Effect of a tailored behavior change program on a composite lifestyle change score: a randomized controlled trial

Twelve Month Efficacy of Computer-Tailored Communication in Boosting Fruit and Vegetable Consumption Among Adults Aged Forty and over: A Three-Level Meta-Analysis and Systematic Review of Randomized Controlled Trials

Computer-tailored health communication (CTC) can enhance fruit and vegetable (F&V) intake and, consequently, health by providing personalized feedback. However, few studies have examined the long-term effects of such interventions in middle-aged and older adults. This research aimed to assess the 12-mo efficacy of CTC in promoting F&V consumption and potentially identify who among middle-aged and older adults changed their diet after the intervention. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) on 2021-12-09, code CRD42022330491. The research was performed without external funding. We searched 6 databases (MEDLINE via PubMed, EMBASE, Scopus, Web of Science Core Collection, Cochrane Library, and PsycINFO) for randomized controlled trials (RCTs) comparing CTC interventions for increasing F&V intake with usual care/no intervention control in adults aged ≥40, measured 12 mo after the pretest. The search covered the period from 1 January 1990 to 1 January 2022. We selected 16 RCTs with 25,496 baseline participants for the review systematic literature reviews (SLR) and 11 RCTs with 19 measurements for the meta-analysis (MA). We assessed risk of bias with the JBI Critical Appraisal Checklist. The SLR revealed that at 1-y postCTC intervention, most of the treatment groups increased F&V intake more than the control groups. The overall bias in the data set was not high. The MA model on 11 RCTs revealed a significant effect size for F&V consumption in intervention groups compared with control, standardized mean difference of 0.21 (confidence interval [CI]: 0.12, 0.30), P = 0.0004. The evidence suggests that CTC is a suitable strategy for public interventions aiming to increase F&V intake in adults aged ≥40. The design of CTC for public interventions should consider the process of change and stages of change addressing awareness, attitudes, self-efficacy, and social influence as promising concepts for influencing behavior change.

Behavioral Counseling Interventions to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Cardiovascular Disease Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Unhealthful dietary patterns, low levels of physical activity, and high sedentary time increase the risk of cardiovascular disease.

OBJECTIVE

To synthesize the evidence on benefits and harms of behavioral counseling interventions to promote a healthy diet and physical activity in adults without known cardiovascular disease (CVD) risk factors to inform a US Preventive Services Task Force recommendation.

DATA SOURCES

MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials through February 2021, with ongoing surveillance through February 2022.

STUDY SELECTION

Randomized clinical trials (RCTs) of behavioral counseling interventions targeting improved diet, increased physical activity, or decreased sedentary time among adults without known elevated blood pressure, elevated lipid levels, or impaired fasting glucose.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating and random effects meta-analysis.

MAIN OUTCOMES AND MEASURES

CVD events, CVD risk factors, diet and physical activity measures, and harms.

RESULTS

One-hundred thirteen RCTs were included (N = 129 993). Three RCTs reported CVD-related outcomes: 1 study (n = 47 179) found no significant differences between groups on any CVD outcome at up to 13.4 years of follow-up; a combined analysis of the other 2 RCTs (n = 1203) found a statistically significant association of the intervention with nonfatal CVD events (hazard ratio, 0.27 [95% CI, 0.08 to 0.88]) and fatal CVD events (hazard ratio, 0.31 [95% CI, 0.11 to 0.93]) at 4 years. Diet and physical activity behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure (systolic mean difference, -0.8 [95% CI, -1.3 to -0.3]; 23 RCTs [n = 57 079]; diastolic mean difference, -0.4 [95% CI, -0.8 to -0.0]; 24 RCTs [n = 57 148]), low-density lipoprotein cholesterol level (mean difference, 2.2 mg/dL [95% CI, -3.8 to -0.6]; 15 RCTs [n = 6350]), adiposity-related outcomes (body mass index mean difference, -0.3 [95% CI, -0.5 to -0.1]; 27 RCTs [n = 59 239]), dietary outcomes, and physical activity at 6 months to 1.5 years of follow-up vs control conditions. There was no evidence of greater harm among intervention vs control groups.

CONCLUSIONS AND RELEVANCE

Healthy diet and physical activity behavioral counseling interventions for persons without a known risk of CVD were associated with small but statistically significant benefits across a variety of important intermediate health outcomes and small to moderate effects on dietary and physical activity behaviors. There was limited evidence regarding the long-term health outcomes or harmful effects of these interventions.

