Title: Measuring effects of web-based, tailored health interventions programs for nutrition and physical
activity on clinical outcomes: A systemic review
Authors:
Jung A Lee, M.A. (Doctoral Student, College of Information, Florida State University)
Mia Liza A. Lustria, Ph.D. (Assistant Professor, College of Information, Florida State University)
Introduction:
Current research in health communication and education has identified the benefits of matching health
messages to relevant characteristics of individuals, potentially boosting the effects of these messages on
the targeted health behaviors (Lustria, Cortese, Noar, & Glueckauf, 2009; Noar, Benac, & Harris, 2007).
Tailored health interventions employ a “combination of information and behavior change strategies
that are unique to that person, related to the outcome of interest and derived from an individual
assessment” (Kreuter, Farrell, Olevitch, & Brennan, 2000). Advances in information and communication
technologies have facilitated tailoring through the use of sophisticated computer algorithms, allowing
the creation of highly individualized messages that can address each individual’s unique needs,
motivations and beliefs related to the health behaviors being targeted. The individual tailoring of health
information theoretically improves the relevance of the information presented and thus generates
greater desired changes in response to the message (Kreuter & Wray, 2003).
Web delivery combined with computer tailoring, has become a common approach for providing primary
prevention interventions for nutrition and physical activity. A number of studies of web-based health
interventions for nutrition and physical activity have reported positive health behavior changes based
on psychosocial determinants of behavior but have rarely reported effects of these programs on clinical
outcomes (Hageman, Walker, & Pullen, 2005; Hurling et al., 2007; Kroeze, Werkman, & Brug, 2006;
Marcus, Lewis, Williams, Dunsiger et al., 2007; Marcus, Lewis, Williams, Whiteley et al., 2007; Norman et
al., 2007). This study reports on the measurement of clinical outcomes within current web-based,
tailored health intervention programs for nutrition and physical activity and suggests how to potentially
improve the efficacy of these using a biopsychosocial approach.
Research Questions:
The current study seeks to explore the following research questions through a systematic review of
web-based tailored interventions for nutrition and physical activity:
1. How are outcomes commonly measured in efficacy studies of web-based, tailored interventions for
nutrition and physical activity?
2. How can outcome measurements be improved for these types of interventions?
3. What are the main challenges, if any, that are faced during the collection of clinical outcomes as
opposed to self-reported data?
4. What are the criteria used for tailoring messages in these interventions?
Rationale:
Efficacy studies of web-based, tailored health intervention programs for nutrition and physical activity
have reported positive changes in most outcomes, although the results are too vague to deduce the
most obvious effects of the mechanism. This is due to the complicated nature of various tailored
intervention programs, as well as the lack of integrative tailored intervention programs for nutrition and
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physical activity. Research concerning the effects of web-based, tailored interventions need to employ
more objective clinical outcomes to provide better evidence for the efficacy of such programs.
Method:
We conducted an extensive search for web-based, tailored health intervention studies for nutrition and
physical activity published in English-language peer-reviewed journals from 1996 to 2009. Two scholarly
databases (Medline and ERIC) were searched using the following main terms in various combinations:
‘Internet’, ‘Web‘, ‘health intervention’, and ‘tailoring’. The main search terms were selected based on
their high recall ratio (or ability to retrieve relevant articles). Secondary search terms that also yielded
relevant citations were: ‘health education’, ‘behavior change programs’, and ‘computer tailoring’. The
initial search yielded thousands of citations – 120 of these were potentially relevant studies and were
archived in an Endnote (ver. 10) database.
Studies were screened in several stages using explicit inclusion and exclusion criteria. First, the citations
were reviewed to judge their general eligibility for the systematic review (e.g., behavioral change
interventions related to physical activity or nutrition, with web component, focused on patient
population, used computer tailoring, evaluated through a randomized controlled trial or quasiexperimental study). The citations were evaluated and generally ineligible studies (i.e., studies that did
not include a behavior change component; studies about online health information seeking,
telemedicine, and web-based continuing medical education) were excluded. Abstracts were further
evaluated and studies that were not randomized controlled trials (RCTs) or quasi-experimental studies,
did not have a web component, and/or did not incorporate any tailoring also were excluded. ‘Computer
tailoring’ was operationally defined as the use of automated methods for collecting, assessing and
providing individualized feedback to patients. Since we were interested in coding and comparing studies
on a wide range of characteristics, comprehensiveness of reporting was also a key consideration in
selection of articles. This second step yielded a total of 13 potentially eligible studies.
Full-text copies of the remaining 13 potentially relevant studies were examined more closely to confirm
whether computer-tailoring was used in the intervention and to examine more closely the measurement
of outcomes. Nine studies were accepted to create the normalized data, from baseline results to post
results, for the cardiovascular risk file, e.g. body mass index (BMI), physical activity, body fat, diastolic
blood pressure (DBP), and high density lipid (HDL).
