Published on 23.06.06 in Vol 8, No 2 (2006)
Why Are Health Care Interventions Delivered Over the Internet? A Systematic Review of the Published Literature
Comment in: Mayo-Wilson E. Health Care Interventions Delivered Over the Internet: How Systematic was the Review? J Med Internet Res. 2006;8(2) p. e11 http://www.jmir.org/2006/2/e11/
Comment in: Griffiths F. Health Care Interventions Delivered Over the Internet: How Systematic was the Review? - Author's Reply. J Med Internet Res. 2006 Jun 30;8(2) p. e12 http://www.jmir.org/2006/2/e12/
Background: As Internet use grows, health interventions are increasingly being delivered online. Pioneering researchers are using the networking potential of the Internet, and several of them have evaluated these interventions.
Objective: The objective was to review the reasons why health interventions have been delivered on the Internet and to reflect on the work of the pioneers in this field in order to inform future research.
Methods: We conducted a qualitative systematic review of peer-reviewed evaluations of health interventions delivered to a known client/patient group using networked features of the Internet. Papers were reviewed for the reasons given for using the Internet, and these reasons were categorized.
Results: We included studies evaluating 28 interventions plus 9 interventions that were evaluated in pilot studies. The interventions were aimed at a range of health conditions. Reasons for Internet delivery included low cost and resource implications due to the nature of the technology; reducing cost and increasing convenience for users; reduction of health service costs; overcoming isolation of users; the need for timely information; stigma reduction; and increased user and supplier control of the intervention. A small number of studies gave the existence of Internet interventions as the only reason for undertaking an evaluation of this mode of delivery.
Conclusions: One must remain alert for the unintended effects of Internet delivery of health interventions due to the potential for reinforcing the problems that the intervention was designed to help. Internet delivery overcomes isolation of time, mobility, and geography, but it may not be a substitute for face-to-face contact. Future evaluations need to incorporate the evaluation of cost, not only to the health service but also to users and their social networks. When researchers report the outcomes of Internet-delivered health care interventions, it is important that they clearly state why they chose to use the Internet, preferably backing up their decision with theoretical models and exploratory work. Evaluation of the effectiveness of a health care intervention delivered by the Internet needs to include comparison with more traditional modes of delivery to answer the following question: What are the added benefits or disadvantages of Internet use that are particular to this mode of delivery?
J Med Internet Res 2006;8(2):e10)
The Internet is still a relatively new medium for seeking and delivering health care, although this use is increasing rapidly [, ] and includes health information seeking [ ], Internet-based peer support groups [ ], online health consultations [ ], and delivery of health interventions [ ]. Some pioneer researchers have published studies that evaluate health interventions delivered directly to the users via the Internet for their ability to improve the health status of their users. In this paper we review their work, focusing on the reasons why these authors chose to use the Internet for delivery of a health care intervention. Our aim was to consolidate the findings from these early research papers to inform the development of future research. We include only health interventions in which the networking provided by the Internet is a component of the intervention. This is to distinguish them from other media such as print material, CD-ROM, and video. We reflect on the drivers to using the Internet for the delivery of health care. This paper does not review the outcomes of the interventions.
Identification of Studies
The initial identification of studies used five sources: three existing systematic reviews of eHealth interventions [- ], a hand search of JMIR (vol 1(1) to vol 8(1)), and our own previous qualitative review of the literature concerning the Internet and consumer health information [ ]. This latter review involved collation and identification of relevant literature through systematic searches of electronic bibliographic databases covering health and social sciences literature (1990 to December 2003, including Medline, HMIC, CINAHL, Sociological Abstracts, Sociofile, and Web of Science). We used search terms such as “Internet,” “electronic mail,” “computer communication networks,” and “health information,” “communication,” or “health informatics.” Two investigators reviewed the list to identify potentially relevant articles. We worked in pairs, reviewing the search results to identify relevant intervention studies. We did not set out to identify every published eHealth intervention paper, but aimed to search the majority of the available literature in a systematic way for a meaningful overview of the field.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria were applied to the studies identified from the three sources described above. We included only peer-reviewed full research papers. We defined intervention studies as the use of information and communication technology to deliver a specific health intervention to a client or patient group. The study had to include a health-related outcome as part of evaluating the intervention, and the intervention had to include use of the networking provided by the Internet. Networked features included the use of email to contact a therapist, the use of chat rooms or bulletin boards by client/patient groups, or the transfer of personal health data via the Web between a health care site and personal network access (eg, between a clinic and patient’s home). Studies with no networked features, such as computer-based decision support systems delivered from a CD or interventions where there was no use of the Internet beyond delivery (ie, they could have been delivered by a CD), were excluded. A further key characteristic of the Internet is its accessibility via a networked computer anywhere and anytime. Hence, we excluded studies in which access to the intervention was provided only in the clinical setting as use of the intervention is restricted in place and time. It is also possible that effectiveness may be influenced by the clinical setting.
