This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
Patient empowerment reflects the ability of patients to positively influence their health and health behavior such as physical activity. While interactive Web-based interventions are increasingly used in various chronic disease settings to enhance empowerment and physical activity, such interventions are still uncommon for cancer survivors.
The objective of this study was to systematically review the literature regarding interactive Web-based interventions. We focused on interventions aimed at increasing patient empowerment and physical activity for various chronic conditions, and explored their possible relevance for cancer survivors.
Searches were performed in PubMed, Embase, and Scopus to identify peer-reviewed papers reporting on randomized controlled trials that studied the effects of Web-based interventions. These interventions were developed for adults with diabetes, cardiovascular disease, chronic obstructive pulmonary disease, heart failure, or cancer. Intervention characteristics, effects on patient empowerment and physical activity, information on barriers to and facilitators of intervention use, users’ experiences, and methodological quality were assessed. Results were summarized in a qualitative way. We used the recommendations of the Institute of Medicine (IOM) regarding cancer survivorship care to explore the relevance of the interventions for cancer survivors.
We included 19 papers reporting on trials with 18 unique studies. Significant, positive effects on patient empowerment were reported by 4 studies and 2 studies reported positive effects on physical activity. The remaining studies yielded mixed results or no significant group differences in these outcomes (ie, no change or improvement for all groups). Although the content, duration, and frequency of interventions varied considerably across studies, commonly used elements included education, self-monitoring, feedback/tailored information, self-management training, personal exercise program, and communication (eg, chat, email) with either health care providers or patients. Limited information was found on barriers, facilitators, and users’ experiences. Methodological quality varied, with 13 studies being of moderate quality. The reported Web-based intervention elements appeared to be highly relevant to address the specific needs of cancer survivors as indicated by the IOM.
We identified 7 common elements of interactive, Web-based interventions in chronic disease settings that could possibly be translated into eHealth recommendations for cancer survivors. While further work is needed to determine optimal intervention characteristics, the work performed in other chronic disease settings provides a basis for the design of an interactive eHealth approach to improve patient empowerment and physical activity in cancer survivors. This may subsequently improve their health status and quality of life and reduce their need for supportive care.
Due to improvements in cancer screening and treatment, the number of people living with cancer or that have been successfully treated for cancer is increasing rapidly [
Patient empowerment can contribute to control over patients’ health and health behavior. It is frequently described as having knowledge about one’s health, and being able and motivated to influence one’s health [
Another factor that positively contributes to quality of life is physical activity. A number of studies have demonstrated many beneficial effects of physical activity on physical and psychosocial well-being, both during and after cancer treatment [
A promising medium for facilitating patient empowerment and physical activity is the Internet. Easily accessible, up-to-date, and tailored information can be provided, often in an interactive way. For example, patients could be asked to provide information or pose questions via a questionnaire to trigger either standardized or tailored feedback from the health care system (given automatically or by a health care provider). The Internet is increasingly used for the delivery of these interactive interventions, both for healthy individuals [
This systematic review has 5 aims: (1) to describe the characteristics (content, length, frequency, duration) of interactive, Web-based interventions in diabetes, chronic obstructive pulmonary disease (COPD), (congestive) heart failure, cardiovascular disease, and cancer, (2) to summarize the effects of these interventions on patient empowerment and physical activity. (3) to identify barriers for and facilitators of the use of Web-based interventions and to describe users’ experiences with such websites, (4) to assess the methodological quality of the studies reviewed, and (5) to evaluate the possible relevance of these interventions for cancer survivors.
We searched the literature in PubMed, Embase, and Scopus. The main search strategy combined four concepts: patient empowerment, physical activity, information technology (IT), and type of chronic disease. For each concept, several search terms were used (see
We used the following inclusion criteria: (1) peer reviewed studies in English describing a randomized controlled trial (RCT), published between 1990 and November 20, 2012, (2) participants were adults and suffered from at least one of the following chronic diseases—cancer, diabetes, heart failure, cardiovascular disease, or COPD, (3) the intervention was Web-based and interactive, (4) the intervention group was compared to a similar patient group (receiving another intervention or usual care), and (5) the study included at least one outcome measure assessing patient empowerment and/or physical activity. For patient empowerment, relevant, related outcomes included self-efficacy, self-management, self-care behavior, and self-control. For physical activity, relevant outcomes could be based on self-report (eg, by questionnaire or interview), performance tests, or observation (eg, accelerometer data).
