Effectiveness of a web-based intervention aimed at healthy dietary and physical activity behavior: a randomized controlled trial about users and usage

Background:\ud Recent studies have shown the potential of Web-based interventions for changing dietary and physical activity (PA) behavior. However, the pathways of these changes are not clear. In addition, nonusage poses a threat to these interventions. Little is known of characteristics of participants that predict usage.\ud \ud Objective:\ud In this study we investigated the users and effect of the Healthy Weight Assistant (HWA), a Web-based intervention aimed at healthy dietary and PA behavior. We investigated the value of a proposed framework (including social and economic factors, condition-related factors, patient-related factors, reasons for use, and satisfaction) to predict which participants are users and which participants are nonusers. Additionally, we investigated the effectiveness of the HWA on the primary outcomes, self-reported dietary and physical activity behavior.\ud \ud Methods:\ud Our design was a two-armed randomized controlled trial that compared the HWA with a waiting list control condition. A total of 150 participants were allocated to the waiting list group, and 147 participants were allocated to the intervention group. Online questionnaires were filled out before the intervention period started and after the intervention period of 12 weeks. After the intervention period, respondents in the waiting list group could use the intervention. Objective usage data was obtained from the application itself.\ud \ud Results:\ud In the intervention group, 64% (81/147) of respondents used the HWA at least once and were categorized as “users.” Of these, 49% (40/81) used the application only once. Increased age and not having a chronic condition increased the odds of having used the HWA (age: beta = 0.04, P = .02; chronic condition: beta = 2.24, P = .003). Within the intervention group, users scored better on dietary behavior and on knowledge about healthy behavior than nonusers (self-reported diet: χ22 = 8.4, P = .02; knowledge: F1,125 = 4.194, P = .04). Furthermore, users underestimated their behavior more often than nonusers, and nonusers overestimated their behavior more often than users (insight into dietary behavior: χ22 = 8.2, P = .02). Intention-to-treat analyses showed no meaningful significant effects of the intervention. Exploratory analyses of differences between pretest and posttest scores of users, nonusers, and the control group showed that on dietary behavior only the nonusers significantly improved (effect size r = −.23, P = .03), while on physical activity behavior only the users significantly improved (effect size r = −.17, P = .03).\ud \ud Conclusions:\ud Respondents did not use the application as intended. From the proposed framework, a social and economic factor (age) and a condition-related factor (chronic condition) predicted usage. Moreover, users were healthier and more knowledgeable about healthy behavior than nonusers. We found no apparent effects of the intervention, although exploratory analyses showed that choosing to use or not to use the intervention led to different outcomes. Combined with the differences between groups at baseline, this seems to imply that these groups are truly different and should be treated as separate entities

Grounding eHealth : towards a holistic framework for sustainable eHealth technologies

Today’s healthcare system faces problems such as aging, a growth in age‐related illness and multi‐morbidity, a serious decrease of available personnel and a limited budget. The grand theme within healthcare is the need to do more with less. `eHealth’, the use of advanced information and communication technologies in healthcare, may contribute to the solution of these problems by supporting a better balance between self‐care and professional care. Yet, despite the large number of eHealth projects to date and the positive outcomes of evaluation studies, the actual take‐up of eHealth services is lower than expected. This thesis presents an investigation into the factors that are critical for the development of sustainable eHealth technologies. To this end, we evaluated various interactive health communication applications in primary care.\ud One of the main problems is that the development of healthcare technology is expert‐driven, resulting in technology that does not meet the users’ needs and that disregards the social‐cultural habits and the complexity of healthcare. In addition to this, eHealth interventions are often based on classic behavioral theories and medical models. They focus on rational decision‐making and discrete individual behavior change and neglect the very interdependencies between technology, care, context and communication. To ground eHealth, we formulated a number of key principles:\ud ●\ud The development of eHealth technologies should be a process of value‐creation to match the technology with needs, motivations, incentives, profiles and contexts.\ud ●\ud The development of eHealth technologies should be a participatory process of co‐creation in order to develop eHealth technologies that matter.\ud ●\ud eHealth technologies should be persuasive to increase adherence.\ud These principles underpin our new holistic framework; the ceHRes (Center for eHealth Research) Roadmap. The ceHRes Roadmap aims to bring together the interdisciplinary fields of policy, research and practice by providing instruments related to participatory development and business modeling. Health 2.0 initiatives to advance sustainable healthcare technologies, the participation of users and stakeholders from different backgrounds and with different interests (political, medical, policy, commercial) are important for trust, commitment and creating ownership and for organizing the resources and capacities for the development of human‐centered and value‐driven eHealth technologies

Evaluation of the lack of quality of e-consultation as perceived by experienced patients and providers in primary care

