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Patient empowerment is growing in popularity and application. Due to the increasing possibilities of the Internet and eHealth, many initiatives that are aimed at empowering patients are delivered online.
Our objective was to evaluate whether Web-based interventions are effective in increasing patient empowerment compared with usual care or face-to-face interventions.
We performed a systematic review by searching the MEDLINE, EMBASE, and PsycINFO databases from January 1985 to January 2009 for relevant citations. From the 7096 unique citations retrieved from the search strategy, we included 14 randomized controlled trials (RCTs) that met all inclusion criteria. Pairs of review authors assessed the methodological quality of the obtained studies using the Downs and Black checklist. A meta-analysis was performed on studies that measured comparable outcomes. The GRADE approach was used to determine the level of evidence for each outcome.
In comparison with usual care or no care, Web-based interventions had a significant positive effect on empowerment measured with the Diabetes Empowerment Scale (2 studies, standardized mean difference [SMD] = 0.61, 95% confidence interval [CI] 0.29 - 0.94]), on self-efficacy measured with disease-specific self-efficacy scales (9 studies, SMD = 0.23, 95% CI 0.12 - 0.33), and on mastery measured with the Pearlin Mastery Scale (1 study, mean difference [MD] = 2.95, 95% CI 1.66 - 4.24). No effects were found for self-efficacy measured with general self-efficacy scales (3 studies, SMD = 0.05, 95% CI -0.25 to 0.35) or for self-esteem measured with the Rosenberg Self-Esteem Scale (1 study, MD = -0.38, 95% CI -2.45 to 1.69). Furthermore, when comparing Web-based interventions with face-to-face deliveries of the same interventions, no significant (beneficial or harmful) effects were found for mastery (1 study, MD = 1.20, 95% CI -1.73 to 4.13) and self-esteem (1 study, MD = -0.10, 95% CI -0.45 to 0.25).
Web-based interventions showed positive effects on empowerment measured with the Diabetes Empowerment Scale, disease-specific self-efficacy scales and the Pearlin Mastery Scale. Because of the low quality of evidence we found, the results should be interpreted with caution. The clinical relevance of the findings can be questioned because the significant effects we found were, in general, small.
Patient empowerment refers to the enhanced ability of patients to actively understand and influence their own health status [
Since its introduction to health care in the 1970s [
During the last decades, the focus on empowerment resulted in many initiatives to increase patient empowerment. In general, strategies to increase patient empowerment have tended to address two aspects of patients’ experience of illness: (1) disease management and (2) relationships with health care providers [
Although some face-to-face or group session interventions to increase patient empowerment have been found to be effective, for example, in decreasing depression [
In this systematic review, we investigated whether these Web-based interventions were effective in increasing patient empowerment compared with usual care or face-to-face interventions.
Only randomized controlled trials (RCT), quasi-randomized controlled trials, before-and-after studies, and interrupted time series analyses were included.
Studies in which the intervention was aimed at patients or clients with a medical problem were included. Studies that included children and adolescents less than 18 years of age were excluded to create more homogeneity in the study population.
Studies in which the treatment consisted of a Web-based intervention were included. Web-based interventions were defined as all interactive Web applications accessed via the Internet or an intranet. Furthermore, we excluded studies if the intervention did not contain any aspects of health education or intention to change health-related behavior.
Studies were included only if the control intervention consisted of either usual care or a face-to-face intervention.
Studies that measured empowerment or an empowerment-related component were included. Given the absence of a generally accepted definition of empowerment and conflicting views on how to measure empowerment, we decided to initially include concepts that are often linked to empowerment. Examples of these are self-efficacy, mastery, self-control, self-esteem, perceived control, perceived competence, or involvement in the decision-making process [
No language restriction was applied.
Publications were retrieved by a search of the following electronic databases:
MEDLINE (l985 to January 2009)
EMBASE (1985 to January 2009)
PsycINFO (1985 to January 2009)
Detailed search strategies are presented in the Multimedia Appendix. Briefly, we combined two search concepts, the first consisting of the outcome measure (eg, “empowerment” or “self-efficacy”) and the second of the intervention (eg, “Internet” or “website”). Various synonyms were used for each concept. We chose a sensitive search strategy so that we would not miss any potentially relevant publications.
