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The Internet is increasingly used as a medium for the delivery of interventions designed to promote health behavior change. However, reviews of these interventions to date have not systematically identified intervention characteristics and linked these to effectiveness. The present review sought to capitalize on recently published coding frames for assessing use of theory and behavior change techniques to investigate which characteristics of Internet-based interventions best promote health behavior change. In addition, we wanted to develop a novel coding scheme for assessing mode of delivery in Internet-based interventions and also to link different modes to effect sizes. We conducted a computerized search of the databases indexed by ISI Web of Knowledge (including BIOSIS Previews and Medline) between 2000 and 2008. Studies were included if (1) the primary components of the intervention were delivered via the Internet, (2) participants were randomly assigned to conditions, and (3) a measure of behavior related to health was taken after the intervention. We found 85 studies that satisfied the inclusion criteria, providing a total sample size of 43,236 participants. On average, interventions had a statistically small but significant effect on health-related behavior (d(+) = 0.16, 95% CI 0.09 to 0.23). More extensive use of theory was associated with increases in effect size (P = .049), and, in particular, interventions based on the theory of planned behavior tended to have substantial effects on behavior (d(+) = 0.36, 95% CI 0.15 to 0.56). Interventions that incorporated more behavior change techniques also tended to have larger effects compared to interventions that incorporated fewer techniques (P < .001). Finally, the effectiveness of Internet-based interventions was enhanced by the use of additional methods of communicating with participants, especially the use of short message service (SMS), or text, messages. The review provides a framework for the development of a science of Internet-based interventions, and our findings provide a rationale for investing in more intensive theory-based interventions that incorporate multiple behavior change techniques and modes of delivery.

Nasal sprays could be used to prevent and manage respiratory tract infections (RTIs). As part of a randomized controlled trial (ISRCTN17936080), participants received one of two nasal sprays (gel-based vs. saline) and a digital intervention. The digital intervention used behaviour change theories to encourage nasal spray use to reduce the severity and occurrences of RTIs. We explored participants’ experiences of the digital intervention and nasal spray. We interviewed 31 participants (aged 19–80), sampled from the two nasal spray intervention trial arms across 3 winter seasons (including at the height of COVID-19). We analysed the interviews using thematic analysis and found two themes regarding facilitators and barriers to nasal spray use. The facilitators of nasal spray use revolved around belief in nasal spray efficacy for infection, belief the nasal spray is safe, motivation to avoid infection, sense of control over infection, and how the nasal spray is integrated into lifestyle. Barriers to nasal spray use included the belief the nasal spray is ineffective, belief the nasal spray is unnecessary, and usage difficulties. Overall, the results highlight the role of beliefs, lifestyle integration, and usage difficulties in nasal spray adherence, with implications for future digital interventions, such as addressing concerns about the nasal spray being perceived as medication.

Background Interest in using digital interventions to provide pre-operative total knee replacement (TKR) education and prehabilitation (health/wellbeing optimization) support is growing. Patient engagement with digital interventions tends to be poor; therefore, exploring the intended users’ perspectives during digital intervention development is vital. This study was part of a project focused on developing a pre-operative TKR education and prehabilitation digital intervention, the ‘Virtual Knee School’ (VKS), and aimed to explore patients’ perspectives of potential barriers/facilitators to engagement with the VKS to inform its development. Methods This United Kingdom-based, qualitative descriptive study involved 14 purposively selected patients who were awaiting/had undergone TKR. Three online focus groups were conducted to explore patients’ perspectives of barriers and facilitators to engagement with the behaviors targeted by the VKS and digital features that could address the barriers/facilitators. The focus groups were audio-recorded, professionally transcribed, and analyzed inductively using reflexive thematic analysis. Three Patient and Public Involvement representatives were involved in aspects such as reviewing the recruitment materials and/or plain English summary of the study findings. Results Two intersecting themes were developed. Theme 1, ‘Accounting for individual differences’ , suggests pre-operative TKR digital interventions should account for the impact of individual differences on engagement with digital technologies, pre-operative education and prehabilitation. Most participants felt a pre-operative TKR digital intervention would be valuable; however, a couple of older participants appeared reluctant to use digital technologies. Participants’ perspectives of specific digital features and pre-operative TKR education and prehabilitation also varied widely. Theme 2, ‘Tailoring to the pre-operative context’ highlights the importance of tailoring pre-operative TKR digital interventions to pre-operative contextual features, including physiological/psychological factors, social/occupational factors and limitations in pre-operative TKR care provision. Various digital features that could address these factors were identified. Conclusions This study’s findings suggest pre-operative TKR digital interventions should account for individual differences and be tailored to the pre-operative TKR context. Given that some patients are reluctant to use digital technologies, also offering pre-operative TKR support in non-digital formats is essential. The findings have been used to inform a VKS prototype and could also be used to inform the development of other pre-operative TKR digital interventions.

