Samenvattingen artikelen Digital Health Communication
Week 1
A theory-based online health behavior intervention for new university students: study protocol
Epton, Norman, Sheeran, Harris, Webb, Ciravegna, Brennan, Meier, Julious, Naughton, Petroczi, Dadzie &
Kruger (2013)
Abstract
Background: Too few young people engage in behaviors that reduce the risk of morbidity and premature
mortality, such as eating healthily, being physically active, drinking sensibly and not smoking. The present
research developed an online intervention to target these health behaviors during the significant life transition
from school to university when health beliefs and behaviors may be more open to change. This paper describes
the intervention and the proposed approach to its evaluation.
Methods/design: Potential participants (all undergraduates about to enter the University of Sheffield) will be
emailed an online questionnaire two weeks before starting university. On completion of the questionnaire,
respondents will be randomly assigned to receive either an online health behavior intervention (U@Uni) or a
control condition. The intervention employs three behavior change techniques (self-affirmation, theory-based
messages, and implementation intentions) to target four heath behaviors (alcohol consumption, physical
activity, fruit and vegetable intake, and smoking). Subsequently, all participants will be emailed follow-up
questionnaires approximately one and six months after starting university. The questionnaires will assess the
four targeted behaviors and associated cognitions (e.g., intentions, self-efficacy) as well as socio-demographic
variables, health status, Body Mass Index (BMI), health service use and recreational drug use. A sub-sample of
participants will provide a sample of hair to assess changes in biochemical markers of health behavior. A health
economic evaluation of the cost effectiveness of the intervention will also be conducted.
Discussion: The findings will provide evidence on the effectiveness of online interventions as well as the
potential for intervening during significant life transitions, such as the move from school to university. If
successful, the intervention could be employed at other universities to promote healthy behaviors among new
undergraduates.
Background
Early adulthood is regarded as an exploratory phase with respect to health behaviors; nevertheless, the
lifestyle habits that are established during this phase often persist into later life and determine long-term
health outcomes. 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. Importantly, this move also typically breaks the environmental context in
which previous un- healthy (or healthy) behaviors were performed and offers young people the opportunity to
develop new (healthier) lifestyle habits while at university.
The present intervention capitalizes on the transition from school to university to promote the adoption of
healthy lifestyle habits in young people.
The use of digital technologies holds the potential to deliver interventions designed to promote healthy life-
style habits to large sections of the population, especially young people, who are prime users of Internet and
digital technologies. Such interventions are convenient for providers as they are easy to disseminate and low in
cost compared to traditional modes of delivery. Furthermore, digital interventions can incorporate interactive
materials, such as video streaming and chat rooms, in order to maximize engagement. Digital interventions are
also available 24-hours a day and so can be accessed at critical moments. The present intervention will take
advantage of widespread access to mobile devices and desktop computing, use of online so- cial media and
Internet connectivity, to provide an on- line space in which participants are encouraged to engage with the
intervention material, using methods and platforms with which they are already familiar.
Theoretical bases of the intervention
Evidence indicates that interventions designed to promote health behavior change that are based on theory
,are more efficacious. The present intervention, therefore, 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,
2. Theory-based messages designed to increase people’s motivation to adopt healthy lifestyle habits,
3. Implementation intention formation designed to increase the likelihood that good intentions are
translated into behavior.
Self-affirmation (= zelfbevestiging)
Self-affirmation theory hypothesizes that messages about future health risks threatens peoples’ 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. This, in turn, allows people
who have self-affirmed to engage in a more open-minded and balanced appraisal of the health-risk message
and its personal relevance. In support of these ideas, self-affirmation has been found to lead to less defensive
processing of health-risk information and to positive changes in people’s health-related attitudes, intentions
and initial precautionary behavior across a range of health-threats, including those from smoking, alcohol, poor
diet and lack of exercise.
The proposed intervention will, therefore, encourage participants to self-affirm before being exposed to
theory-based messages about the health risks of the target behaviors.