Citations and brief records identified by the search strategy were downloaded electronically to the bibliographic management package Reference Manager 11 (Thomson Reuters, Carlsbad, CA, USA). The study selection was completed in three steps. In step 1, two reviewers (authors DS and DB) independently screened the titles, keywords, and abstracts of the studies obtained by the search strategy to determine if they met the inclusion criteria. When inclusion or exclusion of a study could not be based on the screening of the title, keywords, and abstract, in step 2, the full article was retrieved and checked for inclusion. This was again, done by two reviewers (authors DS and NE). A consensus meeting with a third reviewer (DB) was arranged to sort out disagreements between reviewers. In step 3, we searched the reference lists of the included studies to find additional publications. Additionally, from all citations that were initially identified by the search strategy, we checked all systematic reviews concerning Web-based interventions and searched in the reference lists of these reviews to find additional publications that met our inclusion criteria.
Two reviewers (DS and NE) extracted the data using a data extraction form that included information on study design, randomization level, population, follow-up period, description of the intervention and control group treatments, and data on relevant outcomes. If certain studies did not report sufficient information on the outcomes, missing data (for example, standard deviations) were calculated according to guidelines in the
We evaluated the quality of individual studies using the Downs and Black quality assessment method, which is a list of 27 criteria to evaluate both randomized and nonrandomized trials [
Two reviewers (DS and DB) independently assessed the quality of the included studies. A consensus method was used to resolve disagreement.
Analyses of this review were based on the outcome measure, that is, empowerment or an empowerment-related outcome. For studies that were comparable with respect to the control intervention and the outcome, results were pooled using meta-analyses. In these analyses, we included final measurements of continuous data. We were able to do so, because all included studies in this review were RCTs or quasi-RCTs, and no study reported significant baseline differences between the intervention and the control group. Since there were many different scales or instruments used to measure the same outcome, we could not use weighted mean differences and therefore calculated standardized mean differences (SMD). SMDs obtained from the meta-analyses were then reexpressed to a familiar instrument, using a so-called back-translation technique. In this technique, an instrument is selected from a study included in the meta-analysis that is representative of the population and at a low risk of bias, and then the standard deviation of the outcome measure of the control group of this study (the end of study mean) is multiplied by the pooled SMD.
We chose a random-effects meta-analysis because it was considered a more appropriate model to combine the results of the included studies, which were clinically and methodologically diverse [
We present the overall quality of the evidence using the GRADE approach as recommended by the
From all databases combined, we identified a total of 7676 titles: 1823 in MEDLINE, 3540 in EMBASE and 2313 in PsychINFO. After exclusion of duplicates, DS and DB reviewed the 7096 titles and abstracts.