The first author applied the eligibility criteria to the titles and abstracts. When the abstract was considered relevant or in case of ambiguity, two authors reviewed the full publication independently. In cases of disagreement, consensus was sought through discussion. When disagreement persisted, the judgement of a third reviewer was decisive.
The following information was extracted from each publication: study characteristics (source and year of publication, country of origin, aim, and sample size), patient characteristics (type of disease, age, gender, comorbidities, computer experience, and Internet use), intervention characteristics (content, duration, frequency, compliance, and dropout rate), outcome measures (instruments used, and effects on patient empowerment and physical activity), information about barriers to and facilitators of intervention use, and users’ reported experiences with the intervention. The first author independently extracted the data, and the second author checked the data extraction for 20% of the studies to determine inter-rater reliability. This was established by calculating the percentage of agreement. Consensus was reached by discussion. Due to the diversity of outcome measures, sample size, and intervention characteristics, it was not possible to conduct a formal meta-analysis.
The methodological quality of the studies was evaluated, but did not serve as an eligibility criterion. We used a list that was an adapted version of the Cochrane Collaboration Back Review Group [
For each study, all criteria were scored with yes, no, or unclear, resulting in a maximum quality score of 13. In line with other researchers [
To evaluate the relevance of the selected interventions for cancer survivors, we used the 5 factors included as characteristics of cancer survivorship identified by the Institute of Medicine (IOM): surveillance, management of late effects, rehabilitation, psychosocial support, and health promotion [
The initial search yielded 3438 hits. Based on titles and abstracts, 62 publications were selected. The full text of these 62 publications were reviewed, resulting in a selection of 19 publications that met all eligibility criteria [
Flow chart of the search process.
Reviewers’ ratings were in agreement for 89.5% (68/76) of the data extraction elements from the sample. This can be considered as a high level of agreement according to the guidelines of Landis and Koch [
All papers were published in year 2000 or later, with most being published after 2005. The 19 publications described 18 unique studies; two papers by Glasgow et al described the same study at different assessment time-points (4 and 12 months, [
Studies included patients with diabetes (n=11), heart failure (n=3), COPD (n=1), cardiovascular disease (n=1), cancer (n=1), and mixed patient groups (heart disease, lung disease, type 2 diabetes; n=1). The overall mean age of the participants was 60 years (SD 8.5 years, range 40-76 years). For the 18 studies that reported on gender, the median percentage of women was 53.1% (range 6.0%-73.3%). Individuals with comorbid conditions were excluded in 7 studies, and 6 studies provided information about comorbidity (eg, mean number of comorbid conditions). Only 6 studies collected information on participants’ prior experience with computers and/or Internet use. Both computer experience and Internet use were assessed with a variety of self-reported questionnaire items, ranging from times per week to years of experience, making it difficult to compare across studies.
Intervention characteristics for both intervention and control groups are described in
Although the content of the interventions differed, 7 key elements used in the majority of the interventions were identified, including interventions that had significant effects and those that did not. These elements were used in different combinations and were adapted to the specific patient population. The first element was
The overall percentage of dropouts varied between 0.0% and 52.3% (median 17.5%). For the intervention groups (including the control groups that also received a Web-based program) the median dropout rate was 19.7% and for the control groups this was 14.0%. Compliance with the intended intervention varied between 36.6% and 96.0% for the 9 studies that reported on it. The remaining studies did not report compliance, but described aspects of website use, such as number of logins, percentage of people using a certain feature, minutes per session, or percentage of tasks completed. Intervention use varied greatly between studies and participants. All studies that monitored website use found a decline during the intervention period. There was no obvious relationship between dropout rates, compliance, and website use on the one hand, and patient and intervention characteristics on the other hand.
