Summary Digital Health Communication
Tilburg University 2022
800872-M-6
This document contains all relevant material for the exam, including the T-lectures, D-lectures, and the
mandatory literature of the Master course Digital Health communication.
Celeste Graumans
,Inhoud
Lecture 1; Persuasive technology part 1 .................................................................................4
T1 Literature .......................................................................................................................4
Epton et al., 2013 – A theory-based online health behavior intervention for new
university students...........................................................................................................4
Camron et al., 2015 – A theory-based online health behavior intervention for new
university .........................................................................................................................5
T1 Lecture – Persuasive technology part 1 .........................................................................7
Understand the main factors increasing and decreasing the impact of digital health
applications .....................................................................................................................7
Impact – what is the evidence? – healthy eating behavior ...............................................8
Employing theory in digital health applications (Wilmot et al., 2019) ..............................10
Lecture 2; Persuasive technology part 2 ...............................................................................11
T2 Literature .....................................................................................................................11
Hermsen et al., 2016 – Using feedback through digital technology to disrupt and change
habitual behavior: A critical review of current literature ..................................................11
Hermsen et al., 2019 – Effects of eating with an augmented fork with vibrotactile
feedback on eating rate and body weight ......................................................................13
T2 Lecture – Persuasive technology part 2 .......................................................................14
Rational model: Theory of planned behavior (TPB) .......................................................14
Intention-behavior gap ...................................................................................................16
Automatic/habitual versus reflective/rational processes .................................................18
Lecture 3; User characteristics .............................................................................................20
T3 Literature .....................................................................................................................20
Ryan et al., 2018 – Theoretical perspectives of adherence to web-based interventions 20
Smit & Bol (2020) – From self-reliers to expert-dependents: identifying classes based on
the health-related need for autonomy and need for external control among mobile users
......................................................................................................................................26
T3 lecture: User characteristics .........................................................................................27
Different types of theories: media versus user-oriented .................................................27
Technology use prediction vs. individual differences .....................................................28
Personas .......................................................................................................................28
Lecture 4; Social aspects of digital health communication ....................................................29
T4 Literature .....................................................................................................................29
Geusens et al. (2020) – A cross-cultural comparison of the processes underlying the
associations between sharing of and exposure to alcohol references and drinking
intentions.......................................................................................................................29
Petersen et al. (2019) – A comparison of physical activity mobile apps with and without
existing web-based social networking platforms ............................................................30
T4 lecture: Social aspects of digital health communication................................................31
Maximizing the impact of digital health applications .......................................................31
Social norms theory: social norms approach .................................................................31
, Social learning theory: modelling, outcome expectancies, self-efficacy .........................34
Para social interaction and wishful identification ............................................................35
Social support ...............................................................................................................36
Social competition and competition ...............................................................................37
Lecture 5; guest lecture ........................................................................................................37
T5 lecture: virtual reality for health promotion....................................................................37
What is VR? ..................................................................................................................37
Then versus now: experience the future through VR .....................................................38
Somebody else versus me: personalize messages in VR ..............................................39
Seeing versus being: own a different body in VR...........................................................42
Positive versus negative effects? The Proteus effect in relation to VR for health ...........42
Lecture 6; Mode effects and personalization ........................................................................43
T6 Literature .....................................................................................................................43
Meppelink et al., 2015 – The effectiveness of health animations in audiences with
different health literacy levels: an experimental study ....................................................43
Ryan et al., 2015 – Systematic Review of tailor eHealth intervention for weight loss .....44
T6 Lecture – Mode effects & personalization ....................................................................46
Mode effects..................................................................................................................46
Tailoring ........................................................................................................................47
Mode tailoring................................................................................................................48
Lecture 7; Computer-mediated doctor-patient communication ..............................................48
T7 Literature .....................................................................................................................48
Tates et al., 2017 – The effect of screen-to-screen versus face-to-face consultation on
doctor-patient communication........................................................................................48
Bol & Antheunis, 2022 – Skype or Skip? Causes and Consequences of Intimate Self-
Disclosure in Computer-Mediated Doctor-Patient Communication.................................49
T7 Lecture – Computer-mediated doctor-patient communication ......................................50
Doctor-patient communication .......................................................................................50
Computer-mediated doctor-patient communication .......................................................52
Causes and consequences of self-disclosure ................................................................53
Development 1; Outline of CeHRes roadmap and contextual inquiry ....................................55
Development 2; Value specification ......................................................................................56
Development 3; Design ........................................................................................................58
Development 4; Design ........................................................................................................58
Development 5; Operationalization .......................................................................................59
Development 6; Evaluation ...................................................................................................61
, Lecture 1; Persuasive technology part 1
T1 Literature
Epton et al., 2013 – A theory-based online health behavior intervention for
new university students
Use digital technologies
- Easy to disseminate & low cost
- Incorporate interactive materials (e.g., video streaming, chats) for maximum
engagement
- Available 24/7 (access at critical moments)
- Multi-device digital health intervention
- Widespread access to mobile devices & desktop
Convenient & engaging for young people
Freshmen 15: starting university students are likely to gain weight, resulting from unhealthy
lifestyle changes they develop when living on their own.
Three behavior change techniques
1. Self-affirmation: reduce defensive processing of health message
2. Theory-based messages: increase motivation to adopt healthy lifestyle habits
3. Implementation formation intention: increases the likelihood that good intentions
are translated into actual behavior.