Improving the health of young African American women in the preconception period using health information technology: a randomised controlled trial

BACKGROUND

Preconception care focuses on improving women's health before pregnancy as a means to improve their health and future pregnancy outcomes. How to effectively deliver such care is unknown. The aim of this research was to assess the impact of an embodied conversational agent system on preconception risks among African American and Black women.

METHODS

We did an open-label, randomised controlled trial of women aged 18-34 years, self-identified as African American or Black, or both, and not pregnant, recruited from 35 states in the USA. Sealed allocation envelopes (in permuted blocks of six and eight, prepared using a random number generator) were opened after enrolment. Intervention participants received an online conversational agent called Gabby that assessed 102 preconception risks and delivered 12 months of tailored dialogue using synthesised speech, non-verbal behaviour, visual aids, and health behaviour change techniques such as motivational interviewing. The control group received a letter listing their preconception risks and encouraging them to talk with a clinician. The primary outcome was the proportion of identified risks at the action or maintenance stage of change at months 6 and 12. The study is registered with ClinicalTrials.gov, NCT01827215.

FINDINGS

From March 11, 2014, through July 8, 2018, 528 women recruited from 35 states and 242 cities across the USA received the Gabby intervention (n=262) or were assigned to the control group (n=266). Participants identified a mean of 21 preconception risks per woman (SD 9·9). In the intention-to-treat analysis, at 6 months, intervention women reported reaching the action or maintenance stage of change for 50·0% (SD 28·9) of those preconception risks identified compared with 42·7% (28·3) in the control group (incidence rate ratio 1·16, 95% CI 1·07-1·26; p=0·0004). This result persisted at 12 months.

INTERPRETATION

The Gabby system has the potential to improve women's preconception health. Further research is needed to determine if improving preconception risks impacts outcomes such as preterm delivery.

FUNDING

National Institute for Minority Health and Health Disparities.

Obesity in achondroplasia patients: from evidence to medical monitoring

Achondroplasia is a rare genetic disease representing the most common form of short-limb dwarfism. It is characterized by bone growth abnormalities that are well characterized and by a strong predisposition to abdominal obesity for which causes are unknown. Despite having aroused interest at the end of the 20 h century, there are still only very little data available on this aspect of the pathology. Today, interest is rising again, and some studies are now proposing mechanistic hypotheses and guidance for patient management. These data confirm that obesity is a major health problem in achondroplasia necessitating an early yet complex clinical management. Anticipatory care should be directed at identifying children who are at high risk to develop obesity and intervening to prevent the metabolic complications in adults. In this review, we are regrouping available data characterizing obesity in achondroplasia and we are identifying the current tools used to monitor obesity in these patients.

Individual-, family-, and school-level interventions targeting multiple risk behaviours in young people

BACKGROUND

Engagement in multiple risk behaviours can have adverse consequences for health during childhood, during adolescence, and later in life, yet little is known about the impact of different types of interventions that target multiple risk behaviours in children and young people, or the differential impact of universal versus targeted approaches. Findings from systematic reviews have been mixed, and effects of these interventions have not been quantitatively estimated.

OBJECTIVES

To examine the effects of interventions implemented up to 18 years of age for the primary or secondary prevention of multiple risk behaviours among young people.

SEARCH METHODS

We searched 11 databases (Australian Education Index; British Education Index; Campbell Library; Cumulative Index to Nursing and Allied Health Literature (CINAHL); Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Embase; Education Resource Information Center (ERIC); International Bibliography of the Social Sciences; MEDLINE; PsycINFO; and Sociological Abstracts) on three occasions (2012, 2015, and 14 November 2016)). We conducted handsearches of reference lists, contacted experts in the field, conducted citation searches, and searched websites of relevant organisations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster RCTs, which aimed to address at least two risk behaviours. Participants were children and young people up to 18 years of age and/or parents, guardians, or carers, as long as the intervention aimed to address involvement in multiple risk behaviours among children and young people up to 18 years of age. However, studies could include outcome data on children > 18 years of age at the time of follow-up. Specifically,we included studies with outcomes collected from those eight to 25 years of age. Further, we included only studies with a combined intervention and follow-up period of six months or longer. We excluded interventions aimed at individuals with clinically diagnosed disorders along with clinical interventions. We categorised interventions according to whether they were conducted at the individual level; the family level; or the school level.