A total of 13 studies included one or more patient empowerment measures. In 4 studies, patient empowerment increased significantly (
Of the14 studies that assessed physical activity, 2 reported significant improvement (
Intervention characteristics.
Study |
Patient group (sample size) | Study design |
Intervention | Follow-up period |
Artinian et al (2007) |
Congestive heart failure |
Pilot RCT with an intervention group and a comparison group receiving usual care |
Home care monitoring system: |
3 months |
Bond et al (2010) |
Diabetes |
RCT with an intervention group and a comparison group receiving usual care | Focus on self-management and psychosocial well-being: |
6 months |
Glasgow et al (2003) |
Type 2 diabetes |
RCT with 3 intervention groups and an Internet information only comparison group (library with articles, automated dietary goal setting, online assessments) |
Aspects of information only and: |
10 months |
|
|
|
(2) Peer support: |
|
|
|
|
(3) both 1 and 2 |
|
Glasgow et al (2010, 2011) | Type 2 diabetes |
RCT with 2 intervention groups and an enhanced usual care comparison group (health risk appraisal feedback, recommendations of preventive care behavior) |
Self-management program with: |
4 months and 12 months, respectively |
|
|
|
(2) Moderate support: |
|
Kim & Kang (2006) |
Type 2 diabetes |
RCT with an intervention group, a print-material comparison group (booklets with tailored exercise strategies), and a comparison group receiving usual care |
Physical activity (PA) intervention: |
12 weeks |
Liebreich et al (2009) |
Type 2 diabetes |
RCT with an intervention group and a comparison group receiving usual care |
Website and counselling: |
12 weeks |
Lorig et al (2006) |
Heart & lung disease, type 2 diabetes |
RCT with an intervention group and a comparison group receiving usual care |
Self-management program and usual care: |
12 months |
Lorig et al (2010) |
Type 2 diabetes |
RCT with 2 intervention groups (only difference was email support; analyzed together) and a comparison group receiving usual care | Self-management program: |
18 months |
McKay et al (2001) |
Type 2 diabetes |
RCT with an intervention group and an information only comparison group (library articles, glucose tracking plus feedback) |
PA intervention: |
8 weeks |
Nguyen et al (2008) |
COPD |
RCT with an intervention group and a face-to-face intervention comparison group (same intervention components) |
Self-management program: |
6 months |
Nguyen et al (2012) | COPD |
RCT with an intervention group, a face-to-face intervention group and a general health education comparison group (home visit, monthly face-to-face education sessions, phone calls with health information) | Self-management program (same components for online and face-to-face group): |
12 months |
Richardson et al (2007) |
Type 2 diabetes |
Pilot RCT with 2 intervention groups (with a focus on either lifestyle goals or structured goals) |
Pedometer-based walking program with a focus on: |
6 weeks |
|
|
|
(2) Structured goals (only targeting steps taken during bouts of at least 10 minutes with at least 60 steps per minute): |
|
Ross et al (2004) |
Congestive heart failure |
RCT with an intervention group and a comparison group receiving usual care |
Secure Web-interface to 3 features, and reminders for system use: |
12 months |
Ruland et al (2012) | Breast and prostate cancer |
RCT with an intervention group and an information only comparison group | Self-management program: |
12 months |
Tomita et al (2009) |
Heart failure |
RCT with an intervention group and a comparison group receiving usual care |
Self-management program in addition to usual care: |
12 months |
Trief et al (2007) |
Diabetes |
RCT with an intervention group and a comparison group receiving usual care |
Telemedicine case management: |
12 months |
Wangberg (2008) |
Type 2 diabetes |
RCT with 2 intervention groups (with a focus on either high or low self-efficacy) |
Self-care intervention tailored to either high or low self-efficacy: |
1 month |
Zutz et al (2007) |
Cardiovascular disease |
Pilot RCT with an intervention group and an observational control comparison group (no contact with either the research staff or the hospital) |
Cardiac rehabilitation program: |
12 weeks |
Intervention outcomes and dropout rates.
