Digital Health Communication – Literature Summary
Lecture 1 – T1: Persuasive technology pt. 1
What is the scientific evidence for the effectiveness of health applications?
Romeo et al. (2019) – Can smartphone apps increase physical activity? Systematic review and
meta-analysis
- Aim: this systematic review and meta-analysis aimed to determine the effectiveness of
smartphone apps for increasing objectively measured physical activity in adults
- Aim 2: provide current status:
o Which health behaviour theories are employed most often?
o Which features of the apps are used most often?
The app is based on recognized behaviour-change theory:
- Social cognitive theory
- Principles of reinforcement
- Social influencers’ perspective
- Taxonomy of behaviour change
Results of their study:
- No significant effect of app-based physical activity interventions – steps per day and
moderate-to-vigorous PA
o There was only one study that had a significant higher amount of steps in the control
condition
- But: interventions were effective (significant) when the intervention duration was 3 months
or less (compared with longer interventions)
o Engagement with the app decreases after a period of time lower use
- And: physical activity apps that targeted physical activity in isolation were more effective
than apps that targeted physical activity in combination with diet
o What explanation do Cameron et al. (2015) give for this?
The intervention may be affected in changing the one behaviour at some
people, but in another behaviour for other people (which may delute the
effect of the whole intervention)
Villinger et al. (2019) – The effectiveness of app-based mobile interventions on nutrition
behaviours and nutrition-related health outcomes: A systematic review and meta-analysis
Aim of the study: determine the effectiveness of smartphone apps for changing nutrition behaviours
and nutrition-related health outcomes
Results:
- Overall, a small significance of app-based mobile interventions on nutrition behaviours and
nutrition-related outcomes
- Only studies targeting short term and/or intermediate-term follow-up intervals yielded
significant (small) effect sizes; effects of long term follow up not significant
Maximizing the impact of digital health applications: two main factors
- The effective components should be evidence-based
o The application employs features that target determinants from health behaviour
theories / features that are based on established behavioural change techniques
, - The uptake of the application should be sufficient
o The app should be designed based on scientific theories of technology acceptance
and engagement. The app should be human-centred
Importance of theory use in digital health applications
- More likely to find a significant positive effect of the digital health intervention on weight-
related outcomes when extent of theory use was higher, namely
o At least one or more theoretical constructs are explicitly linked to an intervention
technique
o When theoretical constructs are included in evaluations (measured pre and post
intervention)
Not based on intuition, but based on theory: we know how to change it, and
we will search for features to change that
eHealth-based interventions provide vast potential for testing and advancing behaviour change
theories, generating large amounts of ecologically valid, real-time and objective data
Epton et al. (2013) – A theory-based online health behaviour intervention
for new university students: study protocol
The present intervention capitalizes on the transition from school to university to promote the
adoption of healthy lifestyle habits in young people.
Four health behaviours that were tested: fruit and vegetable intake, physical activity, alcohol
consumption, and smoking
Three main reasons why this transition provides a unique opportunity:
o It affords the opportunity to target a large proportion of young people in the UK
o Major life transitions represent critical or “teachable” moments to intervene in order
to promote healthy lifestyle habits people’s health beliefs and behaviours are
likely to be in a state of flux and therefore more likely to change
o The transition from school to university is a predictable event, and therefore,
interventions can be easily implemented to target a large number of people on an
annual basis
- The use of digital technologies helps in these interventions:
o Easy to disseminate and low in cost
o Interactive materials
o Available 24-hours a day, and can so be accessed at critical moments
Theoretical bases of the intervention:
A recent meta-analysis reported that online health behaviour interventions that were based on
theory and used a combination of behaviour change techniques produced stronger effect sizes
- Self-affirmation
o to reduce defensive processing of health messages
o Messages about future health risks not only threaten peoples’ physical integrity, but
also their sense of being sensible, rational, “adaptively and morally adequate” people
(i.e., their self-integrity)
In order to maintain their self-integrity, people often resist messages about
the health risks of certain behaviours
o 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 more open-minded and balanced
, Self-affirmation thus leads to less defensive processing of health-risk
information and to positive changes in people’s health-related attitudes,
intentions and initial precautionary behaviour
- Theory-based messages
o to increase people’s motivation to adopt healthy lifestyle habits
o Theory of Planned Behaviour: the most proximal determinant of behaviour is
intention
Consists out of: attitude, subjective norm, and perceived behavioural control
- Implementation intentions
o to increase the likelihood that good intentions are translated into behaviour
o There is an “intention-behaviour gap”
Forming implementation intentions ensures that the opportunity is highly
accessible, and that the behavioural response is performed relatively
automatically
RQ1: Can an online intervention delivered during the transition from school to university produce
significant changes in the health behaviour of young people?
