Development and implementation of an integrated, multi-modality, user-centered interactive dietary change program

Article (PDF Available)inHealth Education Research 24(3):461-71 · September 2008with20 Reads
DOI: 10.1093/her/cyn042 · Source: PubMed
Abstract
Computer-tailored behavior change programs offer the potential for reaching large populations at a much lower cost than individual or group-based programs. However, few of these programs to date appear to integrate behavioral theory with user choice, or combine different electronic modalities. We describe the development of an integrated CD-ROM and interactive voice response dietary change intervention that combines behavioral problem-solving theory with a high degree of user choice. The program, WISE CHOICES, is being evaluated as part of an ongoing trial. This paper describes the program development, emphasizing how user preferences are accommodated, and presents implementation and user satisfaction data. The program was successfully implemented; the linkages among the central database, the CD-ROM and the automated telephone components were robust, and participants liked the program almost as well as a counselor-delivered dietary change condition. Multi-modality programs that emphasize the strengths of each approach appear to be feasible. Future research is needed to determine the program impact and cost-effectiveness compared with counselor-delivered intervention.
Development and implementation of an integrated,
multi-modality, user-centered interactive dietary
change program
Russell E. Glasgow
1
*, Steve Christiansen
2
, K. Sabina Smith
3
, Victor J. Stevens
3
and Deborah J. Toobert
4
Abstract
Computer-tailored behavior change programs
offer the potential for reaching large popula-
tions at a much lower cost than individual or
group-based programs. However, few of these
programs to date appear to integrate behav-
ioral theory with user choice, or combine dif-
ferent electronic modalities. We describe the
development of an integrated CD-ROM and
interactive voice response dietary change inter-
vention that combines beha vioral pr oblem-
solving theory with a high degree of user choice.
The program, WISE CHOICES, is being evalu-
ated as part of an ongoing trial. This paper
describes the program development, emphasizing
how user preferences are accommodated, and
presents implementation and user satisfaction
data. The program was successfully imple-
mented; the linkages among the central database,
the CD-R OM and the automated telephone com-
ponents were robust, and participants liked the
program almost as well as a counselor-delivered
dietary change condition. Multi-modality pro-
grams that emphasize the strengths of each ap-
proach appear to be feasible. Future research
is needed to determine the program impact
and cost-effectiveness compared with counselor -
delivered intervention.
Introduction
An increasing number of interactive computer pro-
grams for health-related behavior change are avail-
able, and a recent review of automated dietary
change interventions suggests that such programs
can be effective [1]. Several well-controlled studies
have reported significant long-term improvements
from technology-based interventions in dietary
behaviors, weight loss or both, relative to random-
ized control conditions [2–4]. However, almost all
such programs are single modality [e.g. Internet,
CD-ROM/DVD, tailored mailings, Interactive Voice
Response (IVR)] only, and few provide participants
much choice concerning goals or strategies.
Most automated interventions to date have been
based on the appeal of a given technology, rather
than a functional analysis of the relevance of vari-
ous components to the inte rvention goals, and use
of this analysis to decide upon the most relevant
technologies. Thus, we have Internet-based pro-
grams that have great convenience (for those with
access), but which have difficulty delivering high-
performance media and retaining users [2, 5]. Or we
have CD-ROM programs that can easily present
videos, audios and rich graphics, but are often in-
convenient and hard to disseminate. There are IVR
programs that appear successful at reaching and
engaging a high percentage of participants, and es-
pecially lower literacy populations [6, 7], but place
major limits on the complexity of issues that can
be addressed and are limited to a single auditory
modality. For these and other reasons, it often
proves less feasible than anticipated to implement
computer-tailored health behavior programs in
busy, real-world health ca re settings [2, 6, 8].
1
Kaiser Permanente Colorado, PO Box 378066, Denver, CO
80231, USA,
2
InterVision, Eugene, OR 97401, USA,
3
Center
for Health Research, Portland, OR 97227, USA and
4
Oregon
Research Institute, Eugene, OR 97403, USA
*Correspondence to: Russell E. Glasgow.