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Potential relevant studies
screened for retrieval
n=120
Studies excluded:
No web, no tailored, not RCT,
not behavioral, not reported
outcome (baseline & post)
(n=107)
Studies for systemic review
n=13
Studies excluded:
Had incomplete reports of
outcomes (baseline & post),
outliers (n=4)
Studies for normalized rate
n=9
Results:
About 120 studies from the first screening were identified, of this, 13 studies fit the inclusion criteria, 4
of which were later excluded upon closer examination. We found that current efficacy studies of webbased, tailored health intervention programs for nutrition and physical activity were more likely to focus
on health behavior change rather than on improvements in actual clinical outcomes. As a matter of fact,
most outcome measurements were dependent upon the self-reporting of data. This potentially leads to
outcomes with missing or irrelevant data. This downside reflects the limitations of the online
environment for measuring outcomes based on more objective clinical data. It also demonstrates the
difficulty of collecting treatment outcomes in real and actual settings, rather than by research assistants
in controlled environments. Despite these limitations, a small number of studies have been able to
produce positive results in some clinical outcomes such as cardiovascular risk profiles including blood
pressure, cholesterol level, and BMI. In particular, 9 trials of web-based, tailored health intervention
programs for nutrition and physical activity revealed positive treatment effects of tailored interventions
on BMI, physical activity, body fat, DBP, and HDL. The normalized data from this small set of studies
provide positive feedback regarding the potential effectiveness of web-based tailored health behavior
interventions on actual clinical outcomes.
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Figure 1. Normalized data from systematic
review.
Limitations:
Due to the heterogeneous and limited outcomes of web-based, health tailored interventions, for
nutrition and physical activity, the sample sizes were too small to confirm any statistical significance.
Conclusion:
Recently, web-based, tailored intervention programs have been developed as innovative tools to
improve health behaviors. These programs believe that the tailored messages provided can lead to
changes in individual health behaviors and that the latter, in turn, can translate into positive clinical
outcomes such as reduced body fat, increased HDL levels and decreased weight, as examples. However,
the limited measurement of clinical outcomes in most studies constrain our ability to make
generalizations about the effectiveness of web-based, tailored intervention programs. Moreover,
criteria used for tailoring messages in programs often rely on psychosocial determinants of behavior.
We submit that a more accurate profile of patients can be attained through the assessment of
individual, physiological and clinical conditions as a basis for tailoring. Lastly, to create an accessible and
measurable standard for the efficacy of web-based, tailored intervention programs, clinical outcomes,
such as cardiovascular risk profiles including blood pressure, cholesterol level, and body mass index,
should be taken into consideration. Thus, the design of these web-based intervention programs must
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build in mechanisms for measuring health indicators such as BMI, total cholesterol, and waist-to-hip
ratio, which can be used as more accurate measures of intervention efficacy.
REFERENCES
Hageman, P. A., Walker, S. N., & Pullen, C. H. (2005). Tailored versus standard internet-delivered
interventions to promote physical activity in older women. Journal of Geriatric Physical Therapy,
28(1), 28-33.
Hurling, R., Catt, M., Boni, M. D., Fairley, B. W., Hurst, T., Murray, P., et al. (2007). Using internet and
mobile phone technology to deliver an automated physical activity program: randomized
controlled trial. J Med Internet Res, 9(2), e7.
Kreuter, M. W., Farrell, D., Olevitch, L., & Brennan, L. (2000). Tailoring health messages: Customizing
communication with computer technology Mahwah, N.J.: Lawrence Erlbaum Associates.
Kreuter, M. W., & Wray, R. J. (2003). Tailored and targeted health communication: strategies for
enhancing information relevance. Am J Health Behav, 27 Suppl 3, S227-232.
Kroeze, W., Werkman, A., & Brug, J. (2006). A systematic review of randomized trials on the
effectiveness of computer-tailored education on physical activity and dietary behaviors. Annals
of Behavioral Medicine, 31(3), 205-223.
Lustria, M. L. A., Cortese, J., Noar, S. M., & Glueckauf, R. L. (2009). Computer-tailored health
interventions delivered over the web: Review and analysis of key components. Patient
Education and Counseling, 74(2), 156-173.
Marcus, B. H., Lewis, B. A., Williams, D. M., Dunsiger, S., Jakicic, J. M., Whiteley, J. A., et al. (2007). A
comparison of Internet and print-based physical activity interventions. Arch Intern Med, 167(9),
944-949.
Marcus, B. H., Lewis, B. A., Williams, D. M., Whiteley, J. A., Albrecht, A. E., Jakicic, J. M., et al. (2007).
Step into Motion: a randomized trial examining the relative efficacy of Internet vs. print-based
physical activity interventions. Contemp Clin Trials, 28(6), 737-747.
Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring matter? Meta-analytic review of tailored
print health behavior change interventions. Psychological Bulletin, 133(4), 673-693.
Norman, G. J., Zabinski, M. F., Adams, M. A., Rosenberg, D. E., Yaroch, A. L., & Atienza, A. A. (2007). A
review of eHealth interventions for physical activity and dietary behavior change. Am J Prev
Med, 33(4), 336-345.
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