DATA COLLECTION AND ANALYSIS

We identified a total of 34,680 titles, screened 27,691 articles and assessed 424 full-text articles for eligibility. Two or more review authors independently assessed studies for inclusion in the review, extracted data, and assessed risk of bias.We pooled data in meta-analyses using a random-effects (DerSimonian and Laird) model in RevMan 5.3. For each outcome, we included subgroups related to study type (individual, family, or school level, and universal or targeted approach) and examined effectiveness at up to 12 months' follow-up and over the longer term (> 12 months). We assessed the quality and certainty of evidence using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included in the review a total of 70 eligible studies, of which a substantial proportion were universal school-based studies (n = 28; 40%). Most studies were conducted in the USA (n = 55; 79%). On average, studies aimed to prevent four of the primary behaviours. Behaviours that were most frequently addressed included alcohol use (n = 55), drug use (n = 53), and/or antisocial behaviour (n = 53), followed by tobacco use (n = 42). No studies aimed to prevent self-harm or gambling alongside other behaviours.Evidence suggests that for multiple risk behaviours, universal school-based interventions were beneficial in relation to tobacco use (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.60 to 0.97; n = 9 studies; 15,354 participants) and alcohol use (OR 0.72, 95% CI 0.56 to 0.92; n = 8 studies; 8751 participants; both moderate-quality evidence) compared to a comparator, and that such interventions may be effective in preventing illicit drug use (OR 0.74, 95% CI 0.55 to 1.00; n = 5 studies; 11,058 participants; low-quality evidence) and engagement in any antisocial behaviour (OR 0.81, 95% CI 0.66 to 0.98; n = 13 studies; 20,756 participants; very low-quality evidence) at up to 12 months' follow-up, although there was evidence of moderate to substantial heterogeneity (I² = 49% to 69%). Moderate-quality evidence also showed that multiple risk behaviour universal school-based interventions improved the odds of physical activity (OR 1.32, 95% CI 1.16 to 1.50; I² = 0%; n = 4 studies; 6441 participants). We considered observed effects to be of public health importance when applied at the population level. Evidence was less certain for the effects of such multiple risk behaviour interventions for cannabis use (OR 0.79, 95% CI 0.62 to 1.01; P = 0.06; n = 5 studies; 4140 participants; I² = 0%; moderate-quality evidence), sexual risk behaviours (OR 0.83, 95% CI 0.61 to 1.12; P = 0.22; n = 6 studies; 12,633 participants; I² = 77%; low-quality evidence), and unhealthy diet (OR 0.82, 95% CI 0.64 to 1.06; P = 0.13; n = 3 studies; 6441 participants; I² = 49%; moderate-quality evidence). It is important to note that some evidence supported the positive effects of universal school-level interventions on three or more risk behaviours.For most outcomes of individual- and family-level targeted and universal interventions, moderate- or low-quality evidence suggests little or no effect, although caution is warranted in interpretation because few of these studies were available for comparison (n ≤ 4 studies for each outcome).Seven studies reported adverse effects, which involved evidence suggestive of increased involvement in a risk behaviour among participants receiving the intervention compared to participants given control interventions.We judged the quality of evidence to be moderate or low for most outcomes, primarily owing to concerns around selection, performance, and detection bias and heterogeneity between studies.

AUTHORS' CONCLUSIONS

Available evidence is strongest for universal school-based interventions that target multiple- risk behaviours, demonstrating that they may be effective in preventing engagement in tobacco use, alcohol use, illicit drug use, and antisocial behaviour, and in improving physical activity among young people, but not in preventing other risk behaviours. Results of this review do not provide strong evidence of benefit for family- or individual-level interventions across the risk behaviours studied. However, poor reporting and concerns around the quality of evidence highlight the need for high-quality multiple- risk behaviour intervention studies to further strengthen the evidence base in this field.

Internet-based interventions for smoking cessation

BACKGROUND

Tobacco use is estimated to kill 7 million people a year. Nicotine is highly addictive, but surveys indicate that almost 70% of US and UK smokers would like to stop smoking. Although many smokers attempt to give up on their own, advice from a health professional increases the chances of quitting. As of 2016 there were 3.5 billion Internet users worldwide, making the Internet a potential platform to help people quit smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation, whether intervention effectiveness is altered by tailoring or interactive features, and if there is a difference in effectiveness between adolescents, young adults, and adults.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, which included searches of MEDLINE, Embase and PsycINFO (through OVID). There were no restrictions placed on language, publication status or publication date. The most recent search was conducted in August 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention. To be included, studies must have measured smoking cessation at four weeks or longer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and extracted data. We extracted and, where appropriate, pooled smoking cessation outcomes of six-month follow-up or more, reporting short-term outcomes narratively where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI).We grouped studies according to whether they (1) compared an Internet intervention with a non-active control arm (e.g. printed self-help guides), (2) compared an Internet intervention with an active control arm (e.g. face-to-face counselling), (3) evaluated the addition of behavioural support to an Internet programme, or (4) compared one Internet intervention with another. Where appropriate we grouped studies by age.