E-mail: russg@re-aim.net
Ó The Author 2008. Published by Oxford University Press. All rights reserved.
For permissions, please email: journals.permissions@oxfordjournals.org
doi:10.1093/her/cyn042
HEALTH EDUCATION RESEARCH Vol.24 no.3 2009
Pages 461–471
Advance Access publication 18 August 2008
Another key issue is the amount of human con-
tact that is optimal and cost-effective. There have
been several demonstrations in which entirely au-
tomated programs were successful in producing be-
havior change [1, 2, 9], but more often programs
combine automated and human contact [3, 7, 10].
Importantly, little is known about how much human
contact is optimal, for what types of patients and
with what types of behavior change targets. This
paper assesses whether entirely automated pro-
grams were able to be implemented to the same
level and produced user satisfaction ratings as high
as staff-administered programs.
We have developed the WISE CHOICES inter-
active program to help adult women increase their
consumption of fruits and vegetables and decrease
consumption of fat. The new, fully automated in-
tervention program is based on earlier interventions
that successfully used a combination of automated
and in-person counseling to improve dietary quality
[3, 5, 11]. While these interventions were effective,
the reliance on skilled counselors for delivering part
of the program limited the likely scope of dissem-
ination to higher risk patients. The goal of the pres-
ent study is to develop an effective dietary change
intervention that can be delivered entirely through
automated means (CD-ROM and IVR), and would
therefore have the potential for cost-effective and
scalable applications in large populations. The ef-
fectiveness of this intervention is being compared
with other intervention programs in a randomized
trial. Results from that trial will be available in later
years. This current paper focuses on the theoretical,
operational and technical challenges in developing
and implementing a fully automated, multi-modality
dietary change program.
We describe the WISE CHOICES program,
which combined different interactive computer mo-
dalities to help adult women make and maintain
reductions in total fat consumption and increases
in fruit and vegetable intake. This paper (i) dis-
cusses the theoretical basis and operationalization
of different program components in the WISE
CHOICES program, (ii) describes the rati onale for
and use of multiple interactive modalities in a single
program, (iii) summarizes changes made to the
program as a result of formative feedback as the
program was developed and (iv) presents imple-
mentation and user satisfaction data on the program
under completely automated and staff-assisted
conditions.
Methods
Setting and participants
Using electronic medical records, a random sample
of female Kaiser Permanente Northwest (KPNW)
region members, aged 40 years and older, were
selected who met preliminary age, membership
and geographic criteria. Women screened for the
study completed a series of three questionnaires,
including a 27-item dietary intake survey [12].
Those eligible for the study were invited to the re-
search clinic for their first in-office study visit. At
this visit, after completion of informed consent, the
first intervention session was conducted. At the end
of this visit, future contacts were scheduled as de-
scribed below and included a second intervention
visit in approximately 2 weeks. The flow chart in
Fig. 1 summarizes both the content and sequence of
intervention elements. All procedures were approved
by the local Institutional Review Board (IRB).
Automated intervention system overview
The WISE CHOICES program brought together
several media modalities and maximized the poten-
tial of each in the process of engaging users and
helping them reach and maintain behavior change
goals. The rationale and/or theoretical basis for
each of these components is presented when that
component is described. The system design for
WISE CHOICES included three major technologi-
cal components—an intervention CD-ROM con-
taining an array of audios, videos and appealing
graphic elements; an IVR system using automated
telephone reminder calls for following up with par-
ticipants and an intranet-based data management
system for collecting and storing user responses
and guiding participant interactions with the CD-
ROM and the IVR (Fig. 2).