Handwashing to prevent transmission of respiratory tract infections (RTIs) has been widely advocated, especially during the H1N1 pandemic. However, the role of handwashing is debated, and no good randomised evidence exists among adults in non-deprived settings. We aimed to assess whether an internet-delivered intervention to modify handwashing would reduce the number of RTIs among adults and their household members. We recruited individuals sharing a household by mailed invitation through general practices in England. After consent, participants were randomised online by an automated computer-generated random number programme to receive either no access or access to a bespoke automated web-based intervention that maximised handwashing intention, monitored handwashing behaviour, provided tailored feedback, reinforced helpful attitudes and norms, and addressed negative beliefs. We enrolled participants into an additional cohort (randomised to receive intervention or no intervention) to assess whether the baseline questionnaire on handwashing would affect handwashing behaviour. Participants were not masked to intervention allocation, but statistical analysis commands were constructed masked to group. The primary outcome was number of episodes of RTIs in index participants in a modified intention-to-treat population of randomly assigned participants who completed follow-up at 16 weeks. This trial is registered with the ISRCTN registry, number ISRCTN75058295. Across three winters between Jan 17, 2011, and March 31, 2013, we enrolled 20 066 participants and randomly assigned them to receive intervention (n=10 040) or no intervention (n=10 026). 16 908 (84%) participants were followed up with the 16 week questionnaire (8241 index participants in intervention group and 8667 in control group). After 16 weeks, 4242 individuals (51%) in the intervention group reported one or more episodes of RTI compared with 5135 (59%) in the control group (multivariate risk ratio 0·86, 95% CI 0·83–0·89; p<0·0001). The intervention reduced transmission of RTIs (reported within 1 week of another household member) both to and from the index person. We noted a slight increase in minor self-reported skin irritation (231 [4%] of 5429 in intervention group vs 79 [1%] of 6087 in control group) and no reported serious adverse events. In non-pandemic years, an effective internet intervention designed to increase handwashing could have an important effect in reduction of infection transmission. In view of the heightened concern during a pandemic and the likely role of the internet in access to advice, the intervention also has potential for effective implementation during a pandemic. Medical Research Council.

Introduction Diabetic foot ulcers (DFUs) affect approximately one‐quarter of people living with diabetes. They are chronic, recur frequently and are associated with significant psychological distress and behavioural challenges. The REDUCE intervention is a person‐centred, cognitive behavioural intervention designed to reduce the risk of DFU recurrence and support ulcer healing. Here, we describe the iterative development and optimisation of REDUCE, from its inception as a group‐based intervention to an individually tailored intervention delivered via video call or telephone. We outline key stages of the intervention development, including the integration and modification of a digital maintenance intervention (DMI) designed to support long‐term behaviour change and a mixed‐methods external pilot trial which informed a full‐scale clinical and cost‐effectiveness trial. Methods After initial development, the DMI was the subject of nine ‘think‐aloud’ interviews with patient and public contributors. We conducted an external pilot randomised controlled trial, involving 20 patients with recently healed DFUs randomised in a 2:1 ratio (REDUCE + Usual Care vs. Usual Care only). Data collection included patient‐reported outcome measures (baseline and 6 weeks and 3 months post‐randomisation) and qualitative interviews with participants and facilitators. Results Think‐aloud interviews informed key refinements to the DMI to enhance usability and engagement. The pilot trial demonstrated high acceptability of the intervention format and delivery. Patient‐reported outcomes suggested positive trends in psychological well‐being, footcare behaviours and mood among intervention participants. Qualitative findings highlighted the value of individualised delivery, the importance of facilitator support and varied engagement with the DMI. These insights informed further refinements to REDUCE ahead of a full‐scale effectiveness trial. Conclusion We provide a comprehensive account of the evolution of the REDUCE intervention and share broader learnings regarding the development of complex behavioural health interventions. The example of REDUCE highlights the value of iterative, multidisciplinary methods and patient involvement in intervention design and offers practical insights for designing digital and remote health interventions. Patient or Public Contribution Patient and public contributors were involved throughout the research described in this manuscript. Key areas of involvement included co‐creation of all patient‐facing materials, intervention development and informing trial methods.

