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Blended behavior change interventions combine therapeutic guidance with online care. This new way of delivering health care is supposed to stimulate patients with chronic somatic disorders in taking an active role in their disease management. However, knowledge about the effectiveness of blended behavior change interventions and how they should be composed is scattered.
This comprehensive systematic review aimed to provide an overview of characteristics and effectiveness of blended behavior change interventions for patients with chronic somatic disorders.
We searched for randomized controlled trials published from 2000 to April 2017 in PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the Cochrane Collaboration tool. Study characteristics, intervention characteristics, and outcome data were extracted. Studies were sorted based on their comparison group. A best-evidence synthesis was conducted to summarize the effectiveness.
A total of 25 out of the 29 included studies were of high quality. Most studies (n=21; 72%) compared a blended intervention with no intervention. The majority of interventions focused on changing pain behavior (n=17; 59%), and the other interventions focused on lifestyle change (n=12; 41%). In addition, 26 studies (90%) focused on one type of behavior, whereas 3 studies (10%) focused on multiple behaviors. A total of 23 studies (79%) mentioned a theory as basis for the intervention. The therapeutic guidance in most studies (n=18; 62%) was non face-to-face by using email, phone, or videoconferencing, and in the other studies (partly), it was face-to-face (n=11; 38%). In 26 studies (90%), the online care was provided via a website, and in 3 studies (10%) via an app. In 22 studies (76%), the therapeutic guidance and online care were integrated instead of two separate aspects. A total of 26 outcome measures were included in the evidence synthesis comparing blended interventions with no intervention: for the coping strategy catastrophizing, we found strong evidence for a significant effect. In addition, 1 outcome measure was included in the evidence synthesis comparing blended interventions with face-to-face interventions, but no evidence for a significant effect was found. A total of 6 outcome measures were included in the evidence synthesis comparing blended interventions with online interventions, but no evidence for a significant effect was found.
Blended behavior change interventions for patients with chronic somatic disorders show variety in the type of therapeutic guidance, the type of online care, and how these two delivery modes are integrated. The evidence of the effectiveness of blended interventions is inconsistent and nonsignificant for most outcome measures. Future research should focus on which type of blended intervention works for whom.
An important challenge of today’s health care is the management of patients with chronic somatic disorders. In addition, 1 out of 3 European adults deal with consequences of conditions such as heart failure, diabetes, asthma, or rheumatism [
An upcoming and new delivery mode for behavior change interventions is the use of Internet technologies, such as websites and apps. Although traditional behavior change interventions in primary care are restricted to face-to-face sessions, websites and apps are available at any time and place and can act as an extension of care provided by the professional. Online interventions without therapeutic guidance, however, struggle with disappointing adherence rates [
Present blended interventions have in common that they consist of an online element complemented with therapeutic guidance; however, they show a wide variety in how both elements are delivered and combined. For example, the online part can be delivered via a website with solely information texts, but supplementary videos, games, and links can be used as well. In addition, the guidance by a therapist can be delivered in various ways, for example, by providing traditional face-to-face sessions, contact by email, or by videoconferencing [
Although blended care is seen as promising in terms of effectiveness and improving health care access, the actual usage in daily primary care practice is lagging behind [
Which types of blended behavior change interventions for patients with chronic somatic disorders are available in literature?
What is the effectiveness in comparison with no intervention, face-to-face behavior change interventions, and online behavior change interventions without therapeutic guidance?
A comprehensive literature search was conducted using PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials from January 2000 to April 2017. Studies published before 2000 were excluded because of the rapid developments within the field of eHealth. A combination of the following constructs was used: chronic somatic disorder, eHealth, behavior change intervention, and intervention study.
Keywords were adapted to control vocabularies for different databases. Additionally, reference lists of included studies and other systematic reviews [
First step of the study selection consisted of the screening of titles and abstracts of all retrieved studies on eligibility. This was performed by 2 researchers (CK and DB). Subsequently, full texts of all initially relevant studies were independently checked for inclusion by the same researchers. Disagreements about study inclusion were discussed until consensus was reached. Inclusion criteria are provided in
Data were extracted from studies that met the inclusion criteria. These data comprised study characteristics (type of study, year of publication, type of control group, outcome measures, and timing of outcome assessment), study population (number of participants, age, sex, and type of chronic disorder), intervention characteristics (target behavior, described theoretical basis, duration of intervention, delivery mode and frequency of Internet-based element, delivery mode and frequency of therapeutic guidance, integration of online care, and therapeutic guidance), and type of control intervention. A modified version of the delivery coding schemes of Webb et al [
Studies were sorted based on their type of control intervention: (1) no intervention, (2) face-to-face behavior change intervention, and (3) online behavior change intervention without therapeutic guidance.
