Build It, and Will They Come? Unexpected Findings From a Study on a Web-Based Intervention to Improve Colorectal Cancer Screening

"The issue of engagement, not only from the perspective of the health communication messages and approach, but from the initial step of taking action to open or access the Web-based intervention, is critical to the ultimate test of effectiveness."

Given the extensive use of the internet for health information, web-based health promotion interventions are widely perceived as an effective communication channel. The authors conducted this study to determine use of a web-based intervention intended to improve colorectal cancer (CRC) screening in a population of women in the United States, a country where 3 of 4 adults report using the internet, with more than half logging on to seek health information. The study was a randomised controlled trial designed to compare the effectiveness of CRC screening educational materials delivered using the internet versus a printed format. The participants in the study are described as being women at average risk for CRC who have not completed colorectal screening in accordance with current screening recommendations.

In 3 years, 391 women seen for routine obstetrics/gynaecology follow-up at 2 academic centres provided relevant survey information. Of these, 130 were randomised to the web intervention. Participants received voluntary access to a password-protected, study-specific website that provided information about CRC and CRC screening options. Both interventional arms (web and print) contained identical educational content; however, the delivery channel and format differed; for example, the web version is purposefully more visually appealing and media-rich. Pretesting of the web-based channel was performed on approximately 50 women who fit eligibility criteria but were not included in the study. On the basis of this testing, researchers anticipated that participants could review the information on the site in about 5 minutes amongst those with a literacy level of seventh- to eighth-grade reading level. In addition to educational material developed by the research team, hot links were provided for several external websites devoted to CRC and CRC screening.

The main outcome measures were self-reported and actual website use. Only 24.6% of women logged onto the website. Age was the only variable that differentiated users from nonusers (p = .03). In contrast, 16% of participants self-reported web use. There was significant discordance between the veracity of actual and self-reported use (p= .004). Among true users, most (81%) logged on once only. According to the researchers, these findings raise questions about how to increase use of important health communication interventions.

In their words: "Our preliminary findings reported here highlight an emerging, and unanticipated issue in Web-based health promotion interventions; namely, the underuse of these interventions in 'real world' settings. When this project was in development, we implicitly assumed, as did consultants and reviewers, that study participants would embrace the use of the Web intervention as an easily accessible, highly engaging communication channel....While unexpected, these findings regarding Web usage patterns are important to more fully understand, as they could inform planning and implementation of Web-based health interventions and encourage ongoing dialogue among health communication researchers regarding research methodology."

The researchers conclude by suggesting that, "[r]ather than simply continue to develop new technology-based interventions, reallocation of resources towards programs designed to understand how the Internet can best be exploited to improve health may have greater immediate effect. For those currently funded research projects, more data regarding actual use should be reported to fully describe and elucidate this phenomenon. In addition, successful strategies to increase engagement and use should also be reported. For example, we added a reminder letter to encourage those in the Web arm to log into the Web site. Of those who remembered the letter, 46% logged on in comparison with 12% of those who did not remember the letter. As in other industries in which the initial goal is to market the Web site, these types of strategies may be required, especially for health promotion among less compliant populations."