Our review focused on the use of the Internet for delivery of the interventions and therefore did not include non-Internet based telemedicine studies. The focus was on specific interventions for specific health problems, so we excluded interventions involving the provision of general Internet access such as home computers, Internet kiosks, or training in use of the Internet even if the outcomes included health related measures. We only included interventions in which the individuals using them were known to the health care professional or organization delivering the intervention to be sure that the participants were using their real identity and responding in a genuine way to the intervention. This cannot be ensured for a study that recruits participants solely via the Web, with no direct contact between investigators and participants. We excluded studies that solely involved the placing of health information on the Web for public access, even when there was opportunity for interaction or feedback.
When there were several papers concerning the same intervention (eg, a pilot study followed by a full evaluation), we grouped these papers together and treated them as one study. For each study, all the reasons given for delivering the health care intervention on the Internet were listed. These were the reasons the authors of the papers gave for choosing the Internet as the mode of delivery, rather than post hoc reasoning given in the discussion of the study results. We then categorized the reasons; one study could be categorized in a number of different groups. Again, we worked in pairs, comparing results and resolving any discrepancies through further examination of the papers and discussion among team members.
Types of Interventions
We found full evaluations of 28 interventions and a further 9 interventions for which only pilot work had been published (Multimedia Appendix). All the papers were from Europe, North America, or Australia. The interventions were aimed at a wide range of conditions, including cancer (3 studies), HIV/AIDS (3 studies), diabetes (3 studies), mental health (1 study), eating disorders (2 studies), and back pain (1 study). Some targeted health promotion issues such as smoking cessation (1 study), physical activity (1 study), and obesity (3 studies). Other interventions aimed to support caregivers, for example caregivers of people with Alzheimer’s disease (3 studies), stroke patient caregivers (1 study), new or young mothers (2 studies), and parents of children in intensive care (1 study). One intervention aimed at supporting rural women with chronic illness. One study reported the delivery of cognitive behaviour therapy (CBT) for a number of disorders, including headache, tinnitus, and panic disorders; two other studies reported CBT delivery for depression and one for post-traumatic stress disorder. Three interventions offered education and/or communication with specialist nurses for cardiac patients. Three interventions were specifically for young people or children: one for pain self management by children in hospital, one for those with cystic fibrosis, and one for the management of encopresis.
Reasons for Internet Delivery of Interventions
The reasons cited for using the Internet to deliver health interventions included the unique advantages of the Internet technology, reducing cost and increasing convenience for users, reducing health service costs, reaching isolated or stigmatized groups, timeliness of access to the Internet, need for user or supplier control of the intervention, and research-related reasons ().
Not all the studies in the early research papers mentioned the reasons for use of the Internet. Therefore, in the following analysis, the papers referenced are the papers for which the reason for Internet use was mentioned.
Unique Advantages of the Internet Technology
There were 13 interventions studied [, , , , , , , , , , , , , , - ] for which the reason for Internet use was connected with the nature of the technology: reaching many people with just one posting, easy storage of large amounts of information, ease of updating information, providing personalized feedback, and the possibilities of broadband and video transmission. Two of these 13 studies [ , ] expressly valued the Internet for its ability to reach a maximum number of people at minimum cost. All these studies also give other reasons for Internet use.
Reducing Cost and Increasing Convenience for Users
Reducing cost and increasing convenience for the user was given as a reason for delivery over the Internet in 20 of the interventions studied [- , , , , - , , , , - , - , , , ]. These studies targeted a range of health issues. Various aspects of increased convenience to the user were mentioned, including saving the user time, requiring less effort from the user, being more accessible, and not requiring the user to attend a particular facility. One US study [ ], reporting an intervention for women with breast cancer, stated users’ lack of money for a second opinion as one of the reasons for Internet delivery. Two studies advocated use of the Internet as it may reduce the loss of users from their maintenance programs for obesity [ , ].
Reducing Health Service Costs
By using Internet delivery, 14 of the interventions studied [, , , , , - , , , , , , , , , , , , - ] aimed to reduce costs to health services or address a lack of provision. Of these, two studies, one on linking parents with their low-birth-weight babies in intensive care [ ], and the other on the management of encopresis [ ], specified reduction in health service cost as a reason for Internet use. The cost of service provision was also given as a reason by a number of other studies, but with slightly different emphases. One study saw the Internet as a cost-effective way of delivering an intervention to encourage physical activity in a broad range of people in many places [ ]. Five of the interventions studied gave a lack of health service resources as their reason, two citing a lack of practitioners in CBT [ , , ] and the others a lack of support for caregivers of those with Alzheimer’s disease [ , ] and AIDS [ - ]. All the above studies discussed a general lack of these services. None of the studies gave a specific localized service failure as the reason for Internet delivery, but two mentioned service failure more generally. One study [ ] gave the lack of physicians trained in the treatment of encopresis as the reason for Internet delivery, while another study [ ] aimed to reduce barriers to nutrition education due to general practitioners’ lack of skills and time. The authors of one other study [ ] argued for Internet delivery because patients with diabetes have been found to have poor control despite specialist care, and their control may become even worse after the devolution of diabetes care to primary care services.