ObjectivesIncreasing physical activity and effectively managing stress can positively impact immunity and may reduce the duration of respiratory tract infections (RTIs). As part of a larger trial, participants accessed a digital behavioural change intervention that encouraged physical activity and stress management to reduce RTIs. We aimed to understand the barriers and facilitators to engaging in physical activity and stress reduction.DesignA qualitative process analysis from semistructured interviews of the behavioural intervention in a randomised control trial.SettingPrimary care in the UK.Participants34 participants (aged 18–82 years) in the behavioural intervention arm.InterventionsThe larger trial involved four interventions: a gel-based antiviral nasal spray; a saline water-based nasal spray; a behavioural intervention; usual care. In this study, we focused on participants allocated to the behavioural intervention. The behavioural intervention included two components: one to increase physical activity (getting active) and another for stress management techniques (healthy paths) to reduce RTIs.ResultsWe analysed the interviews using thematic analysis with a critical realist perspective (focusing on). We developed five themes: digital intervention engagement, views on intervention allocation, the role of getting active, the role of healthy paths and benefits reinforcing behaviour. Participants’ views on the relevance and benefit of the behavioural intervention shaped their engagement with the intervention website and behaviour. Facilitators of intervention engagement included awareness of inactivity, goal setting, increasing immunity, positive outcome expectations and benefits from changing behaviour. Barriers to engagement included negative outcome expectations, such as around efficacy of the behaviours.ConclusionsOverall, the results highlighted the importance of positive expectations for a digital intervention promoting physical activity and stress management for RTI reduction. Future interventions should consider how to clearly communicate a broad range of perceived benefits to users.Trial registrationsThe trial was prospectively registered with International Standard Randomized Controlled Trial Number (ISRCTN) registry (17936080).

IntroductionDigital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.ObjectiveTo develop a pre-operative TKR education and prehabilitation digital intervention, the ‘Virtual Knee School’ (VKS).MethodsThe VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).ResultsMost participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend:1.Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats.2.Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.ConclusionsIntegrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.Patient or Public ContributionPatient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

Background It is recognised as good practice to use qualitative methods to elicit users' views of internet-delivered health-care interventions during their development. This paper seeks to illustrate the advantages of combining usability testing with 'theoretical modelling', i.e. analyses that relate the findings of qualitative studies during intervention development to social science theory, in order to gain deeper insights into the reasons and context for how people respond to the intervention. This paper illustrates how usability testing may be enriched by theoretical modelling by means of two qualitative studies of users' views of the delivery of information in an internet-delivered intervention to help users decide whether they needed to seek medical care for their cold or flu symptoms. Methods In Study 1, 21 participants recruited from a city in southern England were asked to 'think aloud' while viewing draft web-pages presented in paper format. In Study 2, views of our prototype website were elicited, again using think aloud methods, in a sample of 26 participants purposively sampled for diversity in education levels. Both data-sets were analysed by thematic analysis. Results Study 1 revealed that although the information provided by the draft web-pages had many of the intended empowering benefits, users often felt overwhelmed by the quantity of information. Relating these findings to theory and research on factors influencing preferences for information-seeking we hypothesised that to meet the needs of different users (especially those with lower literacy levels) our website should be designed to provide only essential personalised advice, but with options to access further information. Study 2 showed that our website design did prove accessible to users with different literacy levels. However, some users seemed to want still greater control over how information was accessed. Conclusions Educational level need not be an insuperable barrier to appreciating web-based access to detailed health-related information, provided that users feel they can quickly gain access to the specific information they seek.

ObjectiveTo assess an internet-delivered intervention providing advice to manage respiratory tract infections (RTIs).DesignOpen pragmatic parallel group randomised controlled trial.SettingPrimary care in UK.ParticipantsAdults (aged ≥18) registered with general practitioners, recruited by postal invitation.InterventionPatients were randomised with computer-generated random numbers to access the intervention website (intervention) or not (control). The intervention tailored advice about the diagnosis, natural history, symptom management (particularly paracetamol/ibuprofen use) and when to seek further help.OutcomesPrimary: National Health Service (NHS) contacts for those reporting RTIs from monthly online questionnaires for 20 weeks. Secondary: hospitalisations; symptom duration/severity.Results3044 participants were recruited. 852 in the intervention group and 920 in the control group reported 1 or more RTIs, among whom there was a modest increase in NHS direct contacts in the intervention group (intervention 37/1574 (2.4%) versus control 20/1661 (1.2%); multivariate risk ratio (RR) 2.25 (95% CI 1.00 to 5.07, p=0.048)). Conversely, reduced contact with doctors occurred (239/1574 (15.2%) vs 304/1664 (18.3%); RR 0.71, 0.52 to 0.98, p=0.037). Reduction in contacts occurred despite slightly longer illness duration (11.3 days vs 10.7 days, respectively; multivariate estimate 0.60 days longer (−0.15 to 1.36, p=0.118) and more days of illness rated moderately bad or worse illness (0.52 days; 0.06 to 0.97, p=0.026). The estimate of slower symptom resolution in the intervention group was attenuated when controlling for whether individuals had used web pages which advocated ibuprofen use (length of illness 0.22 days, −0.51 to 0.95, p=0.551; moderately bad or worse symptoms 0.36 days, −0.08 to 0.80, p=0.105). There was no evidence of increased hospitalisations (risk ratio 0.25; 0.05 to 1.12; p=0.069).ConclusionsAn internet-delivered intervention for the self-management of RTIs modifies help-seeking behaviour, and does not result in more hospital admissions due to delayed help seeking. Advising the use of ibuprofen may not be helpful.Trial registration numberISRCTN91518452.