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Expanding the Reach and Impact of
Consumer e-Health Tools

June 2006

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< Appendix 3 (Part 1) Appendix 3 (Part 3) >

Appendix 3. Chapter 3 Literature Review Summary (Part 2)

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Table Reference Number/Authors/
Text Section
Sample Health Topic Area/
Locus of Use/
Description of the Tool Overview Measures Outcomes
Randomized Controlled Trials
12. Glasgow RE, Toobert DJ. Brief, computer-assisted diabetes dietary self-management counseling: effects on behavior, physiologic outcomes, and quality of life. Medical Care 2000;38:1062-73. [Applicability] 320 adult type 2 diabetes patients, mean age 60; 56% female, >89% white, more than one-half had attended at least some college Diabetes: clinic-based computer program Computer program designed to assess dietary patterns, barriers, and supports; then provide tailored feedback and a dietary fat reduction goal All received one computer interaction at baseline and at 3 months. At 3 months, divided into four groups: basic condition (above).Telephone Followup (TF) also received three to four telephone support/problem-solving calls between 3 to 6 months. Community Resources (CR) received information about community resources and newsletters between 3 to 6 months. Combined received all. Used RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate. Other measures: dietary behavioral outcomes, physiological measures, quality of life, patient satisfaction measures, self-efficacy for dietary change, and use of community resources The basic intervention allowed showed improvements in eating habits, especially in reducing fat intake; modest improvements in cholesterol and lipid ratios, and small reduction in HbA1c levels. No changes in quality of life or satisfaction scales. Reach=76% of eligible participated. Possible that the TF and CR interventions not strong enough to produce greater change. Adoption=100% of clinics approached adopted this technology.
13. Glasgow RE, Boles S, McKay G, Feil E, Barrera M. The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results. Preventive Medicine 2003;36;410-19. [Overview, Acceptability, Applicability] 320 adult type 2 diabetes patients, mean age 59, mostly novice computer users, recruited from medical practices, 83% limited or no Internet experience Diabetes: home computer with Internet Diabetes Web site: All groups had online access to articles about diabetes information. The Peer Support (PS) group also had access to peer support, professionally monitored forum, and electronic newsletters. The Tailored Self-Management (TSM) group also had access to online professional for advice and support two times per week, feedback on intake and collaborative goal setting, tailored strategies to overcome barriers, dietitian question and answer conferences, and blood glucose and dietary databases and graphical feedback. These results were a 10-month followup study. All received home computers for 10 months and were randomized into one of the three groups. Dietary, behavioral, biological, and psychosocial outcomes; implementation and process measures Significant improvements from baseline in all groups on the majority of outcomes; significant changes in fat and fiber intake, psychosocial outcomes, modest for biological outcomes; PS condition showed greater increase in support measure. No differential effect of TSM condition. Decline in usage of site over study period. PS group showed most logins, followed by TSM, the basic condition. Reach=62% eligibles. Adoption=100% of clinics, 88% of doctors
14. Green M, Peterson S, Baker M, Harper G, Friedman L, Rubinstein W, et al. Effect of a computer-based decision aid on knowledge, perceptions, and intentions about genetic testing for breast cancer susceptibility: a randomized controlled trial. Journal of the American Medical Association 2004;292:442-52. [Acceptability, Applicability] 211 women with personal or family histories of breast cancer from six U.S. medical centers; 74% <50 years old, 56% college educated, 93% white, >63% used computer sometimes or often Cancer: clinic-based computer program Breast Cancer Risk and Genetic Testing Program: interactive CD-ROM designed to help women make informed decisions about genetic testing. Contains information about who is at risk, how genes affect risk, and pros and cons of testing. Program is self-paced and user-driven. Control group: has standard genetic counseling appointment. Intervention group: interacts with computer program before genetic counseling appointment. Knowledge, perceived risk, intention to undergo genetic testing, satisfaction with decision, state of anxiety, satisfaction with intervention Both groups increased knowledge from baseline level with significant increase in knowledge seen in low-risk women in intervention group as compared to low-risk controls. Greater benefit in women with less education. Overall absolute risk perception high at baseline and reduced in both groups after intervention with greatest reduction in low-risk women in control group. Significant reduction in intention to get testing in low-risk women in both groups. Actual testing did not differ by group. Both groups satisfied with decision. Mean anxiety within normal limits in both groups. Both groups liked interventions; more in computer group felt it made good use of their time.