In six of the interventions studied, researchers wanted to avoid the cost to the health service of providing the intervention face-to-face, including psychological interventions for the treatment of depression , eating disorders[ - ],obesity [ - ], lack of physical activity [ , ], and a range of conditions (headache, tinnitus, panic attacks, and insomnia) [ - ].The authors of the latter intervention studied also argued that Internet delivery increases access to an otherwise costly therapy [ , ]. Another study [ ] explicitly addressed inequalities of health care, suggesting that Internet delivery helped to overcome inequalities of access to health services.
Reaching Isolated Groups
Dimensions of isolation were given as reasons for using the Internet in 13 of the interventions studied [, , , - , , , , , , , , ]; 5 stated geographical isolation as their reason. These studies included interventions for rural women with chronic disease [ ] or diabetes [ ], an intervention for women with breast cancer [ ], a cognitive behavioral program for eating disorders [ ], an intervention for people with post-traumatic stress disorder [ ], and an intervention for children with cystic fibrosis [ ]. The authors of the latter study also mentioned the advantage of providing peer support without the risk of cross infection that can be life threatening for children with cystic fibrosis.
In other studies, the cause of the isolation was not geographical. One [- ] stated the isolation of people living with HIV/AIDS as a reason for Internet delivery. Several studies cited the isolation of caregivers who were unable to easily go out, such as those living with an Alzheimer’s sufferer [ , - ] and young mothers with children at home [ ]. The physical immobility of individuals, including fatigue and disability, was mentioned in interventions focused on people with HIV/AIDS [ ] or breast cancer [ ] and on children with cystic fibrosis [ ].
Several studies mentioned that Internet delivery enabled users to be in contact with people with similar health issues and so receive support. The implication was that this would be unlikely to happen otherwise as the condition was rare or restricting, for example, children in pain , children with cystic fibrosis [ ], young mothers [ ], people living with AIDS [ - , ], and people with type 2 diabetes [ , ].
Reaching Stigmatized Groups
The researchers of 11 interventions saw the Internet as a way of reaching people suffering from conditions that caused them to feel embarrassed or stigmatized [, , , , , , , , , , , , , - ]. The anonymity of Internet delivery was a reason for using the Internet in the following interventions: an intervention for mental health problems [ ], in which the authors considered stigma to be a problem; an intervention for people living with type 2 diabetes [ , ], in which the authors suggested that anonymity prevented people from being judged on the basis of their appearance; two interventions to improve the self-care of people living with AIDS [ , , ]; an intervention for young women at risk of eating disorders [ - ]; and a support intervention for young mothers [ ]. Three studies suggested that Internet delivery avoids embarrassment about the health issue for which the intervention was used. One of these was for breast cancer [ ], the second referred to embarrassment about failure to lose weight in an obesity intervention [ ], and the third was aimed at child encopresis [ ]. One study of a support system for caregivers of patients with Alzheimer’s disease [ , ] and one study of an intervention to encourage physical activity [ ] suggested that Internet delivery encourages openness of communication.
The Timeliness of Access to the Internet
Several interventions [, , , , - , , ] mentioned the need for timely information and advice as a reason for Internet delivery, including interventions to support Alzheimer’s caregivers [ , , ], people with AIDS [ - ], young mothers [ ], those with breast cancer [ ], headache sufferers [ ], and an intervention encouraging physical activity [ , ]. The suggestion was that people need information or advice at a time of crisis, for example, when their child is ill or when they are making a decision such as a change in treatment or their own behavior. The continuous access provided by the Internet was seen as helpful in these situations.
User Control of the Intervention
Many authors advocated use of the Internet because users could take control of the intervention [, , , , , , , , , , , ], tailoring the information they received to their own needs. This included interventions for Alzheimer’s caregivers [ ], those with HIV/AIDS [ ], a glucose modeling tool for type 1 diabetes [ ], and an intervention promoting physical activity [ ]. Other studies advocated use of the Internet because users could use the intervention at their own pace. These included CBT for depression [ ] or tinnitus [ ], an educational program for cardiac patients [ ], peer support interventions providing young mothers with support [ ] or facilitating weight loss [ ], an intervention for those at risk of eating disorders [ , ], and an intervention for encopresis [ ].
Supplier Control of the Intervention
For some interventions that delivered CBT as a self-help program, the Internet was seen as a potentially appropriate mode of delivery for such a structured, evidence-based intervention [- , , , , , , - ]. One author stated that Internet delivery was superior to professional psychologists in delivering structured and standardized interventions [ ]. However, in delivering these structured programs, the studies supplemented the standardized intervention through individualized email feedback, tailored information, online peer support, or a combination of the three.