R. E. Glasgow et al.
462
Greeting and
Introduction to
Study Arm
Video Introduction
and instruction
Select Domain
e.g. Fruits and
Vegetables
Set Goals
Select first area
e.g. Fruits
Select barriers
Self efficacy
assessment
Select strategies
V1
Rand +0
V2
Rand + 3 weeks
Greeting and
welcome back
Video Introduction
and instruction
Select Domain
e.g. Fats
Set Goals
Select first area
e.g. high fat foods
Select barriers
Self efficacy
assessment
Select strategies
Select second
area
e.g. vegetables
Select barriers
Self efficacy
assessment
Select strategies
Select second
area
e.g. portion size
Select barriers
Self efficacy
assessment
Select strategies
Review, change,
accept plan
Take plan home
Review, change,
accept plan
Take plan home
IVR call
1
Rand +
1 week
IVR call
2
Rand +
5 weeks
IVR call
3
Rand +
10
weeks
Visits
Across
Top Line
Fig. 1. Flow chart of WISE CHOICES program.
Multi-modality dietary change program
463
We implemented WISE CHOICES as the center-
piece of a dietary change project. The program was
developed with two approac hes, both using the
media-based system as the core element. One ver-
sion is a stand-alone automated program, relying
primarily on the CD-ROM and IVR for generating
user engagement. The second version includes the
use of a health coach to provide human contact to
the participant as an additional component to the
technology-based interaction. These versions were
compared with each other and to two other condi-
tions: health coach counseling with no automated
components and a control condition consisting of
automated counseling for physical acti vity in a
2 3 2 randomized design.
Action plans
Based upon problem-solving theory [13–15],
a user- driven, self-management Action Plan was
the foundation for the intervention (see screen shot
in Fig. 3). The problem-solving steps toward creat-
ing a successful Action Plan were to (i) assess and
receive feedback on curren t dietary habits, (ii) iden-
tify personal benefits of healthful eating, (iii) select
a specific dietary goal (e.g. fat reduction or fruit and
vegetable increase), (iv) identify barriers that were
most likely to interfere with achievement of the
goal, (v) choose strategies for overcoming those
barriers (see screen shot in Fig. 4) and (vi) review
the overall plan and make any desired changes (see
Fig. 1). Over the course of the program, participants
were guided through all these steps, which yielded
an on-screen Action Plan that was printed out for
the user to take home and review on a regular basis.
Participants first completed a brief dietary ques-
tionnaire, either online or in a telephone interview
[16]. The baseline survey, which collected estimated
daily servings of fruit and vegetables as well as
overall fat intake [12, 17], was stored on a central
database and linked to the other media components
of the system. Since this was a cancer prevention
project, the focus was on overall fat intake, rather
than a particular type of fat. The majority of exam-
ples and strategies, however, targeted animal, satu-
rated and trans fats. The information in this database
was used by the CD-ROM to tailor messages and to
facilitate user interactions with the computer pro-
gram. The IVR telephone system also used informa-
tion from the central database to follow up with
individual participants, present users with opportu-
nities to report on their activities and goal attainment
and to revise their Action Plan, if necessary.
CD-ROM component
We wanted to maximize user engagement and en-
sure that they received the key elements of the in-
tervention. Because we wanted to make full use of
video, audio, animation and rich graphic elements
to enhance user engagement, we selected CD-ROM
as the primary delivery modality (this did, however,
require in-office visits). The interactive computer
session opens with a ‘Welcome’ video message
from the two hosts of the program—a health edu-
cator, who also serves as an on-screen and voice-
over narrator, and a KPNW physician. The health
educator appears frequently throughout the pro-
gram to deliver key health messages and provide
a sense of familiarity and personalized attention for
the user. Based upon information gathered from the
participant’s dietary questionnaire, the WISE
CHOICES program then draws from the local da-
tabase and presents animated graphs that display
the user’s current eating habits (i.e. estimated total
fat intake and fruit and vegetable consumption) and
comparisons with national recommendations. The
program was designed to enhance comprehension
across a broad spectrum of literacy abilities by us-
ing both audio instructions and visual cues. At this
point in the program, the participant chooses
whether to focus on one of two dietary change
domains: increasing fruits and vegetables or reduc-
ing fat. Later, when she returns to the clinic for her
second session, she creates an Action Plan for the
other dietary domain.
If the user sets a goal to reduce fat, she is prompted
to work on two areas where she might make improve-
ments in her eating habits—food choices and portion
size. In each of these areas, the program draws from
the information gathered from the dietary question-
naire, including a list of the high-fat foods in her
current diet. To complete the goal-setting process,
the user chooses several foods that she could eat less
R. E. Glasgow et al.
464
frequently, prepare differently, reduce portion size or
substitute with healthier foods.