15. Gustafson D, Hawkin R, Pingree S, McTavish F, Arora N, Mendenhall J, et al. Effect of computer support on younger women with breast cancer. Journal of General Internal Medicine 2001;16:435-45. [Overview, Applicability, Key Findings] 246 newly diagnosed breast cancer patients under age 60; 74% white, 22.4% African American, 3.6% other persons of color Cancer: home computer connected to central server Comprehensive Health Enhancement Support System (CHESS): contains 11 tools that provide information, decisionmaking tools, and support services Control group: received a breast cancer book. Intervention group: received CHESS. System usage, patient outcomes, social support, information needs, participation in health care, quality of life Used CHESS 155 times/26 weeks of study. Caucasian women spent more time using discussion group, women of color spent more time using the decision services. Outcomes at 2 months: CHESS group higher on information competence, level of comfort with participation in health care, confidence in their doctor. No change in quality-of-life measures. After 5 months, CHESS group higher on social support, information competence. Participation in healthcare measures no longer significant. No change in quality-of-life measures at either point. Interaction effects show greater benefits for women of color, uninsured, less educated.
16. Harvey-Berino J, Pintauro SJ, Gold EC. The feasibility of using Internet support for the maintenance of weight loss. Behavior Modification 2002;26:103-16. [Acceptability, Applicability] 46 overweight adults recruited from newspaper ads; 80.4% female, mean age 46.3, 91% at least some college, predominately white Weight loss: home computer with Internet The Internet-based maintenance condition consisted of biweekly chats, self-monitoring records, video clips of the therapist introducing topic for discussion in chats, e-mail contact from therapist, message boards, and unstructured chats All participated in 15-week in-person behavioral weight control intervention and then randomized into three maintenance conditions: in-person therapist-led, Internet therapist-led, and no treatment control. Both conditions met biweekly for 22 weeks using same content. Satisfaction, attendance, weight loss In-person therapist-led participants were more satisfied and more likely to attend meetings, but no difference between attrition, submission of self-monitoring data, or peer support contacts between intervention groups. No difference in weight loss between intervention groups (may be due to small sample size, inadequate computer systems that did not allow users to access all features).
17. Irvine AB, Ary DV, Grove DA, Gilfillan-Morton L. The effectiveness of an interactive multimedia program to influence eating habits. Health Education Research 2004;19:290-305. [Acceptability, Applicability] 229 subjects recruited from a hospital system in Colorado and 288 subjects from an international corporation in Illinois; 85% Caucasian, 73% female, mean age 43, almost 90% college educated Nutrition: work site computer with interactive multimedia program This program focused on improving nutrition behaviors. It used video narrators targeted to the users’ demographic to provide guidance and support and videos of role models and testimonials to encourage positive behavior change and increase self-efficacy. Program was tailored by gender, content interests, race, and age. Main menu choices included eating strategies, recipes, barriers to healthy eating, assessment of eating habits, information center, and quick tips. Participants from both sites matched on demographics. Pair then randomized into intervention or wait-list control. Data collected from both groups after intervention and then after wait-list control group used the intervention. Fat eating habits and behaviors, fruit and vegetable consumption, healthy eating behaviors, stage of change, attitude toward healthy eating, intention, and self-efficacy Spent an average of 35.75 and 32.09 minutes during the first session. Only 14.7% and 12.07% returned for a second visit, and only 7.5 and 1.7 returned a third time. Most users viewed adding fruit, vegetables, and fiber, then making low-fat food choices. Statistically significant differences found in fat eating habits, fruit and vegetable consumption, program behaviors, self-efficacy, attitude, intent to decrease fat, and stage of change between control and intervention at 1 month, between wait-list control after intervention. Changes in intervention group maintained 1 month after.