Almost all authors justified the evaluation of Internet-delivered interventions by saying that they need evaluating or adapting for specific populations. Six studies give this as their only reason [, , , , , ]. Most studies give examples of successful Internet-delivered interventions to support their own research. However, one study gives, as its only reason for Internet-delivered intervention, that the intervention or a similar intervention had been useful in other studies [ ]. One study [ ] questions whether face-to-face and online support groups for those with breast cancer would work together, and gives this question as the only reason for delivering the intervention via the Internet.
A few studies did not give a research-related reason for evaluating an Internet-delivered intervention. These studies were descriptive accounts of an intervention [, , ] or were evaluating the use of an Internet-delivered intervention that was in response to a specific health service–related problem [ ].
The following reasons, alongside others mentioned above, were also given for delivery of an intervention via the Internet:
- poor information received by patients from health professionals [ ]
- novelty [ , ]
- attractiveness of the Internet to young people and children [ ]
- online communication as one of the main forms of communication used by young people [ ]
We have reviewed many pioneering studies evaluating Internet use for the delivery of health care interventions and found a variety of reasons for delivering interventions through the Internet. All the interventions have been, or could be, delivered by other means. For example, support groups for isolated individuals can use more established means of communication such as telephones and post, and therapeutic programs can be delivered face-to-face. The key differences between non-Internet delivered interventions and those delivered via the Internet relate to time and place. For example, Internet support groups enable quick communication between many isolated individuals, and Internet-delivered therapeutic interventions can be taken up at any time and anywhere with Internet access.
Our literature search strategy was designed to systematically identify the majority of eHealth intervention studies meeting our inclusion criteria. However, as a qualitative analysis that aimed to explore the motivations for delivering such interventions online, it was not necessary to undertake an exhaustive search for every single eHealth study ever published in any language. This contrasts with the methodology of quantitative meta-analysis, which requires the identification of all possible studies to produce one summary result. We believe that our qualitative thematic approach met our objective and was both rigorous and repeatable. Qualitative methods of research synthesis are a relatively new area and can be very valuable in identifying lessons for future work, particularly as they do not focus solely on the results on previous studies, but also consider other factors such as the researchers’ motivations. Our criteria for inclusion and exclusion of studies were designed to maintain the focus of the review on the added value from use of the Internet. Hence, they took account of the key characteristics of the Internet, particularly its networking potential and accessibility. Thus, our criteria differed from definitions of eHealth, for example, by excluding telemedicine  and general public access [ ].
At this early stage of development, researchers should give careful thought to the reasons for using the Internet for any particular intervention. We should try to understand the unique advantages and disadvantages of Internet delivery of health care and in what circumstances Internet use could contribute most effectively to improving health. For example, why might speedier communication and flexibility of location enhance the effectiveness of the intervention? Answers may include, for example, overcoming inequalities of access to health services or encouraging openness of communication. However, to clarify the added contribution of Internet delivery over more traditional forms of delivery, evaluations should include a direct comparison between Internet-delivered interventions and those delivered by the most effective of available conventional means. Such evaluations will enable us to understand the effect of the real differences between the interventions. Few studies in our review undertook such a direct comparison.
Failing to undertake such a direct comparison may result in the failure to identify and quantify situations where face-to-face delivery is better than Internet delivery. For example, among the many studies of structured behavioral programs using Internet delivery, only one intervention [, ] compared the benefits of this delivery method with time-intensive face-to-face therapy, and another compared it with a classroom-based intervention [ , ]. A systematic review comparing the effectiveness of Web-based and non-Web–based interventions [ ] included, apart from the above two interventions, no other trials in which Web-based interventions had been compared to intensive face-to-face interventions. Undertaking an evaluation of Internet-delivered intervention without comparison may inappropriately encourage a reduction of the availability of the effective face-to-face intervention. This would work against the original motivation of the research to increase access to an effective intervention.
The design, delivery, and evaluation of an Internet-delivered intervention also need to consider the following questions: What may be the unintended harmful consequences of Internet delivery? What may be the negative effects of speedier communication and flexibility of location? For example, it is possible that providing low-cost Internet-based support for groups that are not currently provided with adequate support, such as caregivers of those with Alzheimer’s disease, may reinforce the low priority of these groups for health and social services and thus increase their isolation. Providing an intervention via the Internet for individuals living with a health problem they feel is stigmatized could have the unintended consequence of the issue being less talked about outside the anonymity of the Internet and thus reinforcing the stigma (see Textbox). Although identifying such unintended consequences was not an aim of this study, it was notable that we did not identify any reports of such consequences in the papers reviewed.
Evaluations of Internet-delivered interventions should aim to ensure that they include both the benefits and potential harms of the mode of delivery for all those affected by it. For example, an economic evaluation should include not only the cost of the Internet intervention, but also costs to health services, specific services, users, and their social networks. The studies reviewed rarely included an evaluation of such indirect costs.