In the next part of the program, the user selects
two barriers from an updated list that we compiled
from earlier dietary intervention studies. These bar-
riers have been reported as common obstacles to
achieving healthful eating goals [3, 5]. But before
the user moves on to looking at strategies for over-
coming barriers, the program uses motivational
interviewing principles to ask how willing she is
to work on the barriers she has selected. On this
screen, the user is prompted to click on a sliding
scale to identify her level of willingness to work on
her barriers. If she has some concern about moving
forward with her Action Plan, she is encouraged to
select different barriers that might be more relevant
or easier to overcome.
Once the barriers have been chosen and con-
firmed, the participant is presented with each barrier
and a list of suggested strategies for overcoming
that barrier. On this screen, the user has the oppor-
tunity to explore each strategy in more detail by
viewing ‘More Info or using the ‘Write My Own’
feature to type in a strategy that is not on the list.
The strategy selection screen was designed to be
user-friendly and intuitive, offering the participant
graphic, photo and text elements to assist the selec-
tion process, easy-to-use check boxes and a conve-
nient way to write in her own strategy, if necessary
(Fig. 4). After choosing two or three strategies for
each barrier that she wants to try over the next few
months, the user is presented with an on-screen ver-
sion of her completed Action Plan.
At this point, the user can choose to go back to
any part of the Action Plan and make changes. By
clicking on the Goals, Barriers or Strategies sec-
tions of the on-scr een plan (Fig. 3), the user is sent
back to the appropriate parts of the program and
prompted to make new choices. She then has
a chance to review her plan and make additional
changes. Afte r the user has reviewed and settled
on her plan, she clicks a button and the on-screen
Fig. 2. WISE CHOICES interactive components.
Multi-modality dietary change program
465
narrators deliver an exit message, while a copy of
her Action Plan is printed. This process is repeated
in the second in-clinic session for the other dietary
change area.
For each participant, individualized Action Plan
elements—Goals, Barriers and Strategies—were
stored in a local Microsoft Accessä database,
which was linked directly to the CD-ROM. These
data fields were transmitted, on a daily basis, using
a data transformation service, from the local data-
base to the central database, where they were avail-
able to be used by other components of the media-
based system, and for later data analyses.
IVR component
Another innovative aspect of the study was the in-
tegration of automated telephone follow-up deliv-
ered by an IVR system. We wanted a convenient,
low-cost, proactive, automated way to reach partic-
ipants for follow-up contacts and to reinforce prog-
ress. Therefore, we selected IVR technology. Data
collected during the computer sessions were used
by the telephone response system to make brief
phone calls to the participants. The IVR program-
ming system allowed a large number of branching
response levels (e.g. tailored responses based
upon both current and past levels of progress). This
flexibility allowed us to tailor each call to include
information from a previous visit or call (goals
and barriers) and participant-specific information
(greeted by name and confirmation of delivery of
intervention to correct person). The timing and
number of calls made to reach each participant
was implemented via communication between
Fig. 3. Sample WISE CHOICES Action Plan.
R. E. Glasgow et al.
466
the tracking system and the IVR delivery system
(Fig. 2).
The IVR calls ask participants, who are informed
in the first session that they will be receiving these
calls, to review their Action Plan goals and their
motivation for continuing with their plan. They
are given encouragement and the opportunity to
hear some tips or motivational messages.