Study selection
We selected 289 publications for retrieval of full text versions. From these 289 studies, initially 18 publications met our inclusion criteria: these were publications reporting results of 16 RCTs and 2 quasi-RCTs. The main reason for excluding studies was based on the outcome criteria: the majority of the studies did not measure empowerment or an empowerment-related outcome. From the 18 studies that initially met our inclusion criteria, 2 publications of Man et al [
Characteristics of the included studies
Citation | Population/ |
Duration of |
Intervention | Comparison |
Outcome |
Quality |
Cousineau et al 2008 [ |
Online psycho-educational support for infertile women (190, 100%) | 4 weeks (3%) | Tailored website containing in vitro fertilization (IVF)-specific cognitive behavioural skill training (CBT) and stress management. Total content: 90 minutes, available over a 4-week periodb,c,e | Waiting list | Self-efficacy, infertility specific (Infertility Self-Efficacy Scale [ |
26, Excellent |
Gollings et al 2005 [ |
Treatment of body dissatisfaction among women 18 to 30 years old (39, 100%) | 8 weeks (18%) | The Set Your Body Free Group Body Image Program: eight therapist-led, online chat sessions (weekly, session duration: 90 minutes), 24/7 discussion boarda | Face-to-face delivery of the same intervention | Self-esteem (Rosenberg Self-esteem Scale [RSE] [ |
16, Fair |
Hill et al 2006 [ |
Increasing psychological health among chronically ill, rural women(12, 100%) | 12 weeks (17%) | Women-to-Women (WTW) project: an online web-based educational tool aimed at increasing Web skills, coping with chronic illness, handling family finances, etca,b | No care | (1) Empowerment (adapted Diabetes Empowerment Scale [DES] [ |
17, Fair |
Hirai and Clum 2005 [ |
Internet help for patients with posttraumatic stress disorder (36, 78%) | 8 weeks (25%) | Internet-based, interactive cognitive behaviour program (8 weeks) consisting of relaxation training, mastery tests, cognitive restructuring and exposure modulesc | Waiting list | Self-efficacy, post-traumatic syndrome specific (adapted scale) | 15, Fair |
Homko et al 2007 [ |
Managing underserved women with gestational diabetes mellitus in a prenatal clinic (63, 100%) | From 4 to 37 weeks, depending on gestation at inclusion (10%) | Web-based disease management interactive telemedicine system. Components: health information and education, patient electronic medical record, and communication with health teama,b,d | Paper logbook | Empowerment (DES [ |
18, Fair |
Lorig et al 2002 [ |
Internet help for back pain patients (580, 39%) | 1 year (27%) | Closed and moderated email discussion group, copy of the Back Pain Helpbook, and a videotape on how to continue active life with back paina | Usual care | Self-efficacy, specific to management of back pain (adapted scale) | 20, Good |
Lorig et al 2006 [ |
Internet help for patients with chronic diseases (heart or lung disease and type 2 diabetes) (958, 71%) | 1 year (19%) | Interactive website (6-week program) based on the book |
Usual care | Self-efficacy, disease management specific (adapted scale) | 20, Good |
Lorig et al 2008 [ |
Internet-based arthritis self-management program for patients with fibromyalgia (855, 90%) | 6 months (25%) | Arthritis Self-Management (6-week) Program: health education, bulletin board discussion, individual tools such as exercise logs, medication diaries, and a tailored exercise program a,b,c,d,e | Usual care | Self-efficacy, arthritis specific |
22, Good |
Man et al 2006 [ |
Problem-solving skill training for people with acquired brain injury (ABI) (59, 43%) | 8 weeks (24%) | Online interactive multimedia presentations on knowledge and concepts required for persons with ABI to function independently c | Waiting list | Self-efficacy, ABI specific (adapted scale) | 21, Good |
Nguyen et al 2008 [ |
Internet-based dyspnea self-management program for patients with chronic obstructive pulmonary disease (50, 44%) | 6 months (22%) | Website containing structured education for dyspnea management strategies, skills training, peer interaction, symptom and exercise monitoring, and exercise consultations (6- month program)a,b,c,d | Face-to-face delivery of the same intervention | Mastery, subscale of the Chronic Respiratory Questionnaire (CRQ [ |
20, Good |
Ross et al 2004 [ |
Web-based online medical record for patients with congestive heart failure in a speciality clinic (107, 23%) | 6 months (22%) | SPPARO web interface, providing patients with a medical record, educational guide and a messaging systema,b,d | Usual care | Self-efficacy, patient specific (adapted scale) |
23, Good |
Tuil et al 2007 [ |
Internet-based personal health record for patients undergoing IVF and intracytoplasmic sperm injection (ICSI) treatment in an academic research environment |