Although the Internet can overcome isolation of time, mobility, and geography, it may be a poor substitute for face-to-face contact with real people. The balance between use of the Internet and face-to-face contact should be carefully considered in each circumstance. This applies to structured interventions such as CBT as well as to more flexible interventions such as peer-to-peer support. In designing an evaluation, researchers should be aware that Internet-based contact may be providing something different than face-to-face contact and should seek to assess these potentially different effects (see Textbox).
A number of studies gave no reason for use of the Internet as the mode of delivery beyond stating that it exists and needs evaluating. Now that the field of Internet- delivered interventions is established, future researchers should carefully consider how the networking provided by Internet delivery may enhance the effect of an intervention. This should involve exploratory work and more explicit use of existing theory and modeling .
The pioneering researchers who undertook the studies reviewed in this paper were often looking to the Internet for a way to help resolve some of the current difficulties and dilemmas of health care. These included the provision of equal access to health care, limitations on resources for health care, changing roles of health professionals, and changing needs for particular skills. Exploring the possible benefits of using the Internet to address these issues is important, but it is also important to make a meaningful comparison between using the Internet and using other more traditional ways of addressing the issues. Future research will hopefully shed more light on the benefits and disadvantages of Internet use particular to this mode of delivery.
The authors acknowledge the support of the Warwick West Midlands Primary Care Research, and the UK Department of Health, which support their academic posts.
Conflicts of Interest
- Kwankam SY. What e-Health can offer. Bull World Health Organ 2004 Oct;82(10):800-802. [Medline]
- Berry LL, Seiders K, Wilder SS. Innovations in access to care: a patient-centered approach. Ann Intern Med 2003 Oct 7;139(7):568-574 [FREE Full text] [Medline]
- Fox S, Rainie L. The online care revolution: how the Web helps Americans take better care of themselves. 2000 Nov 26. 2000 Nov 26. URL: http://www.pewinternet.org/PPF/r/26/report_display.asp [accessed 2006 Jun 10] [WebCite Cache]
- Eysenbach G. The impact of the Internet on cancer outcomes. CA Cancer J Clin 2003;53(6):356-371 [FREE Full text] [Medline]
- Slack WV. A 67-year-old man who e-mails his physician. JAMA 2004 Nov 10;292(18):2255-2261. [Medline] [CrossRef]
- Christensen H, Griffiths KM, Jorm AF. Delivering interventions for depression by using the internet: randomised controlled trial. BMJ 2004 Jan 31;328(7434):265 [FREE Full text] [Medline] [PMC] [CrossRef]
- Eysenbach G, Powell J, Englesakis M, Rizo C, Stern A. Health related virtual communities and electronic support groups: systematic review of the effects of online peer to peer interactions. BMJ 2004 May 15;328(7449):1166 [FREE Full text] [Medline] [PMC] [CrossRef]
- Murray E, Lo B, Pollack L, Donelan K, Catania J, Lee K, et al. The impact of health information on the Internet on health care and the physician-patient relationship: national U.S. survey among 1.050 U.S. physicians. J Med Internet Res 2003 Aug 29;5(3):e17 [FREE Full text] [Medline] [CrossRef]
- Wantland DJ, Portillo CJ, Holzemer WL, Slaughter R, Mcghee EM. The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. J Med Internet Res 2004 Nov 10;6(4):e40 [FREE Full text] [Medline] [CrossRef]
- Powell JA, Lowe P, Griffiths FE, Thorogood M. A critical analysis of the literature on the Internet and consumer health information. J Telemed Telecare 2005;11 Suppl 1(1):41-43. [Medline] [CrossRef]
- Andersson G, Kaldo V. Internet-based cognitive behavioral therapy for tinnitus. J Clin Psychol 2004 Feb;60(2):171-178. [Medline] [CrossRef]
- Andersson G, Lundström P, Ström L. Internet-based treatment of headache: does telephone contact add anything? Headache 2003 Apr;43(4):353-361. [Medline] [CrossRef]
- Andersson G, Strömgren T, Ström L, Lyttkens L. Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus. Psychosom Med 2002;64(5):810-816. [Medline] [CrossRef]
