Computer-tailored health interventions delivered over the Web: review and analysis of key components

Objective

This systematic review explores how computer-tailored, behavioral interventions implemented and delivered via the Web have been operationalized in a variety of settings.

Methods

Computer-tailored, online behavioral intervention studies published from 1996 to early 2007 were selected and reviewed by two independent coders.

Results

Of 503 studies screened, 30 satisfied the selection criteria. The level of sophistication of these interventions varied from immediate risk/health assessment, tailored web content to full-blown customized health programs. The most common variables for tailoring content were health behaviors and stages of change. Message tailoring was achieved through a combination mechanisms including: feedback, personalization and adaptation.

Conclusions

Tailored, self-guided health interventions delivered via the Web to date have involved a great diversity of features and formats. While some programs have been relatively brief and simple, others have involved complex, theory-based tailoring with iterative assessment, tools for development of self-regulatory skills, and various mechanisms for providing feedback.

Practice implications

Our ability to fully optimize the use of computer-assisted tailoring will depend on the development of empirically based guidelines for tailoring across populations, health foci, health behaviors and situations. Further outcome research is needed to enhance our understanding of how and under what conditions computer-tailoring leads to positive health outcomes in online behavioral interventions.     

The effects of Internet or interactive computer-based patient education in the field of breast cancer: A systematic literature review

Objective

The aim of this systematic review was to analyze what kind of Internet or interactive computer-based patient education programs have been developed and to analyze the effectiveness of these programs in the field of breast cancer patient education. Patient education for breast cancer patients is an important intervention to empower the patient. However, we know very little about the effects and potential of Internet-based patient education in the empowerment of breast cancer patients.

Methods

Complete databases were searched covering the period from the beginning of each database to November 2008. Studies were included if they concerned patient education for breast cancer patients with Internet or interactive computer programs and were based on randomized controlled, on clinical trials or quasi-experimental studies.

Results

We identified 14 articles involving 2374 participants. The design was randomized controlled trial in nine papers, in two papers clinical trial and in three quasi-experimental. Seven of the studies were randomized to experimental and control groups, in two papers participants were grouped by ethnic and racial differences and by mode of Internet use and three studies measured the same group pre- and post-tests after using a computer program. The interventions used were described as interactive computer or multimedia programs and use of the Internet. The methodological solutions of the studies varied. The effects of the studies were diverse except for knowledge-related issues. Internet or interactive computer-based patient education programs in the care of breast cancer patients may have positive effect increasing breast cancer knowledge.

Conclusion

The results suggest a positive relationship between the Internet or computer-based patient education program use and the knowledge level of patients with breast cancer but a diverse relationship between patient's participation and other outcome measures.

Practice implications

There is need to develop and research more Internet-based patient education.     

The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: A systematic review and meta-analysis

Objective

To evaluate the effectiveness of psychosocial interventions for family caregivers on their psychosocial and physical wellbeing, quality of life, and the use of healthcare resources by stroke survivors.

Methods

Electronic English and Chinese bibliographic databases were searched (inception to January 2012) for clinical trials. Two reviewers independently selected and appraised study quality. When possible, data from randomized controlled trials (RCTs) were statistically pooled. Otherwise, a narrative summary was used.

Results

Eighteen studies (psychoeducation and social support group) were included. Pooled analysis of two individual psychoeducation programs showed a small effect on improving family functioning (SMD: −0.12; 95% CI: −0.23 to −0.01; p = 0.03). Caregivers receiving psychoeducation that aimed at equipping caregivers with the skills of problem-solving, caregiving, and stress-coping appeared to have a more positive influence on the caregivers’ psychosocial wellbeing and a reduced use of healthcare resources by stroke survivors.

Conclusion

Evidence on the effects of psychosocial interventions was limited. More RCTs of multifaceted psychoeducation programs are needed to further examine the optimal dose and format.

Practical implications

To support caregivers across the stroke trajectory, the core skills of problem-solving and stress-coping should be included in the psychosocial interventions.     

Complex interventions to improve the health of people with limited literacy: A systematic review

Objective

To evaluate the published literature on the effects of complex (multi-faceted) interventions intended to improve the health-related outcomes of individuals with limited literacy or numeracy.

Methods

We undertook a systematic review of randomized and quasi-randomized controlled trials with a narrative synthesis. The search strategy included searching eight databases from start date to 2007, reference checking and contacting expert informants. After the initial screen, two reviewers independently assessed eligibility, extracted data and evaluated study quality.

Results

The searches yielded 2734 non-duplicate items, which were reduced to 15 trials. Two interventions were directed at health professionals, one intervention was literacy education, and 12 were health education/management interventions. The quality of the trials was mixed, 13/15 trials were conducted in North America, and all focused on literacy rather than numeracy. 13/15 trials reported at least one significant difference in primary outcome, all favoring the intervention group. Only 8/15 trials measured direct clinical outcomes. Knowledge and self-efficacy were the class of outcome most likely to improve.

Conclusion

A wide variety of complex interventions for adults with limited literacy are able to improve some health-related outcomes.

Practice implications

This review supports the wider introduction of interventions for people with limited literacy, particularly within an evaluation context.     

Burnout prevention: A review of intervention programs

Objective

To evaluate the effectiveness of intervention programs at the workplace or elsewhere aimed at preventing burnout, a leading cause of work related mental health impairment.

Methods

A systematic search of burnout intervention studies was conducted in the databases Medline, PsycINFO and PSYNDEX from 1995 to 2007. Data was also extracted from papers found through a hand search.

Results

A total of 25 primary intervention studies were reviewed. Seventeen (68%) were person-directed interventions, 2 (8%) were organization-directed and 6 (24%) were a combination of both interventions types. Eighty percent of all programs led to a reduction in burnout. Person-directed interventions reduced burnout in the short term (6 months or less), while a combination of both person- and organization-directed interventions had longer lasting positive effects (12 months and over). In all cases, positive intervention effects diminished in the course of time.

Conclusion

Intervention programs against burnout are beneficial and can be enhanced with refresher courses. Better implemented programs including both person- and organization-directed measures should be offered and evaluated.

Practice implications

A combination of both intervention types should be further investigated, optimized and practiced. Institutions should recognize the need for and make burnout intervention programs available to employees.     

Innovating information-delivery for potential clinical trials participants. What do patients want from multi-media resources?

Objective

To discover whether the provision of clinical trials information via a multi-media platform could better meet the needs, preferences and practices of potential cancer trial participants.

Methods

A mixed qualitative and quantitative questionnaire was delivered to 72 participants from cancer support groups to elicit views on the provision and design features of multimedia resources in delivering clinical trials information.

Results

Perceived lack of information is an expressed barrier to clinical trials participation. Multimedia resources were viewed positively as a way to address this barrier by most potential clinical trials participants; in particular by helping to align information to individual needs, promote active engagement with information, and by allowing more control of the learning experience. Whilst text remained the most valued attribute of any resource, other highly rated attributes included the resource being simple to use, easily accessible, having a clear focus, incorporating examples and visual aids, and being interactive. Provision of support for the learning resource was also rated highly.

Conclusion

As in other areas, such as education, multimedia resources may enhance the delivery and acceptance of information regarding clinical trials.

Practice implications

Better alignment of information may have a positive impact on recruitment and retention into clinical trials.     

Limited evidence for the effectiveness of educational interventions for renal transplant recipients. Results from a systematic review of controlled clinical trials

Objective

To describe the content and evaluate the effectiveness of patient education programs for renal recipients.

Methods

Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) were identified through systematic literature searches in the Cochrane Central Register of Controlled Trials, Medline, Embase, CINAH, and ERIC. Reference lists and reviews were also examined. Methodological quality was evaluated according to criteria developed by the Cochrane Musculoskeletal Group. Interventional effects were summarized qualitatively.

Results

Nine trials were included, and three were RCT's. The educational interventions varied regarding focus, timing and intensity. No studies were assessed to have low risk of bias. Only two studies, which had a moderate risk of bias, reported beneficial effects in favor of the educational interventions. The strongest evidence was found for the use of preparatory video-assisted teaching prior to discharge and monthly pharmaceutical counseling.

Conclusion

Few included studies with moderate to high risk of bias suggest limited evidence for the effects of educational interventions for renal recipients.

Practice implications

Studies with stronger designs and improved reporting standards are needed. Future educational interventions should include a holistic educational approach and be provided in both early and later stages post transplantation. Furthermore, additional long-term outcome measures are needed.     