Study |
Patient empowerment outcome measurec | Patient empowerment outcomesa,c | Physical activity outcome measurec | Physical activity outcomesa,c | Dropout rate (overall) |
Artinian et al (2007) |
Revised Heart Failure Self-Care Behavior Scale | Self-care + ( |
6 Minutes Walking Test (6MWT) | Exercise performance - ( |
0.0% |
Bond et al (2010) |
Diabetes Empowerment Scale | Self-efficacy + ( |
X | X | 0.0% |
Glasgow et al (2003) |
X | X | Physical Activity Scale for the Elderly | Physical activity - ( |
18.0% |
Glasgow et al (2010) |
Diabetes Self-Efficacy scale | Self-efficacy |
Community Health Activities Model Program for Seniors Questionnaire | Caloric expenditure in physical activity |
4 months |
|
|
12 months + ( |
|
12 months: + ( |
12 months |
Kim & Kang (2006) |
X | X | Self-report instrument adapted from the 7-day physical activity questionnaire (frequency, duration, intensity) | Metabolic equivalents (MET) x hours/week + ( |
0.0% |
Liebreich et al (2009) |
Likert scale (1-5); 12 items |
Self-efficacy - ( |
Godin Leisure-Time Exercise Questionnaire (GLTEQ) |
MET minutes + ( |
10.3% |
|
Likert scale (1-5); 4 items | Behaviour capacity + ( |
GLTEQ | Unweighted minutes + ( |
|
|
|
|
Incorporated in GLTEQ (times/week, average time per session) | Resistance training - ( |
|
Lorig et al (2006) |
Likert scale (1-10) | Self-efficacy - ( |
Scale (0-4) measuring minutes of exercise per week | Stretch/strength exercise + ( |
18.8% |
|
|
|
|
Aerobic exercise - ( |
|
Lorig et al (2010) |
Patient Activation Measure | Patient activation + ( |
A physical activities scale (minutes/week) | Aerobic exercise - ( |
15.8% |
|
Diabetes Self-Efficacy scale | Self-efficacy + ( |
|
|
|
McKay et al (2001) |
X | X | Behavioural Risk Factor Surveillance System | Moderate/vigorous exercise + ( |
12.7% |
|
|
|
|
Walking + ( |
|
Nguyen et al (2008) |
Single question on a 0- to 10- point response scale | Self-efficacy + ( |
Self-report (frequency & duration) | Endurance exercise + ( |
24.0% |
|
|
|
|
Strength exercise + ( |
|
|
|
|
List of 5 descriptions | Stages of change + ( |
|
|
|
|
6MWT | Exercise performance + ( |
|
Nguyen et al (2012) | Single question on a 0- to 10- point response scale | Self-efficacy |
6MWT | Exercise performance |
12.0% |
|
|
|
Incremental treadmill test | Exercise performance |
|
|
|
|
Lifting a wooden dowel | Arm endurance |
|
|
|
|
Self-report (frequency & duration) | Endurance duration |
|
|
|
|
|
Endurance frequency |
|
|
|
|
|
Strengthening frequency |
|
Richardson et al (2007) | X | X | Pedometer (Omron HJ-720IT) | Total steps + ( |
14.0% |
|
|
|
|
Bout steps + ( |
|
Ross et al (2004) |
Kansas City Cardiomyopathy Questionnaire (self-efficacy domain) | Self-efficacy - ( |
X | X | 24.0% |
Ruland et al (2012) | Cancer Behavior Inventory version 2.0 | Self-efficacy |
X | X | 24.6% |
Tomita et al (2009) |
X | X | Self-reported frequency of exercise; participants exercising 2-3 times/week or more were seen as exercisers | Number of exercisers + ( |
19.8% |
Trief et al (2007) |
Diabetes Self-Efficacy scale | Self-efficacy + ( |
X | X | 52.3% |
Wangberg (2008) | Perceived Competence Scales | Self-efficacy - ( |
X | X | 45.9% |
|
Summary of Diabetes Self-Care Activities measure | Self-care behavior + ( |
|
|
|
Zutz et al (2007) |
Likert scoring | Self-efficacy (exercise- specific) + ( |
Minnesota Leisure Time |
Physical activity + ( |
6.7% |
|
|
|
Symptom-limited treadmill exercise stress test | Exercise capacity + ( |
|
a+ is a positive effect; - is no effect