Background: Despite its potential, the use of patient-provider e-consultation has not yet been widespread in primary care due to concerns about the quality of care [1]. However, there is little empirical research into the lack of quality of e-consultation. Objective: To determine the lack of quality as perceived by patient and providers with experience in e-consultation. Methods: We carried out in-depth structured interviews with 19 patients and 11 providers (GP and other care providers), who currently use secure e-consultation systems, i.e. secure internet based systems with direct consultation by email and indirect e-consultation by means of triage systems. In-depth interviews with patients and providers were conducted to assess the quality of e-consultation, using as a framework for the discussion the quality criteria as outlined in the Institute of Medicine report [2]. Quality criteria were tailored to specific e-consultation systems and we assessed lack of quality with regard to e-health policy, implementation, usability, quality of interaction between patient and provider, control of care, and control of information. Results: The 19 patients mentioned 125 incidents of lack of quality and the 11 providers mentioned 105 incidents of lack of quality. Mentioned incidents were categorized independently by two observers into the quality categories. Among patients most incidents of lack of quality were related to inadequate implementation (33%), lack of ability to control information (18%), lack of good usability of the system (17%), poor e-health policy (15%) and poor quality of interaction (14%). Lack of control of care was infrequently mentioned by patients (4%). Among care providers most incidents of lack of quality were related to poor implementation (35%), poor usability of the system (28%), poor quality of interaction (15%) and poor control of care (8%). Lack of control of information was infrequently mentioned by providers (1%). Conclusions: It can be concluded that both among patients and providers inadequate implementation causes most incidents of lack of quality. Among patients lack of quality of control of information is frequently mentioned, but not among providers. This problem can be attributed to the use of medical terms and medical thinking in triage systems, which poorly reflect the problem solving strategies of patients. Unexpectedly, it was also found that care providers do have more problems in usability of e-consultation systems than patients. This is caused by incompatibility of e-health systems with available electronic patient record systems

Grounding eHealth - Development of a Web 2.0 framework for design, implementation and evaluation of eHealth applications

Since the discussion about What is eHealth? and the introduction of the next generation of technology Web 2.0 more and more studies stress the importance of theoretical models or frameworks to provide evidence for bridging the gap between medicine and technology to make eHealth usable. However, most existing frameworks focus almost exclusively on one aspect of eHealth, such as technology acceptance or health information quality, rather than on the multi-determinants that influence the success of eHealth applications. The aim of the present paper is to introduce a Web 2.0 multi-level framework which is the conceptual groundwork for a collaborative tool eHealthWiki aimed at supporting the design, implementation and evaluation of eHealth applications. We suggest that a framework is important for ensuring sustained usage of eHealth and with that to strengthen its evidence. The framework is based on a narrative literature review about current frameworks that are in some extent multi-level focused and on our research experiences with designing and evaluating web-based applications and domotica for disease management. Our hope is that the present paper stimulates a discussion within the research and care providers’ community about the potentials and the limitations of the multi-level eHealth framework for designing high quality eHealth applications and for a more robust evaluation approach to determine the factors that are essential for successful healthcare technology. This discussion will feed the development of the eHealthWiki; a Web 2.0 tool to support eHealth developers and evaluators

Quality demands of patients with regard to e-consult in primary care

Background: Ideally, e-consult systems should satisfy the quality demands and needs of groups most at risk, like the lower educated or elderly patients and those, who frequently use medication or frequently visit their general practitioner [1]. Objective: To examine the quality demands with regard to the use of secure e-consult of various health consumer groups that currently use internet. Methods: Data were collected using an internet based questionnaire. We assessed attitude to e-consult, demanded service quality and those needs that are important in the empowerment of patients by means of five point rating scales. We further assessed age, level of education, chronic use of medication (e.g. for asthma or diabetes) and frequency of GP visits. Results: Of 765 respondents sufficient data were available for statistical analysis, 472 females (62%) and 291 males (38%). In comparison to younger respondents, respondents older than 45 year demanded more service quality from e-consult (P = .01), perceived a higher need of careful use of e-consult (P = .001), a higher need to use e-consult to support direct (P = .001) and indirect control of care (P = .001) and a higher need to use e-consult to support control of information (P = .005). Respondents with a lower level of education (below college level) had a significantly more negative attitude to e-consult (P = .001), demanded a higher level of service quality from e-consult (P = .001), perceived a higher need of careful use of e-consult (P = .001), a higher need to use e-consult to support direct (P = .001) and indirect control of care (P = .001) and a higher need to use e-consult to support control of information (P = .002). Chronic users of medication had a significantly more negative attitude to e-consult (P = .05), demanded a higher level of service quality from e-consult (P = .003), perceived a higher need of careful use of e-consult (P = .004) and a higher need to use e-consult to support direct control of care (P = .001). Patients who frequently visited their GP (at least once every three month), had a significantly more negative attitude to e-consult (P = .05), demanded a higher level of service quality from e-consult (P = .002) and perceived a higher need to use e-consult to support direct control of care (P = .04). Respondents, who did not frequently visit their GP (at least once every three month), perceived a higher need to use e-consult for convenience (P = .002)

Asynchronous and Synchronous Teleconsultation for Diabetes Care: A Systematic Literature Review

Aim: A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. Methods: Electronic databases were searched for relevant publications about asynchronous and synchronous teleconsultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard metaanalytical methods. Results: Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (χ2 = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18). Conclusion: The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs