Digital health communication
Week 1
Mandatory literature
A theory-based online health behavior intervention for new university students: study protocol
& A theory-based online health behavior intervention for new university students
(U@Uni:LifeGuide): results from a repeat randomized controlled trial
The present research developed an online intervention to target health behaviors (e.g., eating
healthily, being physically active, consuming low levels of alcohol and not smoking) during the
significant life transition from school to university when health beliefs and behaviors may be
more open to change.
The transition from school to university marks a significant life change in the lives of many
young people as studying at university typically involves living away from home for the first
time and brings freedom from parental supervision. There are three main reasons why this
transition provides a unique opportunity to intervene in order to promote healthy lifestyle habits.
1. It affords the opportunity to target a large proportion of young people in the UK.
2. Major life transitions, such as the move to university, represent critical or “teachable”
moments to intervene in order to promote healthy lifestyle habits. This move typically
breaks the environmental context in which previous unhealthy (or healthy) behaviors
were performed and offers young people the opportunity to develop new (healthier)
lifestyle habits while at university.
3. Unlike many major life events (e.g., bereavement, loss of employment, divorce) the
transition from school to university is a predictable event and one that is experienced
by a large proportion of young people in the UK at the same time every year; therefore,
interventions can be easily implemented to target a large number of people on an
annual basis.
The use of digital technologies holds the potential to deliver interventions designed to promote
healthy lifestyle habits to large sections of the population, especially young people, who are
prime users of Internet and digital technologies:
- Easy to disseminate and low in cost compared to traditional modes of delivery
- Ability to incorporate interactive materials, such as video streaming and chat rooms, in
order to maximize engagement
- Available 24-hours a day, so can be accessed at critical moments
The present intervention includes three theory-based behavior change techniques to promote
healthy lifestyle habits:
1. A self-affirmation task designed to reduce defensive processing of health messages.
Self-affirmation theory hypothesizes that messages about future health risks not only
threaten peoples’ physical integrity (e.g., by outlining the future morbidities and
heightened risk of premature mortality from continuing risky behavior) but also their
sense of being sensible, rational, “adaptively and morally adequate” people (i.e., their
“self-integrity”). As a result, people often resist messages about the health risks of
certain behaviors (e.g., by derogating the health-risk or counter-arguing) in order to
maintain their self-integrity. Self-affirmation – the process of reflecting upon one’s
cherished values, actions or attributes – provides a simple and effective technique for
reducing defensive resistance to health-risk messages. Encouraging people to self-
affirm enables them to feel sufficiently secure about their self-integrity and removes the
need to maintain self-integrity by rejecting relevant but unwelcome health-risk
information.
, 2. Theory-based messages designed to increase people’s motivation to adopt healthy
lifestyle habits. In order to change health behavior, it is necessary for health messages
to target the key motivational factors that underlie such behavior. According to the
Theory of Planned Behavior (TPB), the most proximal determinant of behavior is
intention which, in turn, is determined by three constructs:
- Attitude (i.e., positive or negative evaluations of performing the behavior)
- Subjective norm (i.e., perceived social pressure to perform or not perform the
behavior)
- Perceived behavioral control (i.e., perceived difficulty of performing the behavior)
Underlying each of these constructs are beliefs about (i) the likely consequences of
performing the behavior, (ii) the views of specific others and (iii) the power of factors to
facilitate or inhibit performance of the behavior, respectively. Importantly, the
determinants of behavior outlined in the TPB are potentially modifiable, unlike more
distal predictors of health behavior, such as gender and ethnicity.
3. Implementation intention formation designed to increase the likelihood that good
intentions are translated into behavior. Interventions may increase people’s intentions
to change but fail to secure the corresponding change in behavior. An implementation
intention takes the form of an if-then plan that links a suitable opportunity to act with a
behavioral response that will help people achieve their goal. Forming implementation
intentions ensures that the opportunity (specified in the “if” part of the plan) is highly
accessible (and so likely to be swiftly and accurately identified) and that the behavioral
response (the “then” part of the plan) is performed relatively automatically (i.e.,
immediately and efficiently) once the critical situation is encountered. Thus,
implementation intention interventions have been found to be most effective when
combined with motivational interventions.
Primary outcome measures: fruit and vegetable intake, physical activity, alcohol and smoking.
Secondary outcome measures: social cognitive variables, health status, recreational drug use,
BMI, health services usage, academic performance, use of university sports facilities,
engagement with the digital intervention and biochemical measures.
The original trial was compromised by a number of study limitations that resulted in low levels
of engagement with the intervention. According to the limitations of the study, a repeat trial
was conducted with a number of changes designed to increase engagement with the
intervention and provide a more accurate estimate of the efficacy of the intervention. The
baseline questionnaire was shortened, another software program was used, and the content
was delivered in a more structured format. These changes were successful in increasing
engagement with the intervention. Despite increased engagement, the primary analyses
indicated that the effect of the intervention on the targeted health behaviors at 6-month follow-
up was non-significant, although the effect on fruit and vegetable intake approached
significance.
Results:
- No significant effects on the primary outcome measures at 6- month follow-up
- A significant effect of the intervention on fruit and vegetable intake
- Significantly fewer participants in the intervention condition had smoked while at
university than in the control condition
- Significantly lower use of alcohol among participants in the intervention condition than
in control condition
Preparation assignment
Article 1:
1. What added value is expected from the use of digital technologies, according to the
authors? Easy to disseminate, low in cost, interactive materials and 24/7 available.
2. Which theories are used in the development of the intervention?
, A self-affirmation task, theory-based messages and implementation intention
information
3. What argumentation do the authors use for selecting these specific theories?
They are theory-based which in general has yields more results than non theory-based
implementations.
4. How are these theories translated into intervention components?
Self affirmation: Participants will be asked to select their most important personal value
from a list of eight commonly held personal values (e.g., sense of humor, academic
achievement, relations with family and friends, social skills, spontaneity, artistic skills/
aesthetic appreciation, religion/faith/ spirituality, respect/ decency/manners) or to
provide their own, and to briefly provide a reason why the value is important to them.
Theory-based messages: The theory-based messages include a mixture of text and
videos, as well as links to other relevant material. In order to ensure that they are not
overwhelmed by the volume of material, participants will be able to selectively access
information that is of interest to them and opt to access more detailed information (using
links to more information and via a search function).
Implementation intention information: a planner that contains instructions to form
implementation intentions to facilitate the translation of good intentions into action.
Participants will be asked to identify (i) a good opportunity to act on their intentions and
(ii) a suitable response to their identified opportunity.
5. Do you think the findings of this planned study potentially contribute to identifying
effective components of the intervention? No, because the study consisted out of too
many interventions. There are three intervention components, and each components
consists of multiple components. Therefore, it’s hard to draw conclusions.
Article 2:
1. In the introduction it is described that the current study is a repeat trial. What were the
main findings of the first study, according to the introduction? What reasons do the
authors mention for repeating the original trial? The first trial comprised low levels of
engagement. Therefore, a second study was conducted with improvements to increase
the level of engagement.
2. Did they find any effects for the primary outcomes? No, no significant effects on the
primary outcomes were measured at the 6-month follow-up.
3. Explain what a per-protocol analysis is and why do you think the authors perform that
analysis. Why do you think the authors mention that the results of the per-protocol
should be treated with caution? According to the article, a per-protocol analysis is an
analysis to assess the effect of variables that might moderate the effect of the
intervention on the primary outcomes. I think that the researchers wanted to see
whether there were individual significant results on the primary outcomes without the
overall result being significant. The results should be treated with caution because per-
protocol analyses only include participants in the intervention condition who completed
all intervention tasks, which can result in introduced bias.
4. What explanation do the authors give for the null findings for the other primary
outcomes? The ‘ceiling effect’, which is the effect in which a task is too easy for the
participant. Herewith nobody fails, making the results negligible.
5. What explanation do the authors give for the small effect sizes? The intervention sought
to target four health behaviours in a single intervention. This leads to smaller effects. A
focus on several health behaviours may dilute the effect of the intervention on individual
behaviours if participants choose only to change a single health behaviour. Besides,
there was a relatively low engagement rate. Furthermore, there was some evidence
that engagement moderated intervention effectiveness, with the per-protocol analyses
revealing a significant effect of the intervention on fruit and vegetable intake (although
other effects remained non-significant). Third, the baseline sample recruited into the
study reported engaging in the recommended health behaviours at a similar or greater
extent than 16–24-year-olds in England. It is therefore possible that the lack of positive
effects for the intervention could be due to a ‘ceiling effect’ at baseline.
, T1 – Persuasive technology (part 1)
A meta-analysis is an examination of data from a number of independent studies on the same
subject in order to determine overall threads.
Previous research showed that the intervention will be more effective when it is theory-based
and when it employs one or more behavioural change technique. So the impact of digital health
applications can be maximized by two main factors:
1. Effective ingredient: the effective components should be evidence-based. The
application employs features that target determinants from health behavior theories, or
features that are based on established behavioral change techniques. The following
theories could, for example, be used:
- Social cognitive theory: rational model of human behaviour
- Principles of reinforcement
- Social influencers’ perspective
- Taxonomy of behaviour change
2. Effective dose: the uptake of the application should be sufficient. The app should be
designed based on scientific theories of technology acceptance and engagement, The
app should be human-centered.
The CeHRes Roadmap is a framework that provides guidelines for a holistic development
approach of eHealth technology. It is a manual to develop impactful interventions. Holism is a
central construct with regard to eHealth development. It means that constructs as technology,
people and context are all interrelated and interdependent, and are all part of one whole
instead of separate elements. While the Roadmap consists of separate blocks, it definitely
does not represent a sequential development process in which one phase has to be finished
before moving on to the next.
It is found that the interventions often are significantly effective when the intervention duration
was ≤ 3, compared to longer durations.
4 extents of theory use:
1. Mentioning it
2. Mentioning and explaining it
3. Applying it to select intervention technique
4. Applying it to tailor intervention technique to the recipient
5. Using the intervention results to build a theory