Automated intervention summary
For the WISE CHOICES study, the key to user
engagement and retention centered on a multiple-
modality concept, where each component—
CD-ROM, IVR and networked database—was used
because of its potential strength for delivering a par-
ticular aspect of the intervention (Fig. 1). Each con-
tact with the pa rticipant, including initial screening
assessments, two CD-ROM sessions at the health
clinic and IVR calls that followed the CD-ROM
sessions, generated information that was stored
and managed in a central database that linked user
responses to other modalities. The CD-ROM, using
high-performance media, including audio, video
and animation, was designed to provide an easy-
to-use, stylish experience for the user without much
previous computer or Internet experience and to
deliver tailored messages about lifestyle change in
a personalized, engaging fashion. The program was
structured to enable a high degree of user choice
and to provide the participant with tools to focus on
her particular dietary goals, obstacles and strategies
for change. The IVR, with its high reach and ability
to generate brief, frequent contacts with participants
at low cost was used to follow up with respondents
after intervention sessi ons. These three modalities,
in concert with each other, presented a seamless,
coordinated display for the participant, and focused
the user interactions with technology on functions
that were appropriate for each medium.
Fig. 4. WISE CHOICES screen shot of strategy selection.
Multi-modality dietary change program
467
Changes as a result of formative research
There were three major revisions and numerous mi-
nor changes made during the formative development
process for the WISE CHOICES program. Formative
testing was conducted on an individual basis, primar-
ily for appeal to different cultures and races. Testers
went through the program ‘talking aloud’ and pro-
vided reactions. Developmental work for the earlier
program had included more systematic focus group
formative research [3, 11]. Most of these revisions
were made to achieve a balance among on-screen
functions—maximizing the amount of available in-
formation, automated tailoring to display options and
facilitating user choice. The first revision related to
presenting a menu of problem-solving strategies
tailored for specific patient-identified barriers. To
accommodate the range of choices and to facilitate
user selection, all available options were presented
on a single computer screen. This was challenging
because some of the strategies, such as ‘Learn how
to estimate reasonable portion sizes’, were not in-
tuitively obvious and required a visual example or
more space than was available on the primary screen.
To address this, we created ‘More Information’ icons
associated with each such strategy. Clicking on the
icon activated a ‘pop-up’ window, which included
a graphic or photograph, and provided a more de-
tailed text explanation.
The second major revision involved substantial
modifications to the dietary change barriers and
strategies used in the program. This revision in-
cluded changes in the content, wording and reduc-
tion in the number of barriers and strategies
presented so that they would fit on a single screen.
These changes were based on the analyses of selec-
tion frequency by women in prior projects, com-
ments from pilot participants and inclusion of
items relevant to African-American populations.
The final major revision had to do with the action
plan that summarized user choices throughout the
program. The primary change involved creating
a more efficient and user-friendly process for allow-
ing participants to review their initial plan on-screen
and to make revisions to the plan. The original pro-
cess involved assessing the user’s self-efficacy, and
if this was <7 on a 10-point scale [18], leading the
user through a series of time-consuming steps to see
if they wished to revise key goals, barriers or strat-
egies. The final process simplified this sequence by
asking users whether they wished to make any
changes to their initial plan, and if so, allowing them
to simply click on the action plan element that they
wished to revise (Fig. 3).
Measures
The primary outcomes for the overall study were
percent of calories from fat, caloric intake and serv-
ings of fruit and vegetables as assessed by food
frequency questionnaires. Measures relevant to this
paper were measures of intervention implementa-
tion and user satisfaction.
Implementation was assessed by automated
records of computer use including time to complete
sessions and options selected. Records of comple-
tion of telephone calls were obtained from auto-
mated data from the IVR system for automated
calls and interventionist records for live counselor
calls.
User satisfaction was assessed by questionnaire
at a 3-month follow-up. Participants were asked to
rate the helpfulness of the six-program components
in Table I on 6-point Likert scales ranging from 1 =
not helpful to 6 = extremely helpful. Finally, par-
ticipants were asked to rate their sati sfaction with
the overall program on a similar 6-point scale.
Analysis
Most results were descriptive, involving means
and standard deviations or percent of participants.
Between-condition comparisons were made on the
helpfulness and satisfaction ratings using analysis
of variance with Tukey’s post-hoc comparisons
where there was a significant overall F value.
Results
Implementation
Almost all participants completed both the interac-
tive CD-ROM office sessions (100% completed
R. E. Glasgow et al.
468
session one, 91% session two). Each session aver-
aged a total of 40- to 50-min duration, approxi-
mately 30 of which were spent on the computer.
