1. Status of the Internet as a Tool for Health Behavior Change Kerry Evers, Ph.D. Carol Cummins, M.Ed., MLIS Mary-Margaret Driskell, M.P.H. James Prochaska, Ph.D. Janice Prochaska, Ph.D. Pro-Change Behavior Systems, Inc. Robin Mockenhaupt, Ph.D. The Robert Wood Johnson Foundation

2. Purpose To examine the state of health behavior change programs on the Internet Part of a larger study contracted by The Robert Wood Johnson Foundation – Review of the literature – Screening of health sites – Full review of health behavior change sites – Development of a measure for readiness to use the Internet for health behavior change

3. An estimated 56% of American adults had access to the Internet at the end of 2000 52 million American adults use the Internet at least once a month to get health & medical information Half say access to information on the Internet has improved the way they take care of themselves The Pew Internet & American Life Project, 2001 Background

4. According to Goldsmith (2000), “The most important effect of the Internet will be to strengthen the consumer’s role” in health care, and to “create a powerful new tool to help people manage their own health risks more effectively.” Healthy People 2010 Goal: Use communication strategically to improve health – Objectives increase proportion of households with access to the Internet at home increase proportion of health-related WWW sites that disclose information that can be used to assess the quality of the site Focus has been on dissemination of health information Little attention has been paid to the content and quality of sites designed to help people change health behaviors Background

5. Target Behaviors Smoking cessation Diet Physical activity Alcohol use Depression management Diabetes management Pediatric asthma

6. Development of screening criteria specific to health behavior change Review of existing guidelines for evaluating health related Web sites Identification of sites focusing on target behaviors Screening to differentiate health information from behavior change sites Development of full review criteria Full evaluation of health behavior change sites Design

7. Development of Review Criteria Criteria from Public Health Service’s Clinical Practice Guideline adapted for Internet programs – Advise: advising about risk & need to change – Assess: assessing variables that could impact behavior – Assist: providing strategies for change – Anticipatory Guidance: providing tips for preventing relapse – Arrange Follow-Up: scheduling follow-up contacts Identified 20 sets of guidelines for evaluating health Web sites – Examined concepts and repetition

8. Sites Identified Web sites in 3 ways: – Online searches – Medical informatics journals – Popular press 294 Web sites identified for screening - 51 diet - 45 depression - 44 exercise - 42 diabetes - 43 smoking - 33 pediatric asthma - 30 alcohol - 6 wellness (multiple behaviors)

9. 273 sites separately rated by 2 reviewers for each of the 5 A’s – Inter-rater reliability ranged from.84 to.93 – Third reviewer rated the site when disagreement The most sites received credit for Assess (N=141; 51.6%) Anticipatory Guidance received the fewest (N=31; 11.4%) Screening of Sites

10. 22 sites (8.1%) received credit in each of the 5 categories 20 (7.3%) received 4 credits Sites identified through online searches met fewer criteria than those identified through other methods (F(2,272)=16.24, p<.001) Sites meeting >4 moved onto full review (N=42): - 12 smoking- 7 diabetes - 11 diet- 6 exercise - 1 depression - 2 asthma - 3 could not be reviewed

11. Content - Ownership (1) - Attribution (2) - Editorial Credibility/Quality (7)- Authorship (2) - Copyright (1)- Language (3) - Accountability (1) - Candor (1) - Disclaimer (1)- Purpose (2) Interactivity (5) Behavior Change (21) Multi-Behavior (2) Design (8) Accessibility/Security (6) Privacy & Confidentiality (11) Advertising (3) Evaluation (4) Full Review Criteria

12. Full Review Highlights Editorial Credibility & Quality: Fewer than half of sites met all of the 7 criteria Behavior Change – Sites included over 350 assessments – 37 sites provided segmented feedback; 5 sites provided individualized feedback based on assessments – 5 sites stated their program was based on a behavior change theory Privacy: 34 sites had privacy policies within 1 click of the home page Evaluation: None of the sites stated if or how they were evaluating their programs for effectiveness, although 6 provided mechanisms for feedback about their programs

13. Web sites are always changing – Content – Links The Internet is non-linear – Everyone can have a different experience – May not be able to get to the same place again Programs “borrow” from other programs Incomplete sites or under construction Challenges

14. Conclusions & Implications Health behavior change on the Internet appears to be in the early stages of development Smoking, exercise, and diet sites seem to be further along than others There are implications for how consumers find sites Little has been known about behavior change on the Internet – What is guiding development? – How effective are Internet behavior change programs?

15. “5 A’s for Effective Health Behavior Change Treatment on the Internet” criteria can be used by consumers, researchers, developers, and practitioners to assure basic behavior change components are present in Internet-based programs Evaluation criteria must be used to examine issues like privacy, confidentiality, credibility, quality Efficacy or effectiveness of programs must be assessed Conclusions & Implications

16. References Goldsmith, J. (2000). How will the Internet change our health system? Health Affairs, 19(1), 148-156. The Pew Internet & American Life Project (2001, February). More online, doing more: 16 million newcomers gain Internet access in the last half of 2000 as women, minorities, and families with modest incomes continue to surge online. Washington, DC: Rainie, L., Packel, D., Fox, S., Horrigan, J., Lenhart, A., Spooner, T., Lewis, O., & Carter, C.