18. Krishna S, Francisco B, Balas A, Konig P, Graff G, Madsen R. Internet-enabled interactive multimedia asthma education program: a randomized trial. Pediatrics 2003;111:503-10. [Applicability, Cost Savings] 228 children with asthma and their caregivers, younger than age 18, with asthma diagnosis seen in a pediatric pulmonary clinic. Caregivers– 88% females, 90% white, 6% African Americans, 4% of other ethnic origins, 44% had high school education, 37% had 1 or more years of college, 9% had junior high school or less Asthma: clinic-based computer program IMPACT Asthma Kids CD consists of vignettes about asthma, environmental triggers, quick-relief and control medicines, and strategies to control and manage asthma. It has animated lessons, real-life scenarios, graphic templates. The program tracked educational progress of each child and generated reports re symptom level and medication use. Control group: traditional asthma education group. Intervention group: received traditional and additional education through computer. Implemented more than three clinic visits. Knowledge, health outcomes, healthcare use The IMPACT program significantly increased asthma knowledge of children and caregivers, decreased asthma symptom days, and decreased the number of ER visits. The intervention group used a significantly lower average dose of inhaled corticosteroids at visit three. Asthma knowledge of all 7- to 17-year-olds correlated with fewer urgent doctor visits and less frequent use of quick-relief medications. ER visit savings: $907.10 per child in the intervention group; $291.40 per control group; reduced school absences–indirect savings realized by working parents and employers; reduction in medication.
19. Lieberman D. Management of chronic pediatric diseases with interactive health games: theory and research findings. Journal of Ambulatory Care Management 2001;24:26-38. [Applicability] 14 children age 8-13 with asthma Asthma: clinic-based computer program Bronkie the Bronchiasaurus computer game Control group: watched a video about asthma; intervention group: played Bronkie. Self-efficacy Self-efficacy for asthma self-management increased for game group, decreased for video group.
20. Lieberman D. Management of chronic pediatric diseases with interactive health games: theory and research findings. Journal of Ambulatory Care Management 2001;24:26-38. [Applicability, Cost Savings] 59 children age 8-16 with diabetes Diabetes: home computer with interactive multimedia program Packy and Marlon, an interactive computer game for diabetes self-care and disease management. Players learn about self-care and social situations. They help character monitor blood glucose, take insulin, eat balanced meals, etc. Control group: given entertainment pinball video game with no health content. Intervention group: given Packy and Marlon. Both groups told they could play as much or as little as they wished. Satisfaction, self-efficacy, communica-tion, self-care, healthcare utilization Intervention group liked the game as well as the control group liked theirs. Increased diabetes-related self-efficacy, in communication with parents about diabetes, and in daily diabetes self-care. By the end of 6 months, intervention group experienced a 77% drop in diabetes-related urgent care and ER visits, an annualized decrease of two urgent visits per patient per year. No decline in control group who remained at 2.4 urgent visits per year.
21. McKay H, Glasgow R, Feil E, Barrera M. Internet-based diabetes self-management and support: initial outcomes from the Diabetes Network Project. Rehabilitation Psychology 2002;47:31-48. [Acceptability, Applicability] 160 type 2 diabetes patients from 16 primary care offices; 75 men and 85 women; mean age 59, 25% with college degree Diabetes: home computer with Internet All received baseline program of access to information about diabetes. The Personal Self-Management (PSM) group had coach to work on dietary goals, online blood glucose tracking and graphing system with real-time feedback. The Peer Support Condition (PSC) had peer-directed forums for communication and support, information exchange. The Combined Condition (CC) had access to all of the above. All received home computers for 10 months and were randomized into one of four groups: information only, PSM coach condition, PSC, or CC. Web site activity, physiologic, diet and eating behavior, and mental health status Little change in physiological measures; general improvement in dietary practices, substantial reduction in fat intake. PSC and CC had larger reductions in cholesterol; PSC and PSM had greater improvement in quality of life; PSM and CC had more logins than other conditions.