Theory-based messages
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:
(i) attitude (i.e., positive or negative evaluations of performing the behavior);
(ii) (ii) subjective norm (i.e., perceived social pressure to perform or not perform the behavior);
(iii) (iii) perceived behavioral control (i.e., perceived difficulty of performing the behavior).
In order to strengthen the effect of the theory-based messages in the present intervention, exten- sive
formative research was conducted in order to identify and target the specific behavioral, normative and control
beliefs that are associated new students’ intentions and behavior in relation to alcohol consumption (binge
drinking), physical activity, fruit and vegetable intake and smoking.
Implementation interventions
Many people fail to adopt healthy lifestyle habits despite having positive intentions (i.e., strong motivation) to
do so. This “intention-behavior gap” is a major obstacle to inter- ventions that seek to promote healthy lifestyle
habits, since interventions may increase people’s intentions to change but fail to secure the corresponding
change in behavior.
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.
The present research
The primary question addressed by the present research is whether an online intervention delivered during the
transition from school to university can produce significant changes in the health behaviors (i.e., fruit and
vegetable intake, physical activity, alcohol consumption and smoking) of young people. In addition, we will
investigate whether the intervention: (i) changes health cognitions (and whether these changes mediate the
,effect of the intervention on the health behaviors), (ii) enhances health status,
(iii) reduces health service usage, (vi) reduces recreational drug use, (v) reduces BMI, and (vi) improves
academic performance.
Methods
Intervention
After completing the baseline questionnaire, respondents in the intervention arm of the trial will be directed to
the online intervention. On their first visit to the intervention website (following study enrolment information,
consent and completion of the baseline questionnaire), participants will be asked to complete a self-affirmation
task. 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. The resultant
information will form part of the user’s profile accessible from the intervention home page that will include
brief personal details (e.g., gender, course), hobbies and interests and the participant’s most important
personal value (and reason for selecting that value).
After completing their profile, participants will have access to theory-based messages pertaining to each of the
four targeted health behaviors. The theory-based messages include a mixture of text and videos, as well as links
to other relevant material. The messages were developed on the basis of formative work, in line with TPB
guidelines, which identified the key behavioral, normative and control beliefs underlying new students’
intentions and behavior for each of the four health behaviors. For each belief, persuasive messages were
developed to either support positive beliefs (e.g., binge drinking has a negative effect on your studies) or
challenge negative beliefs (e.g., binge drinking helps you to make friends). The content of the messages was
informed by further formative research with current university students in order to identify key arguments that
support or challenge these beliefs. For example, a key behavioral belief underlying binge drinking among
students is that binge drinking is sociable and a good way to make friends at university. Messages were
therefore developed to counter this belief (e.g., binge drinking is not the best way to make friends) and to
highlight other ways in which students can make friends without binge drinking (e.g., join student clubs and
societies). In addition, participants will be able to watch videos of current students talking about health
behavior at university that reinforce these messages, as well as follow links to other relevant background
material (e.g., information on the effects of binge drinking, lists of socializing opportunities that do not involve
alcohol, etc.). 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).
Following exposure to the self-affirmation exercise and theory-based messages, participants will be able to
access 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. A series of drop down menus will help
participants to identify suit- able opportunities to act (e.g., “If I am doing my food shopping. . .”, “If someone
offers me a drink. . .”) and suit- able responses to these opportunities (e.g., “. . .then I will look out for special
offers on fruit and vegetables”, “...then I will tell them that I have work to do tomorrow”). Suggestions were
based on formative research with current students. Moreover, participants will also be able to generate their
own opportunities and responses. Once participants have identified an opportunity to promote a healthy
lifestyle and a suitable response, they will be prompted to link them in the “If [opportunity], then [response]”
format that defines successful implementation intention interventions. Participants will also be instructed to
repeat their plan to themselves several times to ensure that they can remember their plan. The plans that
participants make will be stored in a ‘plan repository’ that can be reviewed at any time with a direct link from
the home page. If they wish, participants can also set a reminder for each plan to be repeated at a set time
interval.