16 weeks (26%) | IVF educational interactive website consisting of general information, a personal medical record with tailored clarifications, and communication (forum, email, chat)a,b,d,e | Usual care | (1) General self-efficacy (GES [ |
18, Fair |
Warmerdam et al 2009 [ |
Internet treatment for adults with depressive symptoms (263, 71%) | Intervention 1:12 weeks (46%) Intervention 2: 5 weeks (42%) | Intervention 1: Cognitive Behavioral Therapy (12 weeks) based on changing patients’ cognitive patternsc Intervention 2: Problem-Solving Treatment (5 weeks) aiming at controlling practical problems patients facec | Waiting list | Mastery (Pearlin Mastery Scale [ |
23, Good |
Zutz et al 2007 [ |
Website for potential participants for hospital-based cardiac rehabilitation programs (15, 20%) | 12 weeks (13%) | Website with the ability to interactively monitor heart rate and blood pressure. Plus scheduled one-on-one chat sessions with program nurse case manager, weekly education sessions and monthly ask-an-expert group chata,b,d | Usual care | (1) General Self-efficacy (GSE [ |
15, Fair |
Web-based intervention contains:
a communication options, such as a forum, chat or (moderated) discussion board
b health information to increase knowledge
c disease specific self-management modules
d e-monitoring, such as a patient medical records or symptom diaries
e tailored messages or information
Of the 14 included studies, 13 were RCTs, while the study that was reported in two publications [
The duration of the follow-up measurements varied from 8 weeks [
The number of participants varied from 15 [
Empowerment was explicitly measured in only two studies. Both of these used the Diabetes Empowerment Scale (DES) [
The quality of the included studies varied. According to the calculated quality assessment score (QAS), none of the studies were rated as being of poor quality, 6 studies were rated fair, 7 were rated good, and 1 was rated excellent. The mean QAS for the included studies was 19.6. Studies scored particularly poor on the following items: patient blinding (11 of 14), blinding of the outcome assessor (12 of 14), failure to adjust for confounding factors in the analysis (11 of 14), bias due to losses of patients to follow-up (9 of 14), and insufficient power to detect outcomes that are clinically important (6 of 14). Furthermore, in 9 of the 14 studies the randomization method and concealment were not described adequately. Because participants in Web-based research are not representative of the whole patient population (in this case through a selection process of only Internet users), the external validity of all studies was rated poor.
Empowerment was measured in 2 studies with the Diabetes Empowerment Scale (DES). Homko et al [
Because the study of Hill et al included only the 10-item “Setting and Achieving Goals” subscale from the DES, our comparison of the two studies was based on the results of this subscale alone.
Based on the GRADE approach, we downgraded the level of evidence two levels, that is, from high to low, on basis of the studies’ limitations and imprecision of the results (
Therefore, based on 2 RCTs (combined n = 157) our results, shown in
Comparison of Web-based interventions versus usual care for the outcome empowerment
Of the 14 included studies, 9 studies provided sufficient data for calculation of an SMD for disease-specific self-efficacy outcomes. Cousineau et al [
According to GRADE guidelines, we downgraded the level of evidence for this outcome by one level from high to moderate based on studies’ limitations (see
Visual inspection of the funnel plot on this outcome indicated a possibility of publication bias.
Therefore, there was moderate quality evidence from 9 studies (combined n = 2402) that Web-based interventions had a significant positive effect on self-efficacy measured with disease-specific self-efficacy scales.
Comparison of Web-based versus usual care for the outcome disease-specific self-efficacy
Funnel plot for comparison of Web-based interventions versus usual care for the outcome disease-specific self-efficacy
In three studies, general self-efficacy was measured using general self-efficacy (GSE) scales [
We downgraded the level of evidence by two levels, from high to low, based on limitations in the studies and on basis of imprecision of the results (see
Therefore, based on the GRADE approach, there was low quality evidence from 3 studies (combined n = 293) that there was no statistically significant difference between Web-based interventions and usual care in increasing general self-efficacy. The SMD of these 3 studies was 0.05 (95% CI -0.25 to 0.35). (See
Comparison of Web-based versus usual care for the outcome general self-efficacy
One study used the Pearlin Mastery Scale [
The mean difference [MD] was 2.95 (95% CI 1.66 - 4.24).
Because there was only one study available, according to GRADE there was low quality evidence (one study, n = 263) that Web-based interventions had a significant positive effect on mastery measured with the Pearlin Mastery scale.
Only one study included a measurement of the construct self-esteem, measured with the Rosenberg Self-esteem (RSE) Scale [
For this one study (n = 120), based on the GRADE approach, there was low quality evidence that there was no statistically significant difference between Web-based interventions and usual care in increasing self-esteem.
Summarized in
To be able to make clinical interpretations of the reported SMDs described above, we reexpressed the pooled SMDs into MDs, by using the technique of back-translation to a familiar instrument. This technique has been described in more detail elsewhere [
Overall judgment of quality of evidence using the GRADE approach
Outcome Measure | N of Studies | Limitations | Inconsistency | Indirectness | Imprecision | Quality of Evidence |
Empowerment | 2 | Seriousa,b,c | No serious |
No serious |
Seriousd | Lowe |
Self-efficacy (specific) | 9 | Seriousa,b,c | No serious |
No serious |
No serious |
Moderatef |
Self-efficacy (general) | 3 | Seriousa,b,c | No serious |
No serious |
Seriousd | Lowe |
Mastery | 1 | - | - | - | - | Lowg |
Self-esteem | 1 | - | - | - | - | Lowg |
a Possibility of a lack of allocation concealment
b Lack of blinding
c The majority of the studies did not apply intention-to-treat analyses
d Pooled effect size upper/lower confidence limit crosses 0.5
e Not enough studies available for a funnel plot
f Publication bias is likely, but it does not affect the pooled estimate
g Low quality of evidence on basis of only 1 study available
Back-translation of SMDs into MDs by using a familiar instrument
Outcome |
N of |
Mean Follow- |
Relative Effect | Chosen Instrument for Back-calculation (Range) | Absolute Effect |
Empowerment | 157 | 12 weeks | SMD = 0.61 (95% CI 0.29 - 0.94) | DES [ |
MD 0.31 |
Self-efficacy (specific) | 2402 | 23 weeks | SMD = 0.23 (95% CI 0.12 - 0.33) | Self-efficacy Scale, as used by Lorig et al [ |
MD 0.42 (95% CI 0.22 - 0.6) |
Self-efficacy (general) | 293 | 13 weeks | SMD = 0.05 (95% CI -0.25 to 0.35) | General Self-efficacy Scale Schwarzer [ |
MD 0.02 (95% CI -0.1 to 0.14) |
Nguyen et al [
Because we found only one study (n = 50) in this category, there is low quality evidence that there is no statistically significant difference between Web-based interventions and face-to-face interventions in increasing mastery.
Gollings et al [
Again, because we found only one study (n = 39) in this category, there is low quality evidence that there is no statistically significant difference between Web-based interventions and face-to-face interventions in increasing self-esteem (MD = -0.10, 95% CI -0.45 to 0.25).
The Internet revolution and growing need for patient empowerment initiatives has resulted in many Web-based empowerment interventions that have been scientifically evaluated. With this systematic review we intended to gain more insight into the effectiveness of these interventions on empowerment or empowerment-related outcomes.
In this systematic review, 13 RCTs and 1 quasi-RCT were included. The included studies were clinically heterogeneous regarding included patients, duration and intensity of the intervention, duration of follow-up, and measured outcomes. Statistical pooling was considered to be appropriate in studies measuring the same outcome and comparing the same treatments (either Web-based vs usual care or Web-based vs face-to-face). This resulted in seven comparisons. Statistical pooling within these comparisons showed that Web-based interventions have a significant positive effect on empowerment measured with the DES (2 studies), self-efficacy measured with disease-specific self-efficacy instruments (9 studies), and mastery measured with the Pearlin Mastery Scale (1 study). No significant effects of Web-based interventions were found on self-efficacy measured with general self-efficacy scales (3 studies) and self-esteem measured with the Rosenberg self-esteem scale (1 study). When comparing Web-based interventions with face-to-face deliveries of the same interventions, no statistically significant effect was found in favor of either one of the two deliveries, when the outcome mastery (1 study) or self-esteem (1 study) was measured. Based on the GRADE approach, we found that the evidence for most of the findings described above is of low quality. This means that high quality future research is likely to have an effect on our confidence in the estimate of the effect. The main reason for the low quality of evidence was that many comparisons contained only one study. In the comparisons with more studies available, limitations in study design (lack of blinding, allocation of treatment, not taking into account loss to follow-up) and imprecision of the results, resulted in downgrading the level of evidence.