All outcome measures were distracted and grouped into the following five constructs: (1) symptoms and signs, (2) limitations, (3) dealing with the chronic condition (cognitive and behavioral), (4) emotional outcomes, and (5) quality of life. Means and standard deviations for all outcome measurements (pre- and postvalues) were extracted. A
All articles were independently assessed on methodological quality by 2 researchers (CK and DB). For this assessment, the risk of bias criteria list of the Cochrane collaboration was used [
randomized controlled trial published in the English language
the patient sample comprised adults (≥18 years) with chronic somatic disorders
the study included an intervention aimed to change one or more of the following behaviors: physical activity, dietary intake, pain coping, and time spent in sedentary activity
the intervention consisted of a combination of online care provided through a website, app, or automatic email and contains at least two episodes of contact with a health care professional (either face-to-face, personal emails, telephone, or videoconference)
the blended intervention was compared with waiting list or usual care, a face-to-face intervention, or an online intervention
Best-evidence synthesis.
Level of evidence | Description |
Strong evidence | Consistent findings in multiple (≥3) high-quality RCTsa |
Moderate evidence | Consistent findings in at least one high-quality study and at least one low-quality study, or consistent findings in multiple low-quality studies |
Inconsistent evidence | Inconsistent findings in multiple studies |
Insufficient evidence | Only one or two studies available |
aRCTs: randomized controlled trials.
Points were counted and summarized as a risk of bias score (range 0-10, where 10 indicates low risk of bias for all 10 dimensions). Studies with a score of ≥6 were judged as high methodological quality. Interobserver agreement was expressed as the percentage of agreement on bias dimensions between CK and DB.
A best-evidence synthesis was conducted to summarize the effectiveness of blended behavior change interventions, using the same method used by Proper et al [
The initial literature search resulted in 8992 articles. After deleting duplicates, 6192 unique articles were screened on title and abstract. A total of 111 selected articles were studied on full text, whereof 29 articles met the inclusion criteria. An overview of the selection procedure is shown in
An overview of study characteristics is shown in
Ten different sources of bias were rated to assess the methodological quality of the studies (
In total, 25 studies were rated as high quality [
An overview of intervention characteristics is shown in
Flowchart of selection procedure.
In 7 studies, nothing was mentioned about the use of the website or app during the therapeutic guidance, and therefore, they were classified as nonintegrated [
In the study of Buhrman et al [
Effectiveness of blended behavior change interventions compared with no intervention, face-to-face behavior change intervention, and online behavior change intervention.
Control conditions and constructs | Outcome construct | ||
Pain | Strong evidence for a nonsignificant effect | ||
Fatigue | Strong evidence for a nonsignificant effect | ||
Body weight | Strong evidence for a nonsignificant effect | ||
Disability | Inconsistent evidence | ||
Coping strategy: catastrophizing | Strong evidence for a significant effect | ||
Acceptance | Inconsistent evidence | ||
Coping strategy: praying or hoping | Inconsistent evidence | ||
Fear of movement | Inconsistent evidence | ||
Pain self-efficacy | Inconsistent evidence | ||
Coping strategy: diverting attention | Strong evidence for a nonsignificant effect | ||
Coping strategy: reinterpret pain sensation | Strong evidence for a nonsignificant effect | ||
Coping strategy: coping self-statements | Strong evidence for a nonsignificant effect | ||
Coping strategy: ignore pain sensations | Strong evidence for a nonsignificant effect | ||
Perceived life control | Strong evidence for a nonsignificant effect | ||
Perception of support received from others | Strong evidence for a nonsignificant effect | ||
Perception of received punishing responses | Strong evidence for a nonsignificant effect | ||
Perception of received solicitous responses | Strong evidence for a nonsignificant effect | ||
Perception of received distracting responses | Strong evidence for a nonsignificant effect | ||
Coping strategy: increase activity level | Strong evidence for a nonsignificant effect | ||
Pain interference with daily activities | Strong evidence for a nonsignificant effect | ||
Anxiety | Inconsistent evidence | ||
Depression | Inconsistent evidence | ||
Affective distress | Inconsistent evidence | ||
Generic quality of life | Inconsistent evidence | ||
Health-related quality of life: emotional role impairment | Inconsistent evidence | ||
Health-related quality of life: emotional role impairment | Inconsistent evidence | ||
Physical activity | Inconsistent evidence | ||
Pain | Inconsistent evidence | ||
Body mass index | Inconsistent evidence | ||
Body weight | Strong evidence for a nonsignificant effect | ||
Physical activity | Inconsistent evidence | ||
Anxiety | Strong evidence for a nonsignificant effect | ||
Depression | Inconsistent evidence |
Strong evidence for a nonsignificant effect was found for the coping strategies diverting attention, reinterpret pain sensations, coping self-statements and ignorance of pain sensations, perceived life control, perception of support received from others, perception of received punishing responses, perception of received solicitous responses, and perception of received distracting responses [