Completion of the follow-up phone calls was more
variable. The program was evaluated both in an
entirely automated condition and when combined
with a health counselor. Live phone callers were
extremely successful in reaching participants, with
completion rates ranging from 99% for the first call
to 89% for the third call. Calls averaged 4–5 min.
The automated IVR system was somewhat less suc-
cessful in completing the calls, with rates ranging
from 72% for the first call to 68% for the third call.
Relatively few participants used the write-in op-
tion provided on the CD-ROM. Across the list of
strategies for reducing dietary fat intake and in-
creasing fruit and vegetable intake, users wrote in
their own strategies from 2% to 6% of the time.
User satisfaction
Users rated the various aspects of the WISE
CHOICES progra m as fairly helpful/fairly satisfied.
On the 6-point scale, with 1 = ‘not helpful’ and
6 = ‘extremely helpful’, most ratings were between
four and five. As can be seen in Table I, there
were significant differences among the various con-
ditions of use on all seven of the rating scales.
Tukey’s post-hoc comparisons revealed that on
helpfulness/satisfaction items on which in-person,
automated and combined conditions could reason-
ably be compared, the in-person and combined con-
ditions were rated slightly but non-significantly
higher than the totally automated condition. The
one exception was that follow-up phone calls were
rated as less helpful in the automated condition than
in in-person or combined conditions. In addition,
participants in both computer-delivered or assisted
conditions rated their programs as significantly more
helpful than the control condition (a computer-
administered physical activity change program) on
six of the seven ratings. Users in the entirely auto-
mated condition were moderately satisfied overall
(M = 3.9) and found the action plan (M =4.4),
printed materials (M = 4.7) and personalized feed-
back received (M = 4.4) helpful, ratings equivalent
to those of participants in the in-person condition
on these items.
Discussion
This report demonstrates that a relatively complex,
fully automated dietary behavior change program
that integrates multiple interactive technologies
can be developed and successfully implemented
within the context of a real-world health delivery
system. Possibly because of the prior experience of
the collaborators in both dietary change and inter-
active technology projects, the development pro-
cess went relatively smoothly. One key to having
an attractive, easy-to-use and understandable end
product was allowing adequate time to pilot the
initial version of the program, to fully test the
Table I. Helpfulness and satisfaction ratings by condition
Item Automated
mean (SD)
Combined
mean (SD)
In-person
mean (SD)
Exercise control
mean (SD)
Video/computer information and recommendations 4.2 (1.4)
A
4.3 (1.2)
A
3.2 (2.0)
B
3.4 (1.4)
B
Project staff 4.6 (1.3)
A
4.9 (1.1)
A
4.9 (1.2)
A
4.0 (1.4)
B
Phone calls 3.2 (1.7)
B
3.8 (1.6)
A
4.0 (1.5)
A
3.0 (1.6)
B
Printed materials 4.7 (1.3)
A
4.9 (1.1)
A
4.5 (1.3)
A
3.7 (1.4)
B
Personalized feedback 4.4 (1.5)
A
4.8 (1.2)
A
4.4 (1.3)
A
3.6 (1.5)
B
Action plan 4.3 (1.5)
A
4.4 (1.3)
A
4.4 (1.3)
A
3.8 (1.4)
B
Overall satisfaction 3.9 (1.0)
A
4.2 (0.8)
A
4.2 (0.9)
A
3.5 (1.1)
B
Conditions having different superscript letters are significantly different from each other. Those sharing the same superscript are not
different from each, based upon Tukey’s post-hoc follow-up tests. Ratings on a 1–6 scale with 1 = ‘not helpful’, 4 = between
‘moderately’ and ‘extremely helpful’ and 6 = ‘extremely helpful’. SD = standard deviation.
Multi-modality dietary change program
469
various data exchange interfaces and to make mod-
ifications based upon pilot feedback.