bThe researchers did not provide specific
cX=not applicable
dPositive effect for the Web-based intervention group(s) only
ePositive effect for all groups (including usual care)
fPositive effect for the Web-based intervention group(s) and other intervention groups
Five studies reported on perceived barriers, whereas no studies reported on perceived facilitators of the use of interactive, Web-based interventions. Perceived barriers were typically of a technical nature, including problems with Internet connection, slow loading of website, security concerns, discomfort with using the computer or Internet, and problems with related hardware (eg, PDA, monitor). Ten studies described some users’ experiences, for example, satisfaction scores and a judgment of intervention content. In general, patient satisfaction was high. The personalized nature of the interventions was often cited by participants as being important. In one study [
The concordance between reviewers in rating the methodological quality for the sample of papers evaluated was high (90.3% (47/52), [
Methodological quality assessment.a,b
|
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | Total scored |
Artinian et al (2007) | √ | X | ? | √ | X | √ | ? | √c | X | √ | X | X | √ | 6 |
Bond et al (2010) | √ | X | ? | √ | X | X | √ | √c | X | √ | √ | X | √ | 7 |
Glasgow et al (2003) | √ | X | ? | √ | X | X | ? | √ | X | √ | √ | X | √ | 5 |
Glasgow et al (2010, 2011) | √ | √ | ? | √ | √ | √ | ? | √ | X | √ | √ | √ | √ | 10 |
Kim & Kang (2006) | √ | X | ? | √ | X | X | ? | √c | X | √ | X | X | √ | 5 |
Liebreich et al (2009) | √ | X | ? | X | X | √ | ? | X | X | √ | X | X | √ | 4 |
Lorig et al (2006) | √ | X | ? | √ | √ | X | ? | √ | √ | √ | X | √ | √ | 8 |
Lorig et al (2010) | √ | √ | ? | √ | X | X | ? | √ | √ | √ | X | √ | √ | 8 |
McKay et al (2001) | √ | √ | ? | √ | X | X | ? | √ | X | √ | X | X | √ | 6 |
Nguyen et al (2008) | √ | √ | √ | √ | √ | √ | √ | √ | X | √ | X | √ | √ | 11 |
Nguyen et al (2012) | √ | X | X | √ | √ | √ | √ | √ | X | √ | √ | √ | √ | 10 |
Richardson et al (2007) | √ | X | ? | ? | √ | √ | ? | X | X | √ | X | X | √ | 5 |
Ross et al (2004) | √ | √ | ? | √ | X | X | ? | X | X | √ | X | X | X | 4 |
Ruland et al (2012) | √ | √ | ? | √ | X | √ | ? | X | X | √ | √ | √ | √ | 8 |
Tomita et al (2009) | √ | X | ? | √ | √ | √ | ? | X | X | √ | √ | √ | X | 7 |
Trief et al (2007) | √ | X | ? | √ | X | X | √ | √ | X | √ | X | √ | X | 6 |
Wangberg (2008) | √ | X | ? | √ | X | X | ? | √ | X | √ | √ | X | √ | 6 |
Zutz et al (2007) | √ | X | ? | √ | √ | √ | ? | X | X | √ | X | X | √ | 6 |
a1=specification of eligibility criteria; 2=method of randomization explained; 3=treatment allocation concealed; 4=groups similar at baseline; 5=explicit description of interventions; 6=description of compliance; 7=outcome assessor blinded; 8=description of dropout and comparison with completers; 9=long-term follow-up (> 3 months after post-intervention assessment); 10=timing of outcome assessment comparable; 11=sample size described with power calculation; 12=intention-to-treat analysis; 13=point estimates and measures of variability
b√=reported item; X=unreported item; ?=unclear item
cDropout rate was 0%
dMaximum score was 13
Our judgement of the relevance of the intervention elements for the cancer survivorship setting was based on their
Proposed application of intervention elements that could enhance cancer survivorship care based on findings from this review (cancer-related recommendations).