Within the construct dealing with the chronic condition: behavioral measures, strong evidence for a nonsignificant effect was found for pain interference with daily activities [
This review provides an overview of the intervention characteristics of a new and promising field within health care for patients with chronic somatic disorders. The characteristics of the included blended behavior change interventions showed a wide heterogeneity. For example, length of interventions ranged from 5 weeks to 12 months. A previous systematic review that studied factors related to online adherence showed that shorter interventions are related to higher usage rates [
The theoretical basis of the intervention content was most frequently based on the principles of cognitive behavior therapy. The aim of the cognitive behavior therapy is to change individuals’ unhelpful thoughts, beliefs, and behaviors [
Almost all included studies described that the therapeutic guidance and the online care were integrated with each other. Examples of integration of therapeutic guidance and online care were the provision of therapeutic feedback on online assignments or tailoring of the online intervention by the therapist. This high number of integrated blended interventions surprised us, as in literature, the interconnection of the therapeutic and the Web-based part is described as one of the biggest challenges of blended care [
A wide range of outcome measures were included in our evidence synthesis comparing blended interventions with no interventions or online blended interventions without therapeutic guidance. For some outcome measures, we found inconsistent evidence, and for other outcome measures, we found strong evidence for a nonsignificant effect. The lack of evidence for blended interventions, even when comparing with no intervention, is surprising. Although blended care is described as best of both worlds [
A minority of studies compared blended interventions with face-to-face interventions. The evidence synthesis of this comparison showed inconsistent evidence for improvement in physical activity. Particularly, for the comparison of blended behavior change interventions with face-to-face interventions, it would be interesting to investigate cost-effectiveness, long-term effectiveness, and patient satisfaction. The potential added value of blended care above face-to-face care may be found in these outcome measures instead of outcome measures related to symptoms and signs, limitations, behavior, emotions, and quality of life. To illustrate, if face-to-face sessions are substituted by online care, blended interventions may be cheaper than usual care [
A methodological limitation of our evidence synthesis is the use of multiple outcome measures and multiple comparisons. This multiplicity may result in an increased risk of false-positive statistically significant indications of the effectiveness of blended behavior change interventions [
This review investigated a huge heterogeneity in how blended interventions were composed. For future research, we suggest investigating the effectiveness of different intervention components such as intervention duration, type of face-to-face guidance, and type of online care. Studies included in this review provided the same intervention, with the same amount of ingredients to the entire group of included patients. However, with respect to individual differences, it is presumed that different patients benefit from different blended interventions. For example, considering the ratio between online care and therapeutic guidance, one patient may benefit from more online support, whereas others need more therapeutic guidance. To determine the most optimal ratio in the treatment of patients with depression, the Fit for blended care instrument was recently developed [
Next, there is a substantial need for studies that compare blended interventions with face-to-face interventions. Only 5 studies compared a blended intervention with face-to-face care [
To our knowledge, this is the first comprehensive overview of characteristics of blended behavior change interventions in patients with chronic somatic disorders. The wide variety of intervention characteristics, in terms of type and dose of therapeutic guidance, the type and dose of online care, and how these two delivery modes are integrated, hampered the investigation of intervention subtypes within the entire spectrum of blended behavior change interventions. Overall, within this heterogenic sample of studies, we found no evidence for the effectiveness of blended behavior change interventions in patients with chronic somatic disorders compared with no intervention, face-to-face behavior change interventions, or with online interventions without face-to-face support. With respect to the potential of blended behavior change interventions, we suggest investigating which type of blended intervention works for whom to come to personalized blended care for patients with chronic somatic disorders.
Keywords per construct (PubMed version).
Characteristics of studies, participants, and interventions.
Risk of bias assessment.
Outcome measures of studies with no intervention as control condition.
Outcome measures of studies with control conditions online behavior change intervention.
Outcome measures of studies with control conditions face-to-face behavior change intervention.
chronic obstructive pulmonary disease
randomized controlled trial
None declared.