An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status

Objective

To update a meta-analysis and determine the effectiveness of psychological interventions on glycaemic control measured by HbA_1c and psychological status in type 2 diabetes and to compare effects when interventions are delivered by generalist clinicians compared to psychological specialists.

Methods

We used the original review protocol and searched the Cochrane central register of controlled trials, Medline, Embase, PsychLIT, and Google Scholar from February 2003 (end of previous review) to March 2007. We extracted data on the participants, interventions, delivery methods, comparison groups and outcome measures.

Results

35 trials were reviewed and meta-analysis of 19 trials (n = 1431), reporting HbA_1c found a reduction in HbA_1c by 0.54% (−0.32; 95% CI: −0.47 to −0.16). In nine trials (n = 832) interventions were delivered by diabetes or general clinicians reducing HbA_1c by 0.51% (−0.27; 95% CI: −0.50 to 0.04). In nine trials, interventions (n = 561) were delivered by psychological specialists reducing HbA_1c by 0.57% (−0.36; 95% CI: −0.61 to 0.12). Meta-analysis of 13 trials reporting psychological status found psychological status to be lower in the intervention groups −0.56 (95% CI: 1.00 to −0.13). Trial quality for the majority of studies remained poor.

Conclusion

Our findings suggest that psychological and general clinicians are similarly effective in delivering psychological interventions, however, effect sizes for all clinicians have reduced since the earlier review.

Practice implications

Psychological training opportunities for generalist clinicians could lead to wider availability of effective psychological care.     

A systematic literature review of diabetes self-management education features to improve diabetes education in women of Black African/Caribbean and Hispanic/Latin American ethnicity

Objective

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

Methods

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

Results

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

Conclusion

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

Practical implications

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.     

Effectiveness of self-management interventions on mortality,hospital readmissions,chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: A systematic review

Objective

This review examined the effectiveness of self-management interventions compared to usual care on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

Methods

A systematic review was performed. MEDLINE, EMBASE, CINAHL and the Cochrane Library were searched between 1996 and 2009. Randomized controlled trials were selected evaluating self-management interventions designed for patients with chronic heart failure. Outcomes of interest are mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life.

Results

Nineteen randomized controlled trials were identified. The effectiveness of heart failure management programs initiating self-management interventions in patients with chronic heart failure indicate a positive effect, although not always significant, on reduction of numbers of all-cause hospital readmitted patients and due to chronic heart failure, decrease in mortality and increasing quality of life.

Conclusion

This systematic review found that current available published studies show methodological shortcomings impairing validation of the effectiveness of self-management interventions on mortality, all-cause hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure.

Practice implications

Further research should determine independent effects of self-management interventions and different combinations of interventions on clinical and patient reported outcomes.     

Challenges and recommendations for blinding in behavioral interventions illustrated using a case study of a behavioral intervention to lower blood pressure

Objective

To describe the challenges to blinding in behavioral interventions, specifically those for asymptomatic medical conditions, where the intervention is through counseling, and to provide recommendations for achieving blinding in behavioral randomized controlled trials (RCTs).

Methods

This paper reviews the challenges of preserving blinding in behavioral RCTs with a focus on interventions for asymptomatic medical conditions. This is illustrated using a case study of an ongoing behavioral intervention to improve hypertension control.

Results

In contrast to easily keeping study investigators and participants masked to treatment assignment through the use of identical pills or sham treatments, the need to have differing levels of blinding among study personnel and participants in randomized behavioral intervention trials is presented. Recommendations for achieving this are provided.

Conclusions

Despite the challenges inherent in behavioral interventions, it is possible to achieve differing levels of blinding across study personnel and participants to minimize bias and generate valid data in RCTs that test interventions for asymptomatic medical conditions such as hypertension. Modifications may be needed for RCTs in symptomatic medical conditions.

Practice implications

Researchers designing behavioral RCTs should be aware of the challenges to blinding all staff and study participants, and plan to have procedures in place to standardize outcome data collection and intervention delivery without compromising the varying levels of blinding. The challenges and recommendations described may need modifications in behavioral intervention studies for symptomatic conditions.     

Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials

Objective

Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings.