MAIN RESULTS

We identified 67 RCTs, including data from over 110,000 participants. We pooled data from 35,969 participants.There were only four RCTs conducted in adolescence or young adults that were eligible for meta-analysis.Results for trials in adults: Eight trials compared a tailored and interactive Internet intervention to a non-active control. Pooled results demonstrated an effect in favour of the intervention (RR 1.15, 95% CI 1.01 to 1.30, n = 6786). However, statistical heterogeneity was high (I² = 58%) and was unexplained, and the overall quality of evidence was low according to GRADE. Five trials compared an Internet intervention to an active control. The pooled effect estimate favoured the control group, but crossed the null (RR 0.92, 95% CI 0.78 to 1.09, n = 3806, I² = 0%); GRADE quality rating was moderate. Five studies evaluated an Internet programme plus behavioural support compared to a non-active control (n = 2334). Pooled, these studies indicated a positive effect of the intervention (RR 1.69, 95% CI 1.30 to 2.18). Although statistical heterogeneity was substantial (I² = 60%) and was unexplained, the GRADE rating was moderate. Four studies evaluated the Internet plus behavioural support compared to active control. None of the studies detected a difference between trial arms (RR 1.00, 95% CI 0.84 to 1.18, n = 2769, I² = 0%); GRADE rating was moderate. Seven studies compared an interactive or tailored Internet intervention, or both, to an Internet intervention that was not tailored/interactive. Pooled results favoured the interactive or tailored programme, but the estimate crossed the null (RR 1.10, 95% CI 0.99 to 1.22, n = 14,623, I² = 0%); GRADE rating was moderate. Three studies compared tailored with non-tailored Internet-based messages, compared to non-tailored messages. The tailored messages produced higher cessation rates compared to control, but the estimate was not precise (RR 1.17, 95% CI 0.97 to 1.41, n = 4040), and there was evidence of unexplained substantial statistical heterogeneity (I² = 57%); GRADE rating was low.Results should be interpreted with caution as we judged some of the included studies to be at high risk of bias.

AUTHORS' CONCLUSIONS

The evidence from trials in adults suggests that interactive and tailored Internet-based interventions with or without additional behavioural support are moderately more effective than non-active controls at six months or longer, but there was no evidence that these interventions were better than other active smoking treatments. However some of the studies were at high risk of bias, and there was evidence of substantial statistical heterogeneity. Treatment effectiveness in younger people is unknown.

Can metabotyping help deliver the promise of personalised nutrition?

Over a decade since the completion of the human genome sequence, the promise of personalised nutrition available to all has yet to become a reality. While the definition was originally very gene-focused, in recent years, a model of personalised nutrition has emerged with the incorporation of dietary, phenotypic and genotypic information at various levels. Developing on from the idea of personalised nutrition, the concept of targeted nutrition has evolved which refers to the delivery of tailored dietary advice at a group level rather than at an individual level. Central to this concept is metabotyping or metabolic phenotyping, which is the ability to group similar individuals together based on their metabolic or phenotypic profiles. Applications of the metabotyping concept extend from the nutrition to the medical literature. While there are many examples of the metabotype approach, there is a dearth in the literature with regard to the development of tailored interventions for groups of individuals. This review will first explore the effectiveness of personalised nutrition in motivating behaviour change and secondly, examine potential novel ways for the delivery of personalised advice at a population level through a metabotyping approach. Based on recent findings from our work, we will demonstrate a novel strategy for the delivery of tailored dietary advice at a group level using this concept. In general, there is a strong emerging evidence to support the effectiveness of personalised nutrition; future work should ascertain if targeted nutrition can motivate behaviour change in a similar manner.