- Carlbring P, Nilsson-ihrfelt E, Waara J, Kollenstam C, Buhrman M, Kaldo V, et al. Treatment of panic disorder: live therapy vs. self-help via the Internet. Behav Res Ther 2005 Oct;43(10):1321-1333. [Medline] [CrossRef]
- Carlbring P, Ekselius L, Andersson G. Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation. J Behav Ther Exp Psychiatry 2003 Jun;34(2):129-140. [Medline] [CrossRef]
- Ström L, Pettersson R, Andersson G. A controlled trial of self-help treatment of recurrent headache conducted via the Internet. J Consult Clin Psychol 2000 Aug;68(4):722-727. [Medline] [CrossRef]
- Ström L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol 2004 Feb;72(1):113-120. [Medline] [CrossRef]
- Barrera M, Glasgow RE, Mckay HG, Boles SM, Feil EG. Do Internet-based support interventions change perceptions of social support?: An experimental trial of approaches for supporting diabetes self-management. Am J Community Psychol 2002 Oct;30(5):637-654. [Medline]
- Glasgow RE, Boles SM, Mckay HG, Feil EG, Barrera M. The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results. Prev Med 2003 Apr;36(4):410-419. [Medline] [CrossRef]
- Mckay HG, Glasgow RE, Feil EG, Boles SM, Barrera JM. Internet-based diabetes self-management and support: initial outcomes from the Diabetes Network project. Rehabil Psychol 2002;47(1):31-48. [CrossRef]
- Bass DM, McClendon MJ, Brennan PF, Mccarthy C. The buffering effect of a computer support network on caregiver strain. J Aging Health 1998 Feb;10(1):20-43. [Medline]
- Brennan PF, Moore SM, Smyth KA. ComputerLink: electronic support for the home caregiver. ANS Adv Nurs Sci 1991 Jun;13(4):14-27. [Medline]
- Brennan PF, Moore SM, Smyth KA. Alzheimer's disease caregivers' uses of a computer network. West J Nurs Res 1992 Oct;14(5):662-673. [Medline]
- Brennan PF, Moore SM. Networks for home care support: the ComputerLink project. Caring 1994 Aug;13(8):64-70. [Medline]
- Brennan PF, Moore SM, Smyth KA. The effects of a special computer network on caregivers of persons with Alzheimer's disease. Nurs Res 1995;44(3):166-172. [Medline]
- Casper GR, Calvitti A, Brennan PF, Overholt JL. ComputerLink: the impact of a computer network on Alzheimer's caregivers' decision-making confidence and skill. Medinfo 1995;8:1546. [Medline]
- McClendon MJ, Bass DM, Brennan PF, McCarthy C. A computer network for Alzheimer's caregivers and use of support group services. J Ment Health Aging 1998;4(4):403-419.
- Brennan PF, Ripich S, Moore SM. The use of home-based computers to support persons living with AIDS/ARC. J Community Health Nurs 1991;8(1):3-14. [Medline] [CrossRef]
- Brennan PF, Ripich S. Use of a home-care computer network by persons with AIDS. Int J Technol Assess Health Care 1994;10(2):258-272. [Medline]
- Flatley-Brennan P. Computer network home care demonstration: a randomized trial in persons living with AIDS. Comput Biol Med 1998 Sep;28(5):489-508. [Medline] [CrossRef]
- Chang T, Yeh CJ, Krumboltz JD. Process and outcome evaluation of an online support group for Asian American male college students. J Couns Psychol 2001;48(3):319-329. [CrossRef]
- Christensen H, Griffiths KM, Korten A. Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. J Med Internet Res 2002 Feb 15;4(1):e3 [FREE Full text] [Medline] [CrossRef]
- Cudney SA, Weinert C. Computer-based support groups. Nursing in cyberspace. Comput Nurs 2000;18(1):35-43. [Medline]
- Smith L, Weinert C. Telecommunication support for rural women with diabetes. Diabetes Educ 2000;26(4):645-655. [Medline]
- Delgado DH, Costigan J, Wu R, Ross HJ. An interactive Internet site for the management of patients with congestive heart failure. Can J Cardiol 2003 Nov;19(12):1381-1385. [Medline]
- Wu RC, Delgado D, Costigan J, Maciver J, Ross H. Pilot study of an Internet patient-physician communication tool for heart failure disease management. J Med Internet Res 2005 Mar 26;7(1):e8 [FREE Full text] [Medline] [CrossRef]
- Dunham PJ, Hurshman A, Litwin E, Gusella J, Ellsworth C, Dodd PW. Computer-mediated social support: single young mothers as a model system. Am J Community Psychol 1998 Apr;26(2):281-306. [Medline] [CrossRef]
- Feil EG, Noell J, Lichtenstein E, Boles SM, Mckay HG. Evaluation of an Internet-based smoking cessation program: lessons learned from a pilot study. Nicotine Tob Res 2003 Apr;5(2):189-194. [Medline]
- Glueckauf RL, Loomis JS. Alzheimer's Caregiver Support Online: lessons learned, initial findings and future directions. NeuroRehabilitation 2003;18(2):135-146. [Medline]
