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Status of the Internet as a Tool for Health Behavior Change
Kerry Evers, Ph.D.
Carol Cummins, M.Ed., MLIS
Mary-Margaret Driskell, M.P.H.
James Prochaska, Ph.D.
Janice Prochaska, Ph.D. Pro-Change Behavior Systems, Inc.
Robin Mockenhaupt, Ph.D. The Robert Wood Johnson Foundation
Purpose
To examine the state of health behavior change programs on the Internet
Part of a larger study contracted by The Robert Wood Johnson Foundation– Review of the literature– Screening of health sites– Full review of health behavior change sites– Development of a measure for readiness to use the
Internet for health behavior change
An estimated 56% of American adults had access to the Internet at the end of 2000
52 million American adults use the Internet at least once a month to get health & medical information
Half say access to information on the Internet has improved the way they take care of themselves
The Pew Internet & American Life Project, 2001
Background
According to Goldsmith (2000), “The most important effect of the Internet will be to strengthen the consumer’s role” in health care, and to “create a powerful new tool to help people manage their own health risks more effectively.”
Healthy People 2010 Goal: Use communication strategically to improve health
– Objectives increase proportion of households with access to the Internet at
home increase proportion of health-related WWW sites that disclose
information that can be used to assess the quality of the site
Focus has been on dissemination of health information Little attention has been paid to the content and quality of
sites designed to help people change health behaviors
Background
Target Behaviors
Smoking cessation Diet Physical activity Alcohol use Depression management Diabetes management Pediatric asthma
Development of screening criteria specific to health behavior change
Review of existing guidelines for evaluating health related Web sites
Identification of sites focusing on target behaviors
Screening to differentiate health information from behavior change sites
Development of full review criteria Full evaluation of health behavior change sites
Design
Development of Review Criteria
Criteria from Public Health Service’s Clinical Practice Guideline adapted for Internet programs– Advise: advising about risk & need to change– Assess: assessing variables that could impact
behavior – Assist: providing strategies for change– Anticipatory Guidance: providing tips for preventing
relapse– Arrange Follow-Up: scheduling follow-up contacts
Identified 20 sets of guidelines for evaluating health Web sites– Examined concepts and repetition
Sites
Identified Web sites in 3 ways:
– Online searches
– Medical informatics journals
– Popular press
294 Web sites identified for screening
- 51 diet - 45 depression
- 44 exercise - 42 diabetes
- 43 smoking - 33 pediatric asthma
- 30 alcohol - 6 wellness (multiple behaviors)
273 sites separately rated by 2 reviewers for each of the 5 A’s
– Inter-rater reliability ranged from .84 to .93
– Third reviewer rated the site when disagreement
The most sites received credit for Assess (N=141; 51.6%)
Anticipatory Guidance received the fewest (N=31; 11.4%)
Screening of Sites
Screening of Sites
22 sites (8.1%) received credit in each of the 5 categories
20 (7.3%) received 4 credits
Sites identified through online searches met fewer criteria than those identified through other methods (F(2,272)=16.24, p<.001)
Sites meeting >4 moved onto full review (N=42): - 12 smoking - 7 diabetes
- 11 diet - 6 exercise
- 1 depression - 2 asthma
- 3 could not be reviewed
Content- Ownership (1) - Attribution (2)- Editorial Credibility/Quality (7) - Authorship (2)- Copyright (1) - Language (3)- Accountability (1) - Candor (1)- Disclaimer (1) - Purpose (2)
Interactivity (5) Behavior Change (21) Multi-Behavior (2) Design (8) Accessibility/Security (6) Privacy & Confidentiality (11) Advertising (3) Evaluation (4)
Full Review Criteria
Full Review Highlights
Editorial Credibility & Quality: Fewer than half of sites met all of the 7 criteria
Behavior Change– Sites included over 350 assessments– 37 sites provided segmented feedback; 5 sites provided
individualized feedback based on assessments– 5 sites stated their program was based on a behavior change
theory
Privacy: 34 sites had privacy policies within 1 click of the home page
Evaluation: None of the sites stated if or how they were evaluating their programs for effectiveness, although 6 provided mechanisms for feedback about their programs
Web sites are always changing– Content
– Links
The Internet is non-linear– Everyone can have a different experience
– May not be able to get to the same place again
Programs “borrow” from other programs
Incomplete sites or under construction
Challenges
Conclusions & Implications
Health behavior change on the Internet appears to be in the early stages of development
Smoking, exercise, and diet sites seem to be further along than others
There are implications for how consumers find sites
Little has been known about behavior change on the Internet– What is guiding development?– How effective are Internet behavior change programs?
“5 A’s for Effective Health Behavior Change Treatment on the Internet” criteria can be used by consumers, researchers, developers, and practitioners to assure basic behavior change components are present in Internet-based programs
Evaluation criteria must be used to examine issues like privacy, confidentiality, credibility, quality
Efficacy or effectiveness of programs must be assessed
Conclusions & Implications
References
Goldsmith, J. (2000). How will the Internet change our health system? Health Affairs, 19(1), 148-156.
The Pew Internet & American Life Project (2001, February). More online, doing more: 16 million newcomers gain Internet access in the last half of 2000 as women, minorities, and families with modest incomes continue to surge online. Washington, DC: Rainie, L., Packel, D., Fox, S., Horrigan, J., Lenhart, A., Spooner, T., Lewis, O., & Carter, C.
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