Methods

Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings.

Results

Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio = 1.55 (CI: 1.40–1.71), z = 8.67, p < .001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate.

Conclusion

MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations.

Practice implications

The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.     

A systematic review of the literature reporting on studies that examined the impact of interactive, computer-based patient education programs

Objective

To evaluate studies that examined the impact of interactive, computer-based education (ICBE) programs on patient education.

Methods

The Medline and CINAHL databases were searched to identify randomized controlled studies that evaluated the impact of ICBE programs.

Results

The 25 studies that met the selection criteria generally supported the ability of ICBE programs to promote knowledge gains. Results related to economic or clinical outcomes were less consistent. Significant variations were noted across studies in program features, implementation and integration strategies, and in comparison program attributes and quality. It is likely that these differences contributed to the disparity in findings across studies.

Conclusion

Although significant inconsistencies in results were noted, the research provided collective evidence that ICBE programs had the potential to add great value to the patient education process. Programs must be properly designed and implementation and integration processes effectively planned in order to achieve consistently positive outcomes.

Practice implications

Consideration of the “best practices” derived from the research and noted in this report will assist healthcare providers in designing, selecting, and implementing effective ICBE programs.     

Characterizing explanatory models of illness in healthcare: development and validation of the CONNECT instrument

Objective

A growing body of qualitative and quantitative research suggests that individual patients and physicians often have differing perspectives, or ‘explanatory models,’ regarding the patient's health condition or illness. Discordance between explanatory models may lead to difficulties in communication and poor disease outcomes. However, due to a lack of tools to systematically measure concordance in patient and physician explanatory models, a large-scale study of explanatory models of illness has not been previously possible. The objective of this project was to develop and pilot-test a survey-based tool (the CONNECT Instrument) that measures salient aspects of explanatory models of illness.

Methods

We conducted a multi-method survey development project that included qualitative and quantitative item development, refinement, pilot testing, and psychometric evaluation. We evaluated the instrument in two unique, consecutive cohorts of primary care patients in a variety of private and public settings in Houston, TX. We also used the instrument to examine concordance between patient and physician explanatory models in the second cohort.

Results

The final version of the CONNECT Instrument contains nineteen items that focus on six dimensions of explanatory models. Cronbach alphas ranged from 0.65 to 0.89 for the six CONNECT dimensions. The instrument demonstrated evidence of criterion-related validity when individual CONNECT dimension scores were compared with scores from previously published instruments, and demonstrated expected differences between patients ‘and physicians’ explanatory models of illness.

Conclusion

The CONNECT instrument is a tool with good psychometric properties that enables researchers to measure important aspects of patients ‘and physicians’ explanatory models of illness. Our continuing work will focus on gathering additional validity evidence and evaluating associations between explanatory model concordance and health outcomes.

Practice implications

The CONNECT instrument can be used to improve quality in clinical practice and medical education by measuring an important intermediate outcome in the chain of factors leading to patient trust, satisfaction, and adherence.     

Community mental healthcare providers’ attitudes and practices related to smoking cessation interventions for people living with severe mental illness

Objective

This study aimed to describe mental healthcare providers’ attitudes about tobacco use, their personal smoking status, their confidence in offering smoking cessation support to clients living with severe mental illness, and the extent to which they incorporated smoking cessation interventions into their practice. The study also aimed to determine whether the providers’ attitudes, smoking status, and confidence were associated with offering smoking cessation support to clients.

Methods

Self-administered questionnaires were distributed within community-based mental health agencies to those who provide care and support to adults living with severe mental illness. Outcomes measured included respondents’ smoking status, attitudes related to the provision of smoking cessation support, confidence in providing smoking cessation intervention, and smoking cessation practices. We conducted multivariate analyses using logistic regression analyses to examine the factors associated with the providers’ tobacco-related practices.

Results

In total 282 of 871 care providers responded to the survey, 22% of whom were current smokers. The providers who held sympathetic attitudes about their role and their clients’ role in smoking cessation, who were never or former smokers, who were healthcare professionals rather than paraprofessionals, who had relatively more confidence, and who had more experience working in the mental health field were more likely to engage their clients in tobacco-related interventions.