- Gómez EJ, Cáceres C, López D, Del Pozo F. A web-based self-monitoring system for people living with HIV/AIDS. Comput Methods Programs Biomed 2002 Jul;69(1):75-86. [Medline] [CrossRef]
- Gray JE, Safran C, Davis RB, Pompilio-weitzner G, Stewart JE, Zaccagnini L, et al. Baby CareLink: using the internet and telemedicine to improve care for high-risk infants. Pediatrics 2000 Dec;106(6):1318-1324 [FREE Full text] [Medline] [CrossRef]
- Greist JH, Osgood-Hynes DJ, Baer L, Marks IM. Technology-based advances in the management of depression: focus on the COPE<sup>TM</sup> program. Disease Management & Health Outcomes 2000;7(4):193-200. [CrossRef]
- Gustafson D, Wise M, Mctavish F, et al. Development and pivotal evaluation of a computer-based support system for women with breast cancer. J Psychosoc Oncol 1993;11(4):69-93. [CrossRef]
- Gustafson DH, Hawkins R, Pingree S, Mctavish F, Arora NK, Mendenhall J, et al. Effect of computer support on younger women with breast cancer. J Gen Intern Med 2001 Jul;16(7):435-445. [Medline] [CrossRef]
- Gustafson DH, Hawkins R, Boberg E, Pingree S, Serlin RE, Graziano F, et al. Impact of a patient-centered, computer-based health information/support system. Am J Prev Med 1999 Jan;16(1):1-9. [Medline] [CrossRef]
- Harvey-Berino J, Pintauro S, Buzzell P, Digiulio M, Casey Gold B, Moldovan C, et al. Does using the Internet facilitate the maintenance of weight loss? Int J Obes Relat Metab Disord 2002 Sep;26(9):1254-1260. [CrossRef] [Medline]
- Harvey-berino J, Pintauro SJ, Gold EC. The feasibility of using Internet support for the maintenance of weight loss. Behav Modif 2002 Jan;26(1):103-116. [Medline] [CrossRef]
- Hejlesen OK, Plougmann S, Cavan DA. DiasNet--an Internet tool for communication and education in diabetes. Stud Health Technol Inform 2000;77:563-567. [Medline]
- Holden G, Bearison DJ, Rode DC, Kapiloff MF, Rosenberg G, Rosenzweig J. The impact of a computer network on pediatric pain and anxiety: a randomized controlled clinical trial. Soc Work Health Care 2002;36(2):21-33. [Medline] [CrossRef]
- Hudson DB, Elek SM, Westfall JR, Grabau A, Fleck MO. Young Parents Project: a 21st-century nursing intervention. Issues Compr Pediatr Nurs 1999;22(4):153-165. [Medline] [CrossRef]
- Iafusco D, Ingenito N, Prisco F. The chatline as a communication and educational tool in adolescents with insulin-dependent diabetes: preliminary observations. Diabetes Care 2000 Dec;23(12):1853 [FREE Full text] [Medline]
- Johnson KB, Ravert RD, A Everton H. Teen central: assessment of an Internet-based support system for children with cystic fibrosis. Pediatrics 2001;107(2) art.no.e24. [Medline]
- Lange A, Rietdijk D, Hudcovicova M, Van De Ven JP, Schrieken B, Emmelkamp PMG. Interapy: a controlled randomized trial of the standardized treatment of posttraumatic stress through the internet. J Consult Clin Psychol 2003 Oct;71(5):901-909. [CrossRef] [Medline]
- Lieberman MA, Golant M, Giese-davis J, Winzlenberg A, Benjamin H, Humphreys K, et al. Electronic support groups for breast carcinoma: a clinical trial of effectiveness. Cancer 2003 Feb 15;97(4):920-925. [CrossRef] [Medline]
- Lorig KR, Laurent DD, Deyo RA, Marnell ME, Minor MA, Ritter PL. Can a Back Pain E-mail Discussion Group improve health status and lower health care costs?: A randomized study. Arch Intern Med 2002 Apr 8;162(7):792-796. [Medline] [CrossRef]
- Mahoney DF, Tarlow B, Sandaire J. A computer-mediated intervention for Alzheimer's caregivers. Comput Nurs 1998;16(4):208-216. [Medline]
- Marshall AL, et al. Print versus website physical activity programs: a randomized trial. Am J Prev Med 2003 Aug;25(2):88-94. [Medline]
- 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. Ann Behav Med 2003;25(2):92-99. [Medline] [CrossRef]
- Pierce LL, Steiner V, Govoni AL. In-home online support for caregivers of survivors of stroke: a feasibility study. Comput Inform Nurs 2002;20(4):157-164. [Medline] [CrossRef]
- Ritterband LM, Cox DJ, Walker LS, Kovatchev B, Mcknight L, Patel K, et al. An Internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol 2003 Oct;71(5):910-917. [CrossRef] [Medline]
- Robinson PH, Serfaty MA. The use of e-mail in the identification of bulimia nervosa and its treatment. European Eating Disorders Review 2001;9(3):182-193. [CrossRef]