|
Recommendations for survivorship care | |
Elements of Web-based intervention | Long-term follow-up/surveillance | Management of (late) effects |
Education | Information about reasons for surveillance | Information about possible late effects of cancer treatment |
|
Recommendations for self-screening |
|
Self-monitoring | Reporting results of self-screening | Upload of relevant vital signs (eg, pain scores, blood values) |
Feedback/Tailored information | A personal follow-up schedule with frequency and type of screening | Advice for managing (late) effects as identified by self-monitoring data |
|
Feedback on reported self-screening |
|
Self-management training | Training aimed at performing regular self-screening | Training to learn to cope with late effects of cancer treatment |
Personal exercise program | X | Individual exercise advice to prevent or reduce (late) effects, taking into account a survivor's specific needs and preferences |
Communication with health care provider | Possibility to ask questions about follow-up and self-screening | Possibility to ask questions about symptoms and how to deal with them |
Communication with fellow patients | X | Share experiences and tips about managing (late) effects |
aX=application not relevant
Proposed application of intervention elements that could enhance cancer survivorship care based on findings from this review (health-related recommendations).
|
Recommendations for survivorship care | ||
Elements of Web-based intervention | Rehabilitation | Psychosocial support | Health promotion |
Education | Information about the importance of and possibilities for rehabilitation |
Information about possible psychosocial problems and possibilities to solve them | Information about the importance of and ways to obtain a healthy lifestyle (eg, physical activity, nutrition, smoking cessation) |
Self-monitoring | Upload of relevant vital signs (eg, blood pressure, lung function) or exercise behavior (either self-reported or objective) | Questionnaire(s) measuring psychosocial aspects |
Upload of relevant data such as food intake and exercise behavior |
Feedback/Tailored information | Rehabilitation advice based on self-monitoring data | Advice for dealing with psychosocial problems as identified with questionnaires; following the stepped care principle | Health advice based on uploaded data; following the stepped care principle |
Self-management training | Training to learn to sustain doing rehabilitation exercises | Training aimed at coping with psychosocial problems like anger, fear or frustration | Training aimed at obtaining and sustaining a healthy lifestyle |
Personal exercise program | Individual exercise advice aimed at rehabilitation, taking into account a survivor's specific needs and preferences | Individual exercise advice, taking into account a survivor's specific needs and preferences | Individual exercise advice, taking into account a survivor's specific needs and preferences |
Communication with health care provider | Possibility to ask questions about rehabilitation |
Possibility to ask questions about psychosocial problems; receiving support | Possibility to ask questions about exercise advice |
Communication with fellow patients | Share experiences and tips about rehabilitation | Share experiences and tips about dealing with psychosocial problems | Share experiences and tips about health behavior |
|
|
Provide support | Provide support |
In this paper we have systematically reviewed the empirical literature on Web-based interventions for people with diabetes, COPD, heart failure, cardiovascular disease, and cancer, and have evaluated their potential relevance for cancer survivors. Nineteen publications covering 18 unique studies were included in this review. The RCTs varied greatly in content, duration, and frequency. Significant, positive effects on patient empowerment were found in 4 studies and 2 studies reported positive effects on physical activity. The remaining studies reported mixed results or no significant differences between intervention and comparison groups (ie, either both groups or neither group improved) on these outcomes. The information we could obtain about barriers and facilitators for intervention use and users’ experiences was limited. Nevertheless, we identified 7 elements that were common for the majority of interventions: education, self-monitoring, feedback/tailored information, self-management training, personal exercise program, and communication (with either health care providers or fellow patients). We were able to map these elements onto eHealth features for the recommendations for survivorship care of the IOM.