Does this intervention...
o Change health cognitions
o Enhance health status
o Reduce health service usage
o Reduce recreational drug use
o Reduce BMI
o Improve academic performance
Discussion
It is likely that the combination of the three behaviour change techniques in the online intervention
will have a synergistic effect:
- The self-affirmation task will reduce defensive processing and thereby increase engagement
with the health messages
- The theory-based messages will ensure that the key beliefs underlying each health behaviour
are targeted
- Asking participants to form implementation intentions will assist the translation of good
intentions into behaviour
- Results of the study show that the intervention had a significant effect on smoking
o Fewer current smokers at follow-up in the intervention than in the control condition
o But: the intervention did not significantly affect the other three primary outcomes
Cameron et al. (2015) – A theory-based online health behaviour
intervention for new university students (U@Uni: LifeGuide): Results from
a repeat randomized controlled trial
The present paper reports the results of the repeat randomized controlled trial of a theory-based
online health behaviour intervention delivered during the transition from school to university. The
initial intervention used three theory-based techniques, and found a significant effect on smoking
behaviour only.
The present study repeats the previous trial and focuses on its limitations
- Repeat trial with a number of changes to increase engagement with the intervention and
provide a more accurate estimate of the efficacy of the intervention
o Baseline questionnaire was shortened and simplified
, o Intervention was delivered using the LifeGuie open-source software platform
o The key content of the intervention was delivered in a more structured format so
that participants could quickly access health messages and make plans for all four
health behaviours
- RQ same as in study 1: does the intervention produce significant changes in the health
behaviours of new students at a 6-month follow-up?
Results
There were no significant differences between participants in the intervention and control conditions
on any of the baseline measures ((i) the number of portions of fruit and vegetables consumed per
day, (ii) physical activity in the previous week, (iii) alcohol consumption in the previous week, and (iv)
smoking status)
- However, effects were strongest for the fruit and vegetable intake (p =0.024)
o A marginally larger effect size was found for fruit and vegetable intake in the repeat
trial (d = 0.12) than in the original trial (d = -0.02)
o A marginally larger effect size was found for smoking in the original trial (d = 0.25)
than in the repeat trial (d = 0.10)
The intervention was found to have a number of significant effects on secondary outcomes at 6-
month follow-up
- Smoking 37.16% of participants in the control condition reported that they had smoked
since starting university, compared with only 30.70% of participants in the intervention
condition
- Alcohol use lower levels of alcohol use among participants in the intervention condition
- However, lower self-efficacy scores for fruit and vegetable intake and physical activity than
participants in the control condition
Discussion
- The changes made in the present study compared to the previous study resulted in an
increased engagement with the intervention
- Despite increased engagement, there were no significant effects on the primary analyses
- A per-protocol analysis showed that participants who engaged with the intervention
reported consuming significantly more portions of fruit at 6-month follow-up than
participants in the control condition
o Explanation about per-protocol analysis in beginning lecture T2
- Overall, the effect sizes were very small and (with the exception of smoking status in the
original trial), smaller than those typically found in online health behaviour change
interventions
Lecture 2 – D1: Outline of the CeHReS roadmap and Contextual
Inquiry
eBook Ch. 7 – Holistic development of eHealth technology
CeHReS roadmap
- Provides guidelines for a holistic development approach of e-health technologies
o What’s the context? Who are the people involved? What do they want? How does
the technology contribute to their needs/values/wishes? How are we going to design
the technology as such that it serves these needs?
- Holistic approach
