation of participant data revealed a total of 11,754 participants (5,841 women and 5,729 men). The average age of participants was 41.5 years. In those studies reporting attrition rates, the average drop out rate was 21% for both the intervention and control groups. For the five Web-based studies that reported usage statistics, time spent/session/person ranged from 4.5 to 45 minutes. Session logons/person/week ranged from 2.6 logons/person over 32 weeks to 1008 logons/person over 36 weeks. The intervention designs included one-time Web-participant health outcome studies compared to non-Web participant health outcomes, self-paced interventions, and longitudinal, repeated measure intervention studies. Longitudinal studies ranged from 3 weeks to 78 weeks in duration. The effect sizes for the studied outcomes ranged from -.01 to .75. Broad variability in the focus of the studied outcomes precluded the calculation of an overall effect size for the compared outcome variables in the Web-based compared to the non-Web-based interventions. Homogeneity statistic estimation also revealed widely differing study parameters (Qw16 = 49.993, P ≤ .001). There was no significant difference between study length and effect size. Sixteen of the 17 studied effect outcomes revealed improved knowledge and/or improved behavioral outcomes for participants using the Web-based interventions. Five studies provided group information to compare the validity of Web-based vs. non-Web-based instruments using one-time cross-sectional studies. These studies revealed effect sizes ranging from -.25 to +.29. Homogeneity statistic estimation again revealed widely differing study parameters (Qw4 = 18.238, P ≤ .001). Conclusions The effect size comparisons in the use of Web-based interventions compared to non-Web-based interventions showed an improvement in outcomes for individuals using Web-based interventions to achieve the specified knowledge and/or behavior change for the studied outcome variables. These outcomes included increased exercise time, increased knowledge of nutritional status, increased knowledge of asthma treatment, increased participation in healthcare, slower health decline, improved body shape perception, and 18-month weight loss maintenance.
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              A behavior change model for internet interventions.

              The 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. The 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. The 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. By 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.
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                Author and article information

                Contributors
                Journal
                J Med Internet Res
                JMIR
                Journal of Medical Internet Research
                Gunther Eysenbach (Centre for Global eHealth Innovation, Toronto, Canada )
                1438-8871
                Jan-Mar 2010
                17 February 2010
                : 12
                : 1
                : e4
                Affiliations
                [3] 3simpleResearch Department of Clinical Educational & Health PsychologysimpleUniversity College London 1-19 Torrington PlaceLondonUK
                [2] 2simpleSchool of Psychology Shackleton BuildingsimpleUniversity of Southampton HighfieldSouthamptonUK
                [1] 1simpleDepartment of Psychology simpleUniversity of Sheffield Western BankSheffieldUK
                Article
                v12i1e4
                10.2196/jmir.1376
                2836773
                20164043
                b222002c-6255-46b1-9691-c034b87f6994
                © Thomas L Webb, Judith Joseph, Lucy Yardley, Susan Michie. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 17.02.2010.  

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

                History
                : 09 October 2009
                : 30 October 2009
                : 12 November 2009
                : 16 November 2009
                Categories
                Original Paper

                Medicine
                internet,intervention,behavior change,meta-analysis,review
                Medicine
                internet, intervention, behavior change, meta-analysis, review

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