The 7 common intervention elements were used in different combinations and were adapted to the specific patient population. It is therefore not possible to make a judgment about the individual contribution of these elements to intervention outcomes. Future studies should be more structured, in order to determine the role of individual intervention elements and should also take the duration and frequency of interventions into account. In most studies no intervention schedule was prescribed. Rather, the intensity, frequency, and duration of website use were determined by the participants themselves. In contrast, structured rehabilitation programs usually have schedules to which patients are expected to adhere (eg, performing moderate intensity physical activity (running or cycling) for 30 minutes, 3 times a week, during a 12-week period). It is debatable whether Web-based interventions should or should not have a structured program, but it is conceivable that a certain combination of duration and frequency is optimal for achieving improved patient empowerment and physical activity. A recent review of Web-based interventions for type 2 diabetes [
The relative importance and value of intervention elements, duration, and frequency on outcomes is not yet clear. Other factors may also have played a role in the large variation in patient empowerment and physical activity outcomes observed in the studies reviewed. These include the different measurement tools that were used within and between studies, different sample sizes and different periods between the start of the intervention and the post-intervention measurement. To facilitate future meta-analyses, new investigations should preferably use uniform outcome measures and time intervals for the outcome assessment. The need for a uniform measure of patient empowerment was also pointed out in a paper that discussed the role of assessing patient empowerment in health care evaluation [
Another issue to be considered is that, in the majority of studies where no significant differences between groups were observed, significant, positive effects were found for all groups. In many of these studies, the comparison group(s) received an intervention as well. This may have limited the possibility of detecting an effect in favour of the Web-based interventions. More generally, it is becoming increasingly difficult to establish appropriate control groups, because the usual care situation is evolving rapidly. Although previous studies have shown that effects on knowledge and behavior change were higher for individuals using a Web-based intervention than for individuals using a non-Web-based intervention [
It would have been useful if the RCTs reviewed had provided more information on barriers and facilitators for intervention use. Insight into these factors is very important, because Web-based interventions are often characterised by high dropout rates [
The assessment of the methodological quality of the studies reviewed suggests a number of areas in which there is room for improvement. Future RCTs in the field of Web-based interventions could be improved by clearly describing the method of randomization, concealment of treatment allocation, and an adequate description of sample size calculation. Additionally, researchers should preferably describe explicitly their intervention(s), including specific information about intervention elements, length, frequency, and duration. Studies should carry out the statistical analysis on an intention-to-treat basis (as opposed to only analyzing the participants who completed the intervention). This is important because participants who complete an intervention may differ from those who do not, as a result of which intervention effects may be over- or underestimated. Because it is often the goal to not only enhance patient empowerment and facilitate a physically active lifestyle in the short-term, but to sustain these outcomes over a longer period of time, it is important that RCTs include not only immediate post-intervention outcome assessment, but also longer-term follow-up assessments.
Web-based interventions are being developed at a rapid pace. This is also true for Web-based interventions for cancer survivors. In this review we identified only 1 paper in the cancer field that met our eligibility criteria. Recently, however, positive results of a Web-based intervention to reduce depression in cancer survivors [
Although we identified 7 elements of eHealth interventions that may be relevant for cancer survivors, based on the available evidence, we could not determine which of these elements are the most important and effective. It was also unclear which combinations of intervention elements would be optimal. However, the benefit of the educational element for cancer survivors was supported by a review, which showed that cancer survivors who received sufficient information reported a better quality of life [
In conclusion, our review suggests that Web-based, interactive interventions have a beneficial effect on patient empowerment and/or physical activity in people with various chronic conditions. Program elements that were frequently observed included education, self-monitoring, feedback/tailored information, self-management training, personal exercise program, and communication (with either health care providers or fellow patients). Although the results of these studies did not necessarily differ from those of traditional interventions, it is likely that the elements increased patient centeredness and efficiency of the interventions. Empowered individuals who are physically active are likely to have a better health status and quality of life, therefore the use of interactive Internet interventions in this field would appear promising. Further research is needed to establish optimal intervention characteristics and specific effects in cancer survivor populations. Future studies should also identify perceived barriers for and facilitators of the use of Web-based interventions. The studies that have been conducted in other chronic diseases are likely to constitute a basis for the development of an interactive, Web-based intervention to effectively empower the rapidly growing number cancer survivors.
Search strategy in PubMed.
6 Minutes Walking Test
chronic obstructive pulmonary disease
Godin Leisure-Time Exercise Questionnaire
Institute of Medicine
information technology
metabolic equivalents
physical activity
randomized controlled trial
This research was supported by Alpe d'HuZes, a foundation which is part of the Dutch Cancer Society (KWF Kankerbestrijding). This study was part of the A-CaRe Program [
None declared.