22. McKay HG, King D, Eakin EG, Seeley JR, Glasgow RE. The Diabetes Network Internet-based physical activity intervention: a randomized pilot study. Diabetes Care 2001;24:1328-34. [Acceptability, Applicability] 78 adults with type 2 diabetes; recruited by postings to diabetes-specific usenet groups, listservs, Web sites, and online communities; mean age 53; 53% female; 82% Caucasian; 50% college grads; 62% employed full time Diabetes: home computer with Internet D-NET Active Lives Program: Internet-based supplement to usual care that focuses on providing support for increasing physical activity (PA) including goal-setting, personalized feedback, identification and strategies to overcome barriers, online “personal” coach, peer support and online chat, online database for personal PA. Control group: Internet-based information-only condition; Intervention group: access to intervention Web site Process measures, minutes of PA per week, depressive symptomology No significant change in depressive symptoms. Overall moderate improvement in PA levels in both groups, no significant between-group differences in PA. Further analyses showed that more frequent site users in intervention group derived greater benefits in PA that were not seen in control group. Steep decline in usage in both groups during the course of study. Those in intervention group more satisfied than control.
23. Napolitano MA, Fotheringham M, Tate D, Sciamanna C, Leslie E, Owen N, et al. Evaluation of an Internet-based physical activity intervention: a preliminary investigation. Annals of Behavioral Medicine 2003;25:92-9. [Overview, Acceptability, Applicability] 65 sedentary adult hospital employees; 86% female, 14% male; 91% Caucasian; 92% skilled and confident using the Internet Physical activity: home or work computer with Internet Web site tailored by stage of change for physical activity and includes Activity Quiz, Safety Tips, Becoming Active, Physical Activity and Health, Overcoming Barriers, Planning Activity, Benefits of Activity, links to other sites, plus 12 weekly e-mail tip sheets. Control group: wait-list control; Intervention group: used Web site plus 12 weekly e-mail tip sheets Physical activity stage of change, physical activity, computer use At 1-month follow-up, intervention group had progressed stage of readiness, had significant increases in moderate minutes and walking minutes vs. control. At 3-month followup, difference in moderate activity not significant, walking minutes still significant.
24. Neighbors C, Larimer ME, Lewis MA. Targeting misperceptions of descriptive drinking norms: efficacy of a computer-delivered personalized normative feedback intervention. Journal of Consulting and Clinical Psychology 2004;72:443-7. [Overview, Applicability] 252 heavy drinkers (four to five drinks in one sitting in previous month), college students. 104 men, 148 women, mean age 18.5, 79.5% Caucasian, 7% Asian American, 6.8% other Alcohol: lab-based computer program Intervention provided personalized normative feedback on alcohol consumption delivered by computer. Once baseline assessment completed, user received feedback on screen and print copy. Feedback contained information about how much they drank, how much they thought others drank, and how much typical students actually drank. Control group: no intervention. Intervention group: interacted with computer program. Perceived drinking norms, drinking behavior, social reasons for drinking Intervention had small effects on drinking and medium effects on misperceptions in drinking norms at both 3- and 6-month followup. Changes in perceived norms were responsible for reduced drinking behavior. Social norm interventions appear to be more effective for those who drink for social reasons.
25. Oenema A, Brug J. Feedback strategies to raise awareness of personal dietary intake: results of a randomized controlled trial. Preventive Medicine 2003;36:429-39. [Appropriateness, Applicability, Key Findings] 304 adults who were students and employees of adult education centers in the Netherlands; mean age 44; 60% female; 47% had university degree or higher professional training Nutrition: classroom and office-based computer with Internet Web-based computer-tailored nutrition education session on personal awareness and intentions related to intake of fat, fruit, and vegetables. Program contained four sections: fat, vegetables, fruit, and recipes. In each section, relevant questions appeared, then user received feedback that included how user’s computed scores compared to recommended levels. Control group: received printed nontailored nutrition letter and brochures. Self-test group: used print self-assessments; Intervention group: used the computer-tailored intervention for one session. Food intake, awareness of personal intake levels, attitudes, self-efficacy, usability Those in the tailored group had more realistic self-rated fruit intake and self-rated fat intake, greater intention to decrease fat intake and increase vegetable intake than other groups. Those with less education in tailored intervention had more realistic self-rated fat intake than others. Those in tailored group more significantly reported that they had changed their opinions about their dietary habits and intention to change their diets. Tailored program was more likely to be used again than other interventions.
