Over the past decade there has been an increase in internet based health behaviour interventions. These are often described to as “web-based”, “online” or “e-health” interventions. This is a growing area of research with potential for innovative delivery methods of multiple health behaviour change health education and intervention strategies. There are a number of potential benefits of internet based interventions including: the capacity to reach a large number of people (Marcus, Nigg, Riebe, & Forsyth, 2000); relatively low cost of delivering intervention (Lewis, Williams, Neighbors, Jakicic, & Marcus, 2010); flexibility; convenience for participants and health providers, and; the ability to reach people in rural and remote
internet access with 96% of households with children under 15 years of age having access (Australian Bureau of Statistics, 2014c). Not surprisingly, younger people are the highest users of the internet, but in all age groups internet use is high; 94% of adults aged 35 – 44 years; 89% of adults aged 45 – 54 years, and 78% of adults aged 55 – 64 years old.
A recent systematic review (Kohl, Crutzen, & de Vries, 2013) of online prevention aimed at lifestyle behaviours, identified 41 eligible systematic reviews published between 2005 and 2012. Reviews were analysed in terms of reach, effectiveness and use. Kohl and colleagues found that the interventions were largely targeted at weight loss behaviour with overall effect small, variable and not sustained. They concluded that the determinants of effective interventions are not clear and that most participants are female, highly educated, white and living in high-income countries. One of the main issues with online interventions is low use of the intervention with more research needed to identify effective elements of interventions and long term effectiveness (Kohl et al., 2013).
A recently published comprehensive review of internet based physical activity interventions for adults, identified 72 studies published between 2001 and 2012 (Joseph et al., 2014). Studies were conducted in eleven countries, with most being in the United States (n = 49) followed by Australia (n = 7). The average age of the pooled 24 966 participants was 43.3 years (SD 10.8) with 65.9% being female; seven of the 72 studies focused only on women. Interventions ranged from 2 weeks to 13 months, with the median being 12 weeks; average attrition was calculated to be 22.3% (SD 14.5). Of the 72 studies reviewed, 35 targeted physical activity alone with the remaining 35 studies targeting multiple behaviours including weight loss, diet/nutrition, self-management of cardiovascular risk factors and type 2 diabetes,
weight control and arthritis self-management. Overall, 60% of studies reported significant improvements in physical activity at the end of the intervention (Joseph et al., 2014). Results of a meta-analysis of internet delivered interventions to increase physical activity also indicate that internet delivered interventions produce positive changes in physical activity although average effect size was small d = .14 (p < .01) (Davies, Spence, Vandelanotte, Caperchione, & Mummery, 2012).
Consistent with these studies, a number of internet based physical activity interventions designed specifically for women have shown positive results. The web based ‘Choose to Move’ study, evaluated a 12 week interactive web-based program in 3,796 adult American women, 53.3% of whom were aged 45 to 64 years (Lieber et al., 2012). In 892 participants who completed the final evaluation there was significant positive changes in physical activity, stage of readiness for change, body mass index and composite scores for energy and well-being. In another study targeting women, healthy middle aged women participated in an internet plus email randomised 10 week intervention to promote physical activity (N = 156) (Dunton &
Robertson, 2008). Compared to control participants, those in the intervention group reported significant increases in walking and moderate to vigorous physical activity with an increased proportion of participants in action or maintenance stage of change. There were no significant differences in perceived physical activity benefits and barriers or self-efficacy for exercise (Dunton & Robertson, 2008).
Internet delivered interventions targeting multiple health behaviours are much fewer in number. For example, Cook and colleagues (2007) compared a print based versus web-based multimedia workplace health promotion program (Health Connection) targeting diet, stress and physical activity in 419 American adults (70%
female). Both groups had significant improvements in all health behaviours, with the
web-based program being more effective in the areas of diet and nutrition. Two large studies conducted in the Netherlands provide further evidence that internet delivered MHBC interventions may be effective in changing behaviour. The first of these tested the efficacy of a one month intervention targeting saturated fat intake, physical activity and smoking cessation in 2,159 adults (54% female) (Oenema et al., 2008).
Results of this study were positive with the intervention resulting in a significantly lower saturated fat intake and higher likelihood of meeting PA guidelines; with no significant effect for self-reported smoking status. More recently, the
‘myHealthyBehaviour’ study (Schulz et al., 2014) compared sequential and simultaneous delivery modes of a MHBC intervention for physical activity, fruit and vegetable consumption, alcohol intake and smoking in 5,055 adults with an average age of 44 years old (47.3% female). Compared to the control group, participants in both intervention groups had small self-reported behavioural changes in for all five lifestyle behaviours. The sequential intervention had the most significant effects over 12 months, while the simultaneous intervention was most effective after 24 months (Schulz et al., 2014).
There have been a number of Australian studies evaluating the efficacy of internet delivered interventions for health behaviour change in adults, with most targeting single health behaviours especially physical activity (Ferney, Marshall, Eakin, & Owen, 2009; Marshall, Leslie, Bauman, Marcus, & Owen, 2003; Steele, Mummery, & Dwyer, 2007; Vandelanotte, Duncan, Plotnikoff, & Mummery, 2012).
Three of these studies investigated different intervention delivery modes, finding no significant differences in print versus website (Marshall et al., 2003), internet only/internet mediated versus face to face (Steele et al., 2007) or text based versus video based or combined modes (Vandelanotte et al., 2012). All of these studies
reported increased physical activity in all groups post intervention. One study was identified that trialled a low intensity web-based multiple health behaviour intervention that focused on dietary behaviours, smoking, alcohol intake, physical activity and BMI (Parekh, King, Boyle, & Vandelanotte, 2014). Participants in this study (N = 4676) were recruited through general practitioners and randomised to one of four study groups: intervention with single contact; intervention with dual contact;
control with single contact and control with dual contact. At 12 months, both single and dual contact groups had a significant improvement in dietary behaviours and alcohol consumption; with no significant change in physical activity, smoking or body weight.
The current ‘Women’s Wellness Program’ study, to which this PhD study is linked, has revised and adapted a previous version of the intervention (Anderson &
Graham, 2007) for web-based delivery. This novel community based intervention is tailored for midlife women and targets multiple health behaviours including: aerobic and strength exercise, healthy eating, smoking, alcohol consumption, stress management, sleep, menopausal symptoms, weight management and health screening behaviours. The intervention incorporates a number of behaviour change strategies including health information, goal setting, self-monitoring, social support and health coaching by Registered Nurses. The current study compares three intervention delivery methods: 1) independent online; b) face to face supported, and;
3) online supported. The primary outcome measure for the parent study is BMI, with secondary outcome measures of health behaviours and menopausal symptoms. The study method and intervention is described in greater detail in Chapters 3 and 4.