When it comes to lifestyle recommendations, more is sometimes less: a meta-analysis of theoretical assumptions underlying the effectiveness of interventions promoting multiple behavior domain change

A meta-analysis of 150 research reports summarizing the results of multiple behavior domain interventions examined theoretical predictions about the effects of the included number of recommendations on behavioral and clinical change in the domains of smoking, diet, and physical activity. The meta-analysis yielded 3 main conclusions. First, there is a curvilinear relation between the number of behavioral recommendations and improvements in behavioral and clinical measures, with a moderate number of recommendations producing the highest level of change. A moderate number of recommendations is likely to be associated with stronger effects because the intervention ensures the necessary level of motivation to implement the recommended changes, thereby increasing compliance with the goals set by the intervention, without making the intervention excessively demanding. Second, this curve was more pronounced when samples were likely to have low motivation to change, such as when interventions were delivered to nonpatient (vs. patient) populations, were implemented in nonclinic (vs. clinic) settings, used lay community (vs. expert) facilitators, and involved group (vs. individual) delivery formats. Finally, change in behavioral outcomes mediated the effects of number of recommended behaviors on clinical change. These findings provide important insights that can help guide the design of effective multiple behavior domain interventions.

Personalising nutritional guidance for more effective behaviour change

Improving diet and other lifestyle behaviours has considerable potential for reducing the global burden of non-communicable diseases, promoting better health across the life-course and increasing wellbeing. However, realising this potential will require the development, testing and implementation of much more effective behaviour change interventions than are used conventionally. Evidence-based, personalised (or stratified) interventions which incorporate effective behaviour change techniques (BCT) and which are delivered digitally are likely to be an important route to scalable and sustainable interventions. Progress in developing such interventions will depend on the outcomes of research on: (i) the best bases for personalisation of dietary advice; (ii) identification of BCT which are proven to enhance intervention efficacy; (iii) suitable platforms (digital-based tools) for collection of relevant participant characteristics (e.g. socioeconomic information, current diet and lifestyle and dietary preferences) linked with intelligent systems which use those characteristics to offer tailored feedback and advice in a cost-effective and acceptable manner. Future research should focus on such interventions aiming to reduce health inequalities and to improve overall public health.

Citation searching: a systematic review case study of multiple risk behaviour interventions

BACKGROUND

The value of citation searches as part of the systematic review process is currently unknown. While the major guides to conducting systematic reviews state that citation searching should be carried out in addition to searching bibliographic databases there are still few studies in the literature that support this view. Rather than using a predefined search strategy to retrieve studies, citation searching uses known relevant papers to identify further papers.

METHODS

We describe a case study about the effectiveness of using the citation sources Google Scholar, Scopus, Web of Science and OVIDSP MEDLINE to identify records for inclusion in a systematic review.We used the 40 included studies identified by traditional database searches from one systematic review of interventions for multiple risk behaviours. We searched for each of the included studies in the four citation sources to retrieve the details of all papers that have cited these studies.We carried out two analyses; the first was to examine the overlap between the four citation sources to identify which citation tool was the most useful; the second was to investigate whether the citation searches identified any relevant records in addition to those retrieved by the original database searches.

RESULTS

The highest number of citations was retrieved from Google Scholar (1680), followed by Scopus (1173), then Web of Science (1095) and lastly OVIDSP (213). To retrieve all the records identified by the citation tracking searching all four resources was required. Google Scholar identified the highest number of unique citations.The citation tracking identified 9 studies that met the review's inclusion criteria. Eight of these had already been identified by the traditional databases searches and identified in the screening process while the ninth was not available in any of the databases when the original searches were carried out. It would, however, have been identified by two of the database search strategies if searches had been carried out later.

CONCLUSIONS

Based on the results from this investigation, citation searching as a supplementary search method for systematic reviews may not be the best use of valuable time and resources. It would be useful to verify these findings in other reviews.

Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults

BACKGROUND

Obesity is a global public health threat. The transtheoretical stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably. 

OBJECTIVES

To assess the effectiveness of dietary intervention or physical activity interventions, or both, and other interventions based on the transtheoretical model (TTM) stages of change (SOC) to produce sustainable (one year and longer) weight loss in overweight and obese adults.

SEARCH METHODS

Studies were obtained from searches of multiple electronic bibliographic databases. We searched The Cochrane Library, MEDLINE, EMBASE and PsycINFO. The date of the last search, for all databases, was 17 December 2013.

