Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy

The purpose of this research was to propose a model to help guide future internet intervention development and predict and explain behavior changes and symptom improvement produced by Internet interventions . The study suggests that by grounding internet intervention research within a scientific framework, developers can plan feasible, informed, and testable internet interventions, and this form of treatment will become more firmly established.

Researchers divided internet "mode of delivery" into (i) automated functions, (ii) communicative functions, and (iii) use of supplementary modes. Automated functions included: (a) the use of an enriched information environment (e.g., supplementary content and links, testimonials, videos, or games), (b) automated tailored feedback based on individual progress monitoring (e.g., comparison to norms or goals, reinforcing messages, or coping messages), and (c) automated follow-up messages (e.g., reminders, tips, newsletters, encouragement). Communicative functions included: (d) access to an advisor to request advice (e.g., “ask the expert” facility, expert-led discussion board, or chat sessions), (e) scheduled contact with advisor (e.g., emails), and (f) peer-to-peer access (e.g., buddy systems, peer-to-peer discussions boards, forums, or live chat). Finally, use of supplementary modes included the use of (g) email, (h) telephone, (i) Short Messaging Service (SMS), (j) CD-ROM, or (k) videoconferencing.

From the study: (Footnotes are removed throughout by the editor.) "The most commonly used behavior change techniques (used by 30% or more of interventions) were providing information on the consequences of behavior in general (k = 29), prompting self-monitoring of behavior (k = 28), and identifying barriers and/or problem solving (k = 26). The largest effects on behavior were observed for interventions that provided stress management (d+= 0.50, 95% CI 0.27 to 0.72) or general communication skills training (d+= 0.49, 95% CI 0.25 to 0.73), although these were used by relatively few interventions (k = 5 and 3, respectively). Modeling, relapse prevention/coping planning, facilitating social comparison, goal setting, action planning, and provision of feedback on performance all had effects on behavior that exceeded d+= 0.20 (Median d+= 0.28). Finally, a few strategies had small and non-significant effects on behavior: use of follow-up prompts, self-monitoring of behavioral outcome, emotional control training, and provision of information about others approval. Overall, meta-regression indicated that the number of behavior change techniques employed had a significant positive impact on effect size (ß = 0.36, t = 3.48, P < .001). Interventions that used more techniques tended to have larger effects on behavior than did interventions that used fewer techniques….

The primary aim of the present review was to relate the characteristics of Internet-based interventions to their effectiveness in promoting health behavior change. Like previous reviews, the interventions tended to have variable effects on behavior…, and the average effect on behavior was statistically small. Thus, while some interventions had very large effects…on behavior, others were found to have small or even negative effects on behavior. The considerable variability in the effectiveness of Internet-based interventions makes it important to systematically identify the characteristics of effective interventions and to relate these to effect size….

Interventions differed substantially in their use of theory, but more extensive use of theory was associated with larger effect sizes. This finding is consistent with assertions that interventions can benefit from using behavior change theory… and extends the evidence base to interventions delivered on the Internet. Three theories–social cognitive theory (SCT)…, the transtheoretical model (TTM)…, and the theory of reasoned action/planned behavior (TPB) … –were used much more frequently than others. However, only the use of the TPB to inform intervention design led to substantially larger effects than were observed across all interventions….The finding that interventions that incorporated more behavior change techniques tended to have larger effects than interventions that incorporated fewer techniques justified the investment in relatively elaborate interventions. This finding may be a consequence of different techniques targeting different aspects of the behavior change process…, and future research might usefully consider how particular combinations of techniques might be especially effective in promoting behavior change….

The two behavior change techniques that were associated with the greatest changes in behavior were stress management and general communication skills training. It is interesting that both techniques influence behavior change indirectly via mechanisms such as facilitating problem-solving, promoting self-efficacy …, or diminishing the impact of stressors that may prevent behavior change …."