1. Self-affirmation
Reflecting upon one cherished values, actions, or attributes. Less defensive processing of
health risk info & possible change in health-related behaviors.
- Feel secure about self-integrity & remove the need to reject health-risk information
- Open-minded & balanced appraisal of health risk
Future health risks threaten people’s physical integrity & their sense of being sensible,
rational, ‘adaptively & morally adequate’ people – resist health messages
2. Theory-based messages – Theory of Planned behavior
1. Attitude: positive/negative evaluations of performing the behavior
2. Subjective norm: perceived social pressure to (not) performs the behavior
3. Perceived behavioral control: the perceived difficulty of performing the behavior
All three together predict intention!!
- Beliefs: likely consequence of performing the behavior (attitude)
o Views of specific others (subjective norm)
o Power factors to facilitate/inhibit the performance of behavior (PBC)
Interventions to change attitudes, subjective norms & perceived control have a medium effect
on intentions & behavior. The stronger effect when addressing underlying beliefs.
3. Implementation intentions (volitional techniques (wilskundige technieken))
An if-then plan that links a suitable opportunity to act with a behavioral response to help
people achieve their goals.
- Ensure opportunity is highly accessible & behavioral response is performed relatively
automatically once a critical situation is encountered
- Most effective when combined with motivational intentions – overcome the intention-
behavior gap
,Intervention components
1. Baseline questionnaire: inform about randomization + consent. Follow-up 1 and 6
months after starting university
2. Intervention: online website for laptops, and phones/tablets for greater engagement
a. Self-affirmation task: select most important personal value + reason why
b. Theory-based messages: mix of text, videos, links, etc. for all four targeted
behaviors
i. Support positive beliefs or challenge negative beliefs
ii. Selectively access information of interest and opt to access more
information
c. Implementation intentions: planner to facilitate good intentions into actions
i. Identify good opportunities to act on their intention
ii. Repeat plan to themselves + potential to set a reminder
Limitations
1. Limited time period to recruit potential participants
2. Reduced engagement due to hectic and stressful university time – use digital
technologies
3. Possible contamination intervention and control group (learn about interventions and
try them)
4. Target multiple health behaviors
Camron et al., 2015 – A theory-based online health behavior intervention
for new university
Findings of 1st trial
Significant effect on smoking; fewer smokers in the follow-up survey for the intervention
group. No effect for the other 3 components.
Limitations: low level of engagement (52% affirmation, 35% health message, and 1%
implementation)
- Inaccurate estimate of the effect of intervention and non-sig can result in low
engagement
- Baseline questionnaire was time-consuming (drop-out) – not continue with rest
- Technical glitches in intervention software, not seamless – drop-outs per step
- Intervention group had complete control over the amount and type of intervention
material they viewed
Required a repeat trial to test the efficacy of interventions
Adjustments
1. Shorter baseline questionnaire: shorter and simpler measures
2. Using LifeGuide open software to deliver intervention – seamless
3. Key content intervention delivers in a more structured format
a. Quick access to messages + makes plans for all 4 health behaviors
b. 4 modes: read 1 message and make at least 1 plan before continuing to the
full website
(Before access to messages – need to complete self-affirmation manipulations –
embedded in the profile page)
Primary data/endpoints were significant – no significant differences between intervention vs
control group and hair sample on baseline measures.
, Primary outcomes
- No significant differences between intervention and control condition on primary
outcomes (6-month) – similar to the original trial
- Marginally larger effect size for fruit and vegetable intake (almost significant) +
smaller effect smoking.
- No moderation effect for sex, nationality, and ethnicity
Per-protocol analysis
Assess the effect of engagement with intervention based on primary outcomes.
- Intervention condition: engaged with all three steps – higher fruit and vegetable intake
than the control
o No significant effect on other health aspects
- Only include participants in intervention condition who completed all intervention
tasks
o Potential bias: treat affect fruit and vegetable intake with caution
Secondary outcomes
- Fewer people start smoking and fewer started drinking than the control group
- Lower self-efficacy scores for fruit and vegetable intake + physical activity than
control (6 months)
- Non-significant for all other secondary outcomes (health status, BMI, and health
service use)
The explanation for weak effects
1. A single intervention was used to target 4 health behaviors – dilute effect if
participants only focus on changing 1 behavior
2. Relatively low levels of engagement
3. Baseline sample recruited reported engaging in health behaviors similar/more than
16-24 years old in England (= ceiling effect) – but for the control condition, negative
behavior increased
Conclusions
Should focus on quitting smoking as health-behavior
- Per-protocol analysis: significant effect intervention on fruit and vegetable intake
- Secondary analysis: significant fewer participants in the intervention condition had
smoked while at university than in the control condition
- Analysis of hair samples: significant lower alcohol use in the intervention condition
Limitations
1. Intention-to-treat approach: include all randomized participants for primary
outcomes regardless of drop-out or adherence – ‘normal’ analyses
o Input data from the last observation for missing values
o Create bias, because there is no chance to observe
2. Primary outcomes are assessed by self-report: also use biochemical markers for
a small sample
3. Small number of participants: repeat trial is higher for women and non-UK – lack of
generalizability
4. Attrition higher in repat trial: longer time engaging with intervention (less dropout)
5. Use of 3 theory-based techniques: combined in a single intervention