Although the results of this systematic review indicated that there is some evidence that Web-based interventions are effective in increasing certain empowerment or empowerment-related outcomes, the level of evidence for these effects is rather low, and the results should be interpreted with caution. The basis for the low evidence lies in several methodological issues. First, almost all included studies based their main conclusions on analysis of treatment rather than intention to treat. In this case, results are exposed to a high risk of bias, because characteristics from participants who comply with the treatment may differ from non-participants. This is especially the case in Web-based interventions, where it is known that selection bias is evident, that is, familiarity with the use of computers and the Internet leads to self selection in the use of these technologies [
Another concern is the likelihood of publication bias. In the comparison where disease-specific self-efficacy was the outcome, a funnel plot showed some evidence of bias due to publication of smaller and more effective studies or pilot studies [
Despite these limitations, our meta-analysis included only RCTs or quasi RCTs, which gives our findings a greater robustness than would have been possible if other study designs had been included. Furthermore, by applying the GRADE approach to determine the level of evidence of the effect of an intervention on a set of relevant outcomes, we were able to draw balanced conclusions and give transparency on the basis of how this level of evidence was determined.
A final point involving the methodology of this review is our choice to statistically pool the results of some of the included studies. Even though pooling included studies that measured the same outcome, these studies were clinically heterogeneous with regard to types of patients, duration and intensity of intervention, and duration of follow-up measurements. It has been argued that in the face of this diversity one should not attempt to perform a meta-analysis [
Statistically significant effectiveness of Web-based interventions on disease-specific self-efficacy was found. On the other hand, no effects were found for general self-efficacy. Because general self-efficacy refers to a broad and stable sense of personal competence, it is possible that Web-based interventions aimed at a specific target patient population are too specific to influence a stable personal characteristic (ie, a trait). Therefore, it has been recommended that for the majority of applications, perceived self-efficacy should be conceptualized in a situation-specific manner [
From the results of this review, little is known about the sustainability of the effects. In most cases we included data that was measured directly after participants were exposed to the intervention. The effects that are reported, therefore, reflect a direct effect of the intervention. On the other hand, in the studies of Lorig et al [
We calculated SMDs in this review. This means that the effect sizes presented do not represent certain improvements on specific instruments. To be able to say something about the magnitude of the effect sizes we found, we used back translations of SMDs to a familiar instrument. The results of these back calculations are shown in
Based on this review, there is some evidence that the Internet can be an effective method to increase patient empowerment. The results from this review show that Web-based interventions can be effective in increasing empowerment among patients who are, for example, suffering from diabetes, depression, infertility, or arthritis. These findings are in line with the growing literature on the effectiveness of eHealth interventions in general, and on outcomes other than patient empowerment [
The outcome empowerment usually refers to achieving self-efficacy, mastery, and control. Although many researchers underline that these constructs are closely related to the concept empowerment [
We thank Ilse Jansma for her contribution in developing the search strategy and Piet Kostense for statistical support.
None declared
DS and DB contributed to protocol design, selection of studies, data extraction, statistical analysis, and data interpretation. NE contributed to the selection of studies and data extraction. DS wrote the manuscript, which was commented on by DB, NE, HA, and AB. All authors have seen and approved the final version of this paper.
Medline search strategy
acquired brain injury
cognitive behavioral therapy
chronic obstructive pulmonary disease
Chronic Respiratory Questionnaire
Diabetes Empowerment Scale
General Self-Efficacy Scale
intracytoplasmic sperm injection
in vitro fertilization
mean difference
problem-solving treatment
quality assessment scale
randomized controlled trial
Rosenberg Self-esteem Scale
standardized mean difference
Women-to-Women
World Health Organization