Discussion
It is likely that the combination of the three behavior change techniques in the online intervention will have a
synergistic effect as, together, they address three key factors that may hinder attempts to change health
behavior. First, the self-affirmation task will reduce defensive processing and thereby increase engagement
, with the health messages. Second, the theory-based messages will ensure that the key beliefs underlying each
health behavior are targeted. Third, asking participants to form implementation intentions will assist the
translation of good intentions into behavior. If the intervention is found to improve students’ health behavior
during the first six months of university life, future experimental work may be required to identify the “active
ingredients” of the intervention, for example, whether it is necessary to include the self-affirmation
manipulation and/or prompt participants to form implementation intentions along with the health messages.
A theory-based online health behaviour intervention for new university students: Results from a repeat
randomized controlled trial
Cameron, Epton, Norman, Sheeran, Harris, Webb, Julious, Brennan, Thomas, Petroczi, Naughton & Shah (2015)
Abstract
Background: This paper reports the results of a repeat trial assessing the effectiveness of an online theory-
based intervention to promote healthy lifestyle behaviours in new university students. The original trial found
that the intervention reduced the number of smokers at 6-month follow-up compared with the control
condition, but had non-significant effects on the other targeted health behaviours. However, the original trial
suffered from low levels of engagement, which the repeat trial sought to rectify.
Methods: Three weeks before staring university, all incoming undergraduate students at a large university in
the UK were sent an email inviting them to participate in the study. After completing a baseline questionnaire,
participants were randomly allocated to intervention or control conditions. The intervention consisted of a self-
affirmation manipulation, health messages based on the theory of planned behaviour and implementation
intention tasks. Participants were followed-up 1 and 6 months after starting university. The primary outcome
measures were portions of fruit and vegetables consumed, physical activity levels, units of alcohol consumed
and smoking status at 6-month follow-up.
Results: The study recruited 2,621 students (intervention n = 1346, control n = 1275), of whom 1495 completed
at least one follow-up (intervention n = 696, control n = 799). Intention-to-treat analyses indicated that the
intervention had a non-significant effect on the primary outcomes, although the effect of the intervention
on fruit and vegetable intake was significant in the per-protocol analyses. Secondary analyses revealed that the
intervention had significant effects on having smoked at university (self-report) and on a biochemical marker of
alcohol use.
Conclusions: Despite successfully increasing levels of engagement, the intervention did not have a significant
effect on the primary outcome measures. The relatively weak effects of the intervention, found in both the
original and repeat trials, may be due to the focus on multiple versus single health behaviours. Future
interventions targeting the health behaviour of new university students should therefore focus on single health
behaviours.
Background
An earlier trial tested the efficacy of a theory-based online intervention (U@Uni) targeting four health
behaviours (fruit and vegetable intake, physical activity, alcohol consumption, and smoking) during the
transition from school to university. Such life transitions are ideal opportunities to intervene as they represent
‘teachable’ moments; times when people’s social environments and supporting cues for behaviour are in a
state of flux and people are therefore more amenable to change.
The intervention had a significant effect on smoking, with fewer current smokers at follow-up in the
intervention than in the control condition, although the intervention did not significantly affect the other three
primary outcomes (i.e., fruit and vegetable intake, physical activity, alcohol consumption). Despite these largely
non-significant effects, the health economic modelling revealed that rolling out the intervention to other
universities would be likely to be cost-effective, primarily because of the low cost of the intervention and the
impact of reduced smoking on future health outcomes.
Unfortunately, the first trial was compromised by a number of limitations, which resulted in low levels of
engagement with the intervention. Only 52 % of participants allocated to the intervention condition completed
the self-affirmation task, only 35 % accessed the health messages and only 1 % formed an implementation