Conclusions

In this study the healthcare providers working in community-based mental health have a smoking prevalence rate that exceeds that of the region's general population and did not provide optimal smoking cessation support to their clients.

Practice implications

Interventions that bolster the confidence of providers to engage is smoking cessation activities and that support a shift in attitudes about the role of tobacco use in mental health are required.     

Testing the utility of a cancer clinical trial specific Question Prompt List (QPL-CT) during oncology consultations

Objective

A Question Prompt List (QPL) is a proven, simple intervention to aid patients to be active participants in consultations with their physicians by asking questions. We aimed to further develop and test the efficacy of a targeted QPL for clinical trials (QPL-CT).

Methods

Breast, Lung and Genitourinary cancer patients who were facing a discussion about a therapeutic clinical trial completed short pre- and post-consultation questionnaires and used the QPL-CT in their discussions with their oncologists.

Results

30 participants were recruited from 6 oncologists. All QPL-CT questions were selected by at least one-third of participants. Participants mostly wanted and asked questions about personal trial benefit. Oncologists provided information about personal benefit to varying degrees, thus patients did not ask some questions. Patients were still left with some unasked and unanswered questions.

Conclusion

The QPL-CT has potential as a simple, inexpensive intervention to aid such communication. Further investigation is needed to demonstrate the efficacy of the QPL-CT in improving cancer patient outcomes.

Practice implications

These preliminary finding suggest that important areas of clinical trials are overlooked in clinical consultations. The QPL-CT may be an effective method to encourage oncologists to endorse patient question asking about clinical trials and prompt patient questions.     

Mediating the effect of self-care management intervention in type 2 diabetes: A meta-analysis of 47 randomised controlled trials

Objective

To perform a meta-analysis assessing the effects of self-care management interventions in improving glycaemic control in type 2 diabetes by analysing the impact of different study characteristics on the effect size.

Methods

A literature search in eight scientific databases up to November 2007 included original studies of randomised controlled trials involving adult patients diagnosed with type 2 diabetes and evaluating a self-care management intervention.

Results

The 47 included studies yielded 7677 participants. The analysis showed a 0.36% (95% CI 0.21–0.51) improvement in glycaemic control in people who received self-care management treatment. In the univariate meta-regression sample size (effect size 0.42%, p = 0.007) and follow-up period (effect size 0.49%, p = 0.017) were identified to have significant effect on the effect size in favour of small studies and short follow-up. For type of intervention and duration of intervention there was a non-significant effect on effect size in favour of educational techniques and short interventions.

Conclusion

In type 2 diabetes, there are improvements in glycaemic control in people who receive self-care management treatment with a small advantage to intervention with an educational approach.

Practice implications

Further research on frequency and duration of intervention may provide useful information to identify the most effective regime.     

A pilot randomized controlled trial of a depression and disease management program delivered by phone

Background

Depression in medically ill patients occurs at twice the rate found in the general population. Though pharmacologic and psychotherapeutic interventions for depression are effective, response to treatment and access to care are barriers for this population. A multidimensional telehealth intervention was designed to focus on these barriers by delivering a phone based intervention that addressed managing one's illness and coping emotionally.

Methods

Veterans with diabetes, hypertension, or chronic pain and depressive symptoms were randomized to one of three conditions: Usual Care (n=23), Illness Management Only (n=31), or Combined Psychotherapy and Illness Management (n=29). Those randomized to the Combined or Illness Management Only intervention group received 10 phone visits. Veterans in the Combined group received all aspects of the illness management program plus a manualized depression intervention. Subjects completed assessments at baseline, week 5, and 10 to test the main hypothesis that veterans in the Combined condition would have a greater decline in depressive symptoms.

Results

The Combined intervention yielded a significant decline in depressive symptoms when compared with Usual Care. However, the there was no significant difference between the Combined and Illness Management Only groups.

Limitations

This is a pilot study with a small sample size relative to a standard randomized controlled trial in psychotherapy.

Conclusions

This telephone-based intervention succeeded in reducing depressive symptoms in veterans with chronic illness. It adds to the building evidence base for providing phone-delivered mental health services.     

Twelve-month outcomes of an Internet-based diabetes self-management support program

Objective

Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs.

Methods

We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n = 463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors.

Results

Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size = .09–.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants.

Conclusions

The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes.

Practice implications

Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.