SELECTION CRITERIA

Trials were included if they fulfilled the criteria of randomised controlled clinical trials (RCTs) using the TTM SOC as a model, that is a theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical activity interventions, versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss, measured as change in weight or body mass index (BMI); participants were overweight or obese adults only; and the intervention was delivered by healthcare professionals or trained lay people at the hospital and community level, including at home.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data, assessed studies for risk of bias and evaluated overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). We resolved disagreements by discussion or consultation with a third party. A narrative, descriptive analysis was conducted for the systematic review.

MAIN RESULTS

A total of three studies met the inclusion criteria, allocating 2971 participants to the intervention and control groups. The total number of participants randomised to the intervention groups was 1467, whilst 1504 were randomised to the control groups. The length of intervention was 9, 12 and 24 months in the different trials. The use of TTM SOC in combination with diet or physical activity, or both, and other interventions in the included studies produced inconclusive evidence that TTM SOC interventions led to sustained weight loss (the mean difference between intervention and control groups varied from 2.1 kg to 0.2 kg at 24 months; 2971 participants; 3 trials; low quality evidence). Following application of TTM SOC there were improvements in physical activity and dietary habits, such as increased exercise duration and frequency, reduced dietary fat intake and increased fruit and vegetable consumption (very low quality evidence). Weight gain was reported as an adverse event in one of the included trials. None of the trials reported health-related quality of life, morbidity, or economic costs as outcomes. The small number of studies and their variable methodological quality limit the applicability of the findings to clinical practice. The main limitations include inadequate reporting of outcomes and the methods for allocation, randomisation and blinding; extensive use of self-reported measures to estimate the effects of interventions on a number of outcomes, including weight loss, dietary consumption and physical activity levels; and insufficient assessment of sustainability due to lack of post-intervention assessments.

AUTHORS' CONCLUSIONS

The evidence to support the use of TTM SOC in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn. When combined with diet or physical activity, or both, and other interventions we found very low quality evidence that it might lead to better dietary and physical activity habits. This systematic review highlights the need for well-designed RCTs that apply the principles of the TTM SOC appropriately to produce conclusive evidence about the effect of TTM SOC lifestyle interventions on weight loss and other health outcomes.

Internet-based interventions for smoking cessation

BACKGROUND

The Internet is now an indispensable part of daily life for the majority of people in many parts of the world. It offers an additional means of effecting changes to behaviour such as smoking.

OBJECTIVES

To determine the effectiveness of Internet-based interventions for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register. There were no restrictions placed on language of publication or publication date. The most recent search was conducted in April 2013.

SELECTION CRITERIA

We included randomized and quasi-randomized trials. Participants were people who smoked, with no exclusions based on age, gender, ethnicity, language or health status. Any type of Internet intervention was eligible. The comparison condition could be a no-intervention control, a different Internet intervention, or a non-Internet intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted data. Methodological and study quality details were extracted using a standardized form. We extracted smoking cessation outcomes of six months follow-up or more, reporting short-term outcomes where longer-term outcomes were not available. We reported study effects as a risk ratio (RR) with a 95% confidence interval (CI). Clinical and statistical heterogeneity limited our ability to pool studies.

MAIN RESULTS

This updated review includes a total of 28 studies with over 45,000 participants. Some Internet programmes were intensive and included multiple outreach contacts with participants, whilst others relied on participants to initiate and maintain use.Fifteen trials compared an Internet intervention to a non-Internet-based smoking cessation intervention or to a no-intervention control. Ten of these recruited adults, one recruited young adult university students and two recruited adolescents. Seven of the trials in adults had follow-up at six months or longer and compared an Internet intervention to usual care or printed self help. In a post hoc subgroup analysis, pooled results from three trials that compared interactive and individually tailored interventions to usual care or written self help detected a statistically significant effect in favour of the intervention (RR 1.48, 95% CI 1.11 to 2.78). However all three trials were judged to be at high risk of bias in one domain and high statistical heterogeneity was detected (I² = 53%), with no obvious clinical explanation. Pooled results from two studies of an interactive, tailored intervention involving the Internet and automated phone contacts also detected a significant effect (RR 2.05, 95% CI 1.42 to 2.97, I² = 42%). Results from a sixth study comparing an interactive but non-tailored intervention to control did not detect a significant effect, nor did the seventh study, which compared a non-interactive, non-tailored intervention to control. Three trials comparing Internet interventions to face-to-face or phone counselling also did not detect evidence of an effect, nor did two trials evaluating Internet interventions as adjuncts to other behavioural interventions. A trial in college students increased point prevalence abstinence after 30 weeks but had no effect on sustained abstinence. Two small trials in adolescents did not detect an effect on cessation compared to control.Fourteen trials, all in adult populations, compared different Internet sites or programmes. Pooled estimates from three trials that compared tailored and/or interactive Internet programmes with non-tailored, non-interactive Internet programmes did not detect evidence of an effect (RR 1.12, 95% CI 0.95 to 1.32, I² = 0%). One trial detected evidence of a benefit from a tailored email compared to a non-tailored one, whereas a second trial comparing tailored messages to a non-tailored message did not detect evidence of an effect. Trials failed to detect a benefit of including a mood management component (three trials), or an asynchronous bulletin board.

