Adaptive e-learning to improve dietary behaviour: A systematic review and cost-effectiveness analysis

Article (PDF Available) · October 2011with79 Reads
DOI: 10.3310/hta15370 · Source: PubMed
UK public health policy strongly advocates dietary change for the improvement of population health and emphasises the importance of individual empowerment to improve health. A new and evolving area in the promotion of dietary behavioural change is 'e-learning', the use of interactive electronic media to facilitate teaching and learning on a range of issues including health. The high level of accessibility, combined with emerging advances in computer processing power, data transmission and data storage, makes interactive e-learning a potentially powerful and cost-effective medium for improving dietary behaviour. This review aims to assess the effectiveness and cost-effectiveness of adaptive e-learning interventions for dietary behaviour change, and also to explore potential psychological mechanisms of action and components of effective interventions. Electronic bibliographic databases (Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Dissertation Abstracts, EMBASE, Education Resources Information Center, Global Health, Health Economic Evaluations Database, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science) were searched for the period January 1990 to November 2009. Reference lists of included studies and previous reviews were also screened; authors were contacted and trial registers were searched. Studies were included if they were randomised controlled trials, involving participants aged ≥ 13 years, which evaluated the effectiveness of interactive software programs for improving dietary behaviour. Primary outcomes were measures of dietary behaviours, including estimated intakes or changes in intake of energy, nutrients, dietary fibre, foods or food groups. Secondary outcome measures were clinical outcomes such as anthropometry or blood biochemistry. Psychological mediators of dietary behaviour change were also investigated. Two review authors independently screened results and extracted data from included studies, with any discrepancies settled by a third author. Where studies reported the same outcome, the results were pooled using a random-effects model, with weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated. Cost-effectiveness was assessed in two ways: through a systematic literature review and by building a de novo decision model to assess the cost-effectiveness of a 'generic' e-learning device compared with dietary advice delivered by a health-care professional. A total of 36,379 titles were initially identified by the electronic searches, of which 43 studies were eligible for inclusion in the review. All e-learning interventions were delivered in high-income countries. The most commonly used behavioural change techniques reported to have been used were goal setting; feedback on performance; information on consequences of behaviour in general; barrier identification/problem solving; prompting self-monitoring of behaviour; and instruction on how to perform the behaviour. There was substantial heterogeneity in the estimates of effect. E-learning interventions were associated with a WMD of +0.24 (95% CI 0.04 to 0.44) servings of fruit and vegetables per day; -0.78 g (95% CI -2.5 g to 0.95 g) total fat consumed per day; -0.24 g (95% CI -1.44 g to 0.96 g) saturated fat intake per day; -1.4% (95% CI -2.5% to -0.3%) of total energy consumed from fat per day; +1.45 g (95% CI -0.02 g to 2.92 g) dietary fibre per day; +4 kcal (95% CI -85 kcal to 93 kcal) daily energy intake; -0.1 kg/m2 (95% CI -0.7 kg/m2 to 0.4 kg/m2) change in body mass index. The base-case results from the E-Learning Economic Evaluation Model suggested that the incremental cost-effectiveness ratio was approximately £102,112 per quality-adjusted life-year (QALY). Expected value of perfect information (EVPI) analysis showed that although the individual-level EVPI was arguably negligible, the population-level value was between £37M and £170M at a willingness to pay of £20,000-30,000 per additional QALY. The limitations of this review include potential reporting bias, incomplete retrieval of completed research studies and data extraction errors. The current clinical and economic evidence base suggests that e-learning devices designed to promote dietary behaviour change will not produce clinically significant changes in dietary behaviour and are at least as expensive as other individual behaviour change interventions. FUTURE WORK RECOMMENDATIONS: Despite the relatively high EVPI results from the cost-effectiveness modelling, further clinical trials of individual e-learning interventions should not be undertaken until theoretically informed work that addresses the question of which characteristics of the target population, target behaviour, content and delivery of the intervention are likely to lead to positive results, is completed. The National Institute for Health Research Health Technology Assessment programme.
    • "A recent systematic review of adaptive e-learning interventions for dietary behaviour change Harris and co-authors [59] reported that only one-third of the interventions that state to be theory-based measure theoretically predicted mediators; without this, the statement that the intervention is theory-based has limited scientific value. There are three main benefits of applying theory/theoretical framework . "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Food, nutrition and health policy makers are poised with two pertinent issues more than any other: obesity and climate change. Consumer research has focused primarily on specific areas of sustainable food, such as organic food, local or traditional food, meat substitution and/or reduction. More holistic view of sustainable healthy eating behaviour has received less attention, albeit that more research is emerging in this area. Methods/design: This study protocol that aims to investigate young consumers' attitudes and behaviour towards sustainable and healthy eating by applying a multidisciplinary approach, taking into account economical, marketing, public health and environmental related issues. In order to achieve this goal, consumers' reactions on interactive tailored informational messages about sustainable from social, environmental and economical point of view, as well as healthy eating behaviour in a group of young adults will be investigated using randomized controlled trial. To undertake the objective, the empirical research is divided into three studies: 1) Qualitative longitudinal research to explore openness to adopting sustainable healthy eating behaviour; 2) Qualitative research with the objective to develop a sustainable healthy eating behaviour index; and 3) Randomised controlled trial to describe consumers' reactions on interactive tailored messages about sustainable healthy eating in young consumers. Discussion: To our knowledge, this is the first randomised controlled trial to test the young adults reactions to interactive tailor made messages on sustainable healthy eating using mobile smartphone app. Mobile applications designed to deliver intervention offer new possibilities to influence young adults behaviour in relation to diet and sustainability. Therefore, the study will provide valuable insights into drivers of change towards more environmentally sustainable and healthy eating behaviours. Trial registration: NCT02776410 registered May 16, 2016.