- Ross SE, Moore LA, Earnest MA, Wittevrongel L, Lin CT. Providing a web-based online medical record with electronic communication capabilities to patients with congestive heart failure: randomized trial. J Med Internet Res 2004 May 14;6(2):e12 [FREE Full text] [Medline] [CrossRef]
- Southard BH, Southard DR, Nuckolls J. Clinical trial of an Internet-based case management system for secondary prevention of heart disease. J Cardiopulm Rehabil 2003;23(5):341-348. [Medline] [CrossRef]
- Takahashi Y, Satomura K, Miyagishima K, Nakahara T, Higashiyama A, Iwai K, et al. A new smoking cessation programme using the Internet. Tob Control 1999;8(1):109-110 [FREE Full text] [Medline]
- Tate DF, Wing RR, Winett RA. Using Internet technology to deliver a behavioral weight loss program. JAMA 2001 Mar 7;285(9):1172-1177 [FREE Full text] [Medline] [CrossRef]
- Tate DF, Jackvony EH, Wing RR. Effects of Internet behavioral counseling on weight loss in adults at risk for type 2 diabetes: a randomized trial. JAMA 2003 Apr 9;289(14):1833-1836 [FREE Full text] [CrossRef] [Medline]
- Verheijden M, Bakx JC, Akkermans R, Van Den Hoogen H, Godwin NM, Rosser W, et al. Web-based targeted nutrition counselling and social support for patients at increased cardiovascular risk in general practice: randomized controlled trial. J Med Internet Res 2004 Dec 16;6(4):e44 [FREE Full text] [Medline] [CrossRef]
- Winzelberg AJ, Classen C, Alpers GW, Roberts H, Koopman C, Adams RE, et al. Evaluation of an internet support group for women with primary breast cancer. Cancer 2003 Mar 1;97(5):1164-1173. [CrossRef] [Medline]
- Dev P, Winzelberg AJ, Celio A, Taylor CB. Student bodies: psycho-education communities on the Web. Proc AMIA Symp 1999:510-514. [Medline]
- Celio AA, Winzelberg AJ, Wilfley DE, Eppstein-Herald D, Springer EA, Dev P, et al. Reducing risk factors for eating disorders: comparison of an Internet- and a classroom-delivered psychoeducational program. J Consult Clin Psychol 2000 Aug;68(4):650-657. [Medline] [CrossRef]
- Winzelberg AJ, Taylor CB, Sharpe T, Eldredge KL, Dev P, Constantinou PS. Evaluation of a computer-mediated eating disorder intervention program. Int J Eat Disord 1998 Dec;24(4):339-349. [Medline] [CrossRef]
- Winzelberg AJ, Eppstein D, Eldredge KL, Wilfley D, Dasmahapatra R, Dev P, et al. Effectiveness of an Internet-based program for reducing risk factors for eating disorders. J Consult Clin Psychol 2000 Apr;68(2):346-350. [Medline] [CrossRef]
- Zabinski MF, Pung MA, Wilfley DE, Eppstein DL, Winzelberg AJ, Celio A, et al. Reducing risk factors for eating disorders: targeting at-risk women with a computerized psychoeducational program. Int J Eat Disord 2001 May;29(4):401-408. [Medline] [CrossRef]
- Zabinski MF, Wilfley DE, Pung MA, Winzelberg AJ, Eldredge K, Taylor CB. An interactive internet-based intervention for women at risk of eating disorders: a pilot study. Int J Eat Disord 2001 Sep;30(2):129-137. [Medline] [CrossRef]
- Low KG, Charanasomboon S, Lesser J, Reinhalter K, Martin R, Jones H, et al. Effectiveness of a computer-based interactive eating disorders prevention program at long-term follow-up. Eat Disord 2003;14(1):17-30. [Medline] [CrossRef]
- Pagliari C, Sloan D, Gregor P, Sullivan F, Detmer D, Kahan JP, et al. What is eHealth (4): a scoping exercise to map the field. J Med Internet Res 2005 Mar 31;7(1):e9 [FREE Full text] [Medline] [CrossRef]
- Wyatt JC, Sullivan F. eHealth and the future: promise or peril? BMJ 2005 Dec 10;331(7529):1391-1393. [Medline] [CrossRef]
- Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. BMJ 2000 Sep 16;321(7262):694-696 [FREE Full text] [PMC] [Medline]
|AIDS: acquired immunodeficiency syndrome|
|CBT: cognitive behavior therapy|
|HIV: human immunodeficiency virus|
Edited by G. Eysenbach; submitted 20.12.05; peer-reviewed by E Murray; comments to author 10.01.06; revised version received 23.02.06; accepted 07.03.06; published 23.06.06
© Frances Griffiths, Antje Lindenmeyer, John Powell, Margaret Thorogood. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 23.06.2006. Except where otherwise noted, articles published in the Journal of Medical Internet Research are distributed under the terms of the Creative Commons Attribution License (http://www.creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited, including full bibliographic details and the URL (see "please cite as" above), and this statement is included.