Both the automated and staff-assisted conditions
were consistently implemented and rated as helpful
by participants. The IVR aspects of the program were
delivered somewhat less consistently and rated some-
what lower than the CD-ROM program components,
possibly reflecting our team’s greater experience with
CD-ROM modalities. If later outcome data demon-
strate that the automated program is effective in pro-
ducing dietary changes, it appears that the WISE
CHOICES intervention may be a scalable, relatively
low-cost method of delivering behavior change serv-
ices relative to in-person counseling. Obviously, fu-
ture research is needed to document program
effectiveness at both short-term and longer term
follow-ups and the intervention costs.
These preliminary data suggest that it may be
possible to fully automate health behavior change
interventions. Our implementation and user satis-
faction results suggest that CD-ROM elements
worked very well, but that the IVR aspects of the
program could be enhanced or possibly that some
follow-up activities should be conducted by staff to
enhance the connect ion of users to the clinical set-
ting offering the program.
Other lessons learned include the advantage of
delivering health education information and behav-
ioral strategies via multiple redundant channels
(e.g. text, video models and voice-over narration)
to provide benefit for a wide range of users. The use
of a central database to coordinate various interven-
tion modalities also worked well and proved to be
both robust and secure. In WISE CHOICES, we did
not allow users to select different modalities, but
rather decided upon the best technology for each
intervention purpose (e.g. initial motivation, late r
follow-up, active problem-solving, goal monitor-
ing). Future research may want to experiment with
providing users their choice of modalities (e.g. Web
versus IVR versus in-person) for components such
as follow-up contact.
The satisfaction data suggest that the menu of
strategies provi ded were seen as relevant to this
target population. Although used infrequently, the
write-in option may be important because having
the option of further personalizing one’s action
plan—regardless of whether it is actually used—
may contribute to perceptions of relevance and
control. Unlike some interactive technology-based
programs that completely tailor user strategies, we
attempted to balance theoretical and experience-
based suggestions wi th provision of choices for
users. We feel that this element of user-tailoring
adds value to the program.
The various technologies used in WISE
CHOICES all had strong ‘reach’ [19], but the
CD-ROM component did require participants to
come to a clinic to complete the two action planning
sessions. We chose to use CD-ROM rather than In-
ternet because we did not want to limit participation
to health plan members who had high-speed com-
puter access, but future investigations may want to
investigate mailed DVD or Internet-delivery options,
especially as part of patient portals offered by an in-
creasing number of health plans and organizations
such as the Veterans Administration [20, 21].
In conclusion, we encourage future projects to
explore mul ti-media programs that combine differ-
ent technologies in creative and integrated ways,
rather than relying on a single technology/modality
to carry the entire weight of the intervention [22].
Other future directions include testing different pro-
gram variations to identify the optimal and most
cost-effective use of human contact and the impact
of interactive technology programs on the behavior
of different patient subgroups (e.g. across levels of
education, race/ethnicity computer experience and
health literacy).
Funding
National Cancer Institute (grant no. RO1 Ca
098496).
Acknowledgements
Appreciation is expressed to Amanda Petrik, MS,
for her assistance with data analyses. InterVision
Media, which was the primary developer of the
CD-ROM portion of this program, received
R. E. Glasgow et al.
470
a 2007 Horizon Interactive Award for excellence in
interactive media production for this project.
Conflict of interest statement
None declared.
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Received on December 22, 2006; accepted on July 3, 2008
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    • "Collectively, these five dimensions provide necessary information to shift our current system of prenatal care towards an improved system of care. Since the original RE-AIM paper in 1999, there have been approximately 100 publications on RE-AIM by a variety of authors in fields as diverse as aging [25], cancer screening [26], dietary change [27], physical activity [28], health policy [29], environmental change [30], chronic illness self-management [31], well-child care [32], eHealth [33], worksite health promotion [34], women's health [35], smoking cessation [36], and practice-based research [37]. The RE-AIM framework provides valuable framework for evaluating the translation of health care innovations such as CP into clinical settings [38, 39]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Centering Pregnancy (CP) is an effective method of delivering prenatal care, yet providers have been slow to adopt the CP model. Our main hypothesis is that a site's adoption of CP is contingent upon knowledge of the CP, characteristics health care personnel, anticipated patient impact, and system readiness. Methods: Using a matched, pretest-posttest, observational design, 223 people completed pretest and posttest surveys. Our analysis included the effect of the seminar on the groups' knowledge of CP essential elements, barriers to prenatal care, and perceived value of CP to the patients and to the system of care. Results: Before the CP Seminar only 34% of respondents were aware of the model, while knowledge significantly after the Seminar. The three greatest improvements were in understanding that the group is conducted in a circle, the health assessment occurs in the group space, and a facilitative leadership style is used. Child care, transportation, and language issues were the top three barriers. The greatest improvements reported for patients included improvements in timeliness, patient-centeredness and efficiency, although readiness for adoption was influenced by costs, resources, and expertise. Discussion: Readiness to adopt CP will require support for the start-up and sustainability of this model.