    Full-text · Article · Dec 2016
    • "For example, web-based interventions targeting smoking cessation [25] or increasing physical activity [26, 27] are effective in promoting, at least in the short-term, the desired change in behaviour. In other areas, however, the evidence is more equivocal, e.g. in reducing alcohol consumption [28] or changing dietary patterns [29]. There are similarly positive and negative findings where multiple behaviours are targeted303132. "
    [Show abstract] [Hide abstract] ABSTRACT: Dementia prevalence is increasing as populations live longer, with no cure and the costs of caring exceeding many other conditions. There is increasing evidence for modifiable risk factors which, if addressed in mid-life, can reduce the risk of developing dementia in later life. These include physical inactivity, low cognitive activity, mid-life obesity, high blood pressure, and high cholesterol. This study aims to assess the acceptability and feasibility and impact of giving those in mid-life, aged between 40 and 60 years, an individualised dementia risk modification score and profile and access to personalised on-line health information and goal setting in order to support the behaviour change required to reduce such dementia risk. A secondary aim is to understand participants’ and practitioners’ views of dementia prevention and explore the acceptability and integration of the Innovative Midlife Intervention for Dementia Deterrence (In-MINDD) intervention into daily life and routine practice. In-MINDD is a multi-centre, primary care-based, single-blinded randomised controlled feasibility trial currently being conducted in four European countries (France, Ireland, the Netherlands and the UK). Participants are being recruited from participating general practices. Inclusion criteria will include age between 40 and 60 years; at least one modifiable risk factor for dementia risk (including diabetes, hypertension, obesity, renal dysfunction, current smoker, raised cholesterol, coronary heart disease, current or previous history of depression, self-reported sedentary lifestyle, and self-reported low cognitive activity) access to the Internet. Primary outcome measure will be a change in dementia risk modification score over the timescale of the trial (6 months). A qualitative process evaluation will interview a sample of participants and practitioners about their views on the acceptability and feasibility of the trial and the links between modifiable risk factors and dementia prevention. This work will be underpinned by Normalisation Process Theory. This study will explore the feasibility and acceptability of a risk profiler and on-line support environment to help individuals in mid-life assess their risk of developing dementia in later life and to take steps to alleviate that risk by tackling health-related behaviour change. Testing the intervention in a robust and theoretically informed manner will inform the development of a future, full-scale randomised controlled trial. Trial registration ISRCTN Registry: ISRCTN 98553005 (DOI: 10.1186/ISRCTN98553005).
    Full-text · Article · Dec 2015
    • "Until now, adaptation in the medical education domain has been mainly based on the enhancement of tutoring and cooperative aspects (Legg et al., 2009), adapting courses to learner's cognitive and learning styles (Cook, 2012 ), or adapting information to students' knowledge (Pagesy et al., 2002; Romero et al., 2006; Cook et al., 2008b). Contrasting effects were observed with the use of adaptive systems: a systematic review could not find any advantage of adaptive methods over traditionally based educational programs in changing dietary behavior (Harris et al., 2011), a randomized controlled trial showed instead a positive effect in efficiency for an adaptive system taking into account the learner's prior knowledge (Cook et al., 2009). Lexical competence is a possible target for adaptivity. "
    [Show abstract] [Hide abstract] ABSTRACT: Distance learning is used in medical education, even if some recent meta-analyses indicated that it is no more effective than traditional methods. To exploit the technological capabilities, adaptive distance learning systems aim to bridge the gap between the educational offer and the learner’s need. A decrease of lexical competence has been noted in many western countries, so lexical competence could be a possible target for adaptation. The “Adaptive message learning” project (Am-learning) is aimed at designing and implementing an adaptive e-learning system, driven by lexical competence. The goal of the project is to modulate texts according to the estimated skill of learners, to allow a better comprehension. LexMeter is the first of the four modules of the Am-learning system. It outlines an initial profile of the learner’s lexical competence and can also produce cloze tests, a test based on a completion task. A validation test of LexMeter was run on 443 medical students of the first, third, and sixth year at the University “Sapienza” of Rome. Six cloze tests were automatically produced, with 10 gaps each. The tests were different for each year and with varying levels of difficulty. A last cloze test was manually created as a control. The difference of the mean score between the easy tests and the tests with a medium level of difficulty was statistically significant for the third year students but not for first and sixth year. The score of the automatically generated tests showed a slight but significant correlation with the control test. The reliability (Cronbach alpha) of the different tests fluctuated under and above 0.60, as an acceptable level. In fact, classical item analysis revealed that the tests were on the average too simple. Lexical competence is a relevant outcome and its assessment allows an early detection of students at risk. Cloze tests can also be used to assess specific knowledge of technical jargon and to train reasoning skill.
    Full-text · Article · Feb 2015
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