AUTHORS' CONCLUSIONS

Results suggest that some Internet-based interventions can assist smoking cessation at six months or longer, particularly those which are interactive and tailored to individuals. However, the trials that compared Internet interventions with usual care or self help did not show consistent effects and were at risk of bias. Further research is needed despite 28 studies on the subject. Future studies should carefully consider optimising the interventions which promise most effect such as tailoring and interactivity.

Change in lifestyle through health promotion program without face-to-face intervention in a large-scale Japanese enterprise

OBJECTIVE

The aim of this study was to assess the effect of a health promotion program with 2-3-month Internet or printed material support without a face-to-face intervention at a large-scale worksite.

METHODS

An uncontrolled intervention was conducted. In 2005, 22,429 employees underwent a health check-up and a lifestyle assessment. In 2006, 2,096 employees were recruited to participate in an intervention group (IntG), and the remaining 20,228 employees were allocated to a control group (ConG). After one-year follow-up, 1,888 employees in IntG and 15,474 employees in ConG were analyzed by Breslow's lifestyle index, overall prevalence of cardiovascular risk (OPCR) and 10% 10-year risk based on cardiovascular risk factors in 2007.

RESULTS

Breslow's lifestyle index (over 5 points) in IntG showed a higher OR (1.13 with a 95% CI of 1.01-1.26) than that in ConG. Compared with those with a poor lifestyle, the subjects who had maintained or improved their lifestyle showed a lower OPCR (OR 0.88, 95% CI 0.79-0.97; OR 0.84, 95% CI 0.74-0.95 [p for trend=0.003]) and 10% 10-year risk trend (OR 0.38, 95% CI 0.31-0.47; OR: 0.29, 0.22-0.37 [p for trend <0.001]).

CONCLUSION

The present study showed that there was a modest lifestyle behavior change using a program without face-to-face contact. The employees who maintained and improved their lifestyle had a lower OPCR and 10% 10-year risk. Future study should increase the number of employees actively attempting to improve their lifestyles at a worksite

Social influence as a driver of engagement in a web-based health intervention

Background

Web-based health interventions can drive behavior change, but their effectiveness depends on participants’ usage. A well-recognized challenge with these interventions is nonusage attrition or weak engagement that results in participants receiving low doses of the intervention, negatively affecting outcomes. We present an approach based on the theoretical concepts of social influence and complex contagion in an effort to address the engagement problem in a specific, commercial, online behavior change intervention.

Objective

To examine the relation between social ties and engagement within a specific online intervention. The aims were (1) to determine whether experiencing the intervention socially influences engagement, such that individuals with social ties show higher engagement than those without ties, and (2) to evaluate whether complex contagion increases engagement—that is, whether engagement increases as the number of ties an individual has in the intervention increases.

Methods

We analyzed observational data from 84,828 subscribed members of a specific Web-based intervention, Daily Challenge. We compiled three measures of engagement for every member: email opens, site visits, and challenge completions (response to action prompts). We compared members with and without social ties within the intervention on each measure separately using 2-tailed independent-sample t tests. Finally, we performed linear regressions with each simple engagement measure as the dependent variable and number of social ties as the independent variable.

Results

Compared with those without social ties, participants with social ties opened more emails (33.0% vs 27.2%, P < .001), visited the website more often (12.6 vs 6.7 visits, P < .001), and reported completing more of the actions they were prompted to perform (11.0 vs 6.1 actions, P < .001). Social ties were significant predictors of email opens (beta = 0.68, P < .001), site visits (beta = 1.52, P < .001), and reported action completions (beta = 1.32, P < .001).

Conclusions

Our initial findings are higher engagement in participants with social ties in the program and are consistent with the view that social influence can drive engagement in a Web-based health intervention.