    Full-text · Article · Feb 2014
    • "Despite having offered guidelines for writing goals, the authors concluded that participants needed more assistance with goal-setting in order to facilitate behavior change. Goal-setting interventions with no face-to-face interaction need to provide support for setting quality goals either through detailed instructions or through a guided-goal setting tool [18,20,21] . Finally, qualitative research could help to identify both important program processes from the participants' perspectives and alternative ways of assessing both the quantity and quality of participation with communitybased interventions [22]. "
    [Show abstract] [Hide abstract] ABSTRACT: Few lifestyle interventions have successfully prevented excessive gestational weight gain. Understanding the program processes through which successful interventions achieve outcomes is important for the design of effective programs. The objective of this study was to evaluate the effect of the quantity and quality of participation in a healthy lifestyle intervention on risk of excessive gestational weight gain. Pregnant women (N = 179) received five newsletters about weight, nutrition, and exercise plus postcards on which they were asked to set related goals and return to investigators. The quantity of participation (dose) was defined as low for returning few or some vs. high for many postcards (N = 89, 49.7%). Quality of participation was low for setting few vs. high for some or many appropriate goals (N = 92, 51.4%). Fisher's exact tests and multivariate logistic regression were used to analyze the effect of participation variables on the proportion with excessive weight gain. Quantity and quality of participation alone were each not significantly associated with excessive gestational weight gain, while quality of participation among those with high-levels of participation approached significance (p = 0.07). The odds of gaining excessively was decreased when women had both a high quantity and quality of participation (OR = 0.04, 95% CI = 0.005, 0.30). Both quantity and quality of participation are important program process measures in evaluations of lifestyle interventions to promote healthy weight gain during pregnancy.
    Full-text · Article · Feb 2013
    • "This stage also includes usability testing with subcultural group members to identify and address issues arising from technological components of the intervention (e.g., interactive voice response systems, touch-screen computer kiosks, web-based programs, smart phones; Zimmerman, Akerelrea, Buller, Hau, & Leblanc, 2003). The " think aloud " method, in which participants verbalize their thoughts as they interact with technology procedures, can be useful (Glasgow et al., 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To reduce health disparities, behavioral health interventions must reach subcultural groups and demonstrate effectiveness in improving their health behaviors and outcomes. One approach to developing such health interventions is to culturally adapt original evidence-based interventions. The goals of the article are to (a) describe consensus on the stages involved in developing cultural adaptations, (b) identify common elements in cultural adaptations, (c) examine evidence on the effectiveness of culturally enhanced interventions for various health conditions, and (d) pose questions for future research. Method: Influential literature from the past decade was examined to identify points of consensus. Results: There is agreement that cultural adaptation can be organized into 5 stages: information gathering, preliminary design, preliminary testing, refinement, and final trial. With few exceptions, reviews of several health conditions (e.g., AIDS, asthma, diabetes) concluded that culturally enhanced interventions are more effective in improving health outcomes than usual care or other control conditions. Conclusions: Progress has been made in establishing methods for conducting cultural adaptations and providing evidence of their effectiveness. Future research should include evaluations of cultural adaptations developed in stages, tests to determine the effectiveness of cultural adaptations relative to the original versions, and studies that advance our understanding of cultural constructs' contributions to intervention engagement and efficacy.
    Full-text · Article · Jan 2012
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