26. Oenema A, Brug J, Lechner L. Web-based tailored nutrition education: results of a randomized controlled trial. Health Education Research 2001;16:647-60. [Appropriateness, Acceptability, Applicability] 200 adults recruited from adult education institutions in the Netherlands; mean age 44; 62% female; 47% had college degree Nutrition: classroom and office-based computer with Internet Web-based computer-tailored nutrition education session on personal awareness and intentions related to intake of fat, fruit, and vegetables. Program contains four sections: fat, vegetables, fruit, and recipes. In each section, relevant questions appear, then user receives feedback that includes how user’s computed scores compare to recommended levels. Control group: received general nutrition information letter. Intervention group: interacted with the computer program for one session. Food intake, awareness of personal intake levels, attitudes, self-efficacy and stage of change, usability Significant differences in awareness of self-rated fat intake compared to others and intention to change were found between intervention and control at posttest. Tailored intervention was better appreciated, rated as more personally relevant, and had more subjective impact on opinion and intention to change than general nutrition information. Both groups read most of information and rated them attractive to read. Tailored program was more likely to be used again and rated information as more personally relevant and newer to them. No effect of computer literacy on perceived attractiveness of computer program; however, those with lower computer literacy also reported that the program was more difficult to use.
27. Pinto BN, Friedman R, Marcus BH, Kelley H, Tennstedt S, Gillman MW. Effects of a computer-based, telephone-counseling system on physical activity. American Journal of Preventive Medicine 2002;23:113-20. [Overview, Acceptability, Applicability] 298 adults from a large medical practice. Mean age 45.9; 72.1% women; 44.9% Caucasian, 44.6% African Americans, 24.2% educated beyond college (same sample as Delichatsios et al., 2001) Physical activity: home telephone-linked communication (TLC) system TLC-PA: a program designed to increase physical activity in adults. System inquires about current levels of activity, intentions, and whether they have met goals then tailors feedback to stage of motivational readiness. System asks users to set a task for themselves. Users call system each week. Control group: received TLC-Eat. Intervention group: received TLC-PA. Physical activity, stage of motivational readiness for physical activity Intervention group had greater percentage of individuals meeting recommended levels of moderate or vigorous physical activity at 3 months, but not significant at 6 months. At 3 months, a significantly greater number of intervention group in action, but results were not maintained at 6 months. Fewer calls to TLC-PA as compared to TLC-Eat. Usage declined over the intervention period. Number of calls to the system did not predict outcome—no dose-response.
28. Proudfoot J, Goldberg D, Mann A, Everitt B, Marks I, Gray JA. Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice. Psychological Medicine 2003;33:217-27. [Overview, Applicability] 167 Adults recruited from general medical practices in England with anxiety, depression, or mixed anxiety/depression; mean age 44; 88% Caucasian Depression and anxiety: clinic-based computer with interactive multimedia program Beating the Blues: interactive multimedia program of cognitive-behavioral techniques; also includes homework projects. Has one introductory and eight 50-minute treatment sessions; expected to be used weekly. Control group: received treatment as usual. Intervention group: received treatment as usual with exception of no face-to-face counseling or psychological intervention and interaction with computer program. Depression, anxiety, work, and social adjustment Intervention group showed significantly greater improvement in depression and anxiety compared to treatment as usual by the end of treatment and at 6 months’ followup. Mean scores of depression and anxiety fell to almost near-normal levels. Also showed improvement in work and social adjustment.

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