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eHealth interventions show stronger effects when informed by solid behavioral change theories; for example, self-regulation models supporting people in translating vague intentions to specific actions have shown to be effective in altering health behaviors. Although these theories inform developers about which behavioral change techniques should be included, they provide limited information about how these techniques can be engagingly implemented in Web-based interventions. Considering the high levels of attrition in eHealth, investigating users’ experience about the implementation of behavior change techniques might be a fruitful avenue.
The objective of our study was to investigate how users experience the implementation of self-regulation techniques in a Web-based intervention targeting physical activity and sedentary behavior in the general population.
In this study, 20 adults from the general population used the intervention for 5 weeks. Users’ website data were explored, and semistructured interviews with each of the users were performed. A directed content analysis was performed using NVivo Software.
The techniques “providing feedback on performance,” “action planning,” and “prompting review of behavioral goals” were appreciated by users. However, the implementation of “barrier identification/problem solving” appeared to frustrate users; this was also reflected by the users’ website data—many coping plans were of poor quality. Most users were well aware of the benefits of adopting a more active way of living and stated not to have learned novel information. However, they appreciated the provided information because it reminded them about the importance of having an active lifestyle. Furthermore, prompting users to self-monitor their behavioral change was not sufficiently stimulating to make users actually monitor their behavior.
Iteratively involving potential end users offers guidance to optimally adapt the implementation of various behavior change techniques to the target population. We recommend creating short interventions with a straightforward layout that support users in creating and evaluating specific plans for action.
eHealth, or “the use of technology to improve health care” [
There are strong indications that eHealth interventions should be informed by sound theories. Research has shown that applying a theoretical basis to eHealth interventions increases their effectiveness [
Although behavioral change theories inform us about which behavioral change techniques should be included, they provide limited information about how these techniques can be implemented in an engaging way [
Involving the target population has given researchers insight into what motivates users to start and adhere to a Web-based intervention; for example, Bardus et al. found that the expectation of receiving reminders regarding physical activity was an important reason to start with a Web-based physical activity intervention [
This study aims to investigate how users experience self-regulation techniques implemented in an eHealth intervention. For this purpose, we used the eHealth intervention “MyPlan 2.0,” which supports users to be more physically active or less sedentary in a step-by-step manner. This intervention is informed using self-regulation theory and considers users as their own expert in the behavioral change process. Through a semistructured interview and an examination of users’ website data, information was obtained about the appreciation of the website and intervention in general and the experience of users with various self-regulation techniques (ie, goal setting, providing information, providing feedback on performance, action planning, barrier identification/problem solving, prompting self-monitoring, planning social support, and reviewing behavioral goals). The findings derived from this study might help other eHealth developers on how (not) to implement self-regulation techniques in Web-based interventions.
In this study, 20 adults from the general population volunteered to participate; this number was based on previous qualitative research about eHealth by Yardley et al. [
“MyPlan 2.0” is a self-regulation-based intervention consisting of 5 weekly Web-based sessions. It aims to increase physical activity and decrease sedentary behavior in adults and is designed and created by our research group. “MyPlan 2.0” is based on a previous version named “MyPlan 1.0” [
In the first session, participants started by creating a profile and provided general information (eg, gender, age, and working status) to enable personalized messages during the intervention. In addition, they chose which behavior, physical activity or sedentary behavior, they wanted to change during the intervention (ie, “goal setting”). The website offers the option to take a quiz regarding the chosen health behavior (ie, “providing information on the consequences of the behavior”). Thereafter, participants completed a short questionnaire regarding the selected health behavior, that is, a shortened version of the International Physical Activity Questionnaire (IPAQ) [
After 1 week, users received an email to return to the eHealth program to revise their plan. According to the technique “Prompt review of behavioral goals,” they were asked how well the behavioral change was going and whether they wanted to adapt or maintain their plan. If they wanted to adapt their plan, action planning was again completed. In all cases, users were prompted for barrier identification and problem solving. To motivate users to think about more personally relevant barriers and solutions, users now answered an open-ended question instead of selecting an option from a predefined list. A summary of their answers was shown in the action plan, and users were prompted to self-monitor their behavior. In addition, users could again read the information about social support and receive extra tips and tricks, and this illustrated the use of different self-regulation techniques, such as “prompting rewards,” prompting focus on past success,” “providing instructions,” “teaching to use prompts/cues,” and “prompting self-talk;” this cycle was the same for each of the 4 follow-up sessions.
The effect of “MyPlan 2.0” will be tested by a randomized controlled trial. If the intervention is effective, it will be disseminated and implemented by the “Flemish Institute for Healthy Living,” which is the Flemish center of expertise regarding health promotion and illness prevention.
Participants were contacted by telephone and informed about the study. When participants decided to take part in the study, they received an email with a website link to the intervention and the documents to provide their informed consent. Participants were instructed to complete the intervention on their own. When researchers noted that participants forgot to log in at the scheduled time, they were reminded of doing so by a telephone call. After completing 5 intervention sessions, users’ website data were downloaded, and a date to perform a semistructured interview was scheduled. Before the start of the interview, participants completed questions about demographic characteristics (ie, age, gender, educational level, height, and weight). The interviews took place at the research department or via a telephone call. The interviews were audiorecorded with permission of participants.
The questions and content of the semistructured interview were based on the results of the previous qualitative research with the intervention “MyPlan 1.0” [
The following information was derived from the users’ website data. First, we identified how many users selected sedentary behavior and physical activity as their target behavior and how many received the tailored feedback that they did not meet the respective health norm (ie, 30 minutes of, at least, moderate physical activity a day [
Flowchart of the first session.
Interviews were transcribed verbatim, and a directed content analysis was performed using NVivo Software (QSR International, Melbourne, Australia, Version 11, 2015) [
Flowchart of the follow-up sessions.
When contacted via telephone, 30 participants were willing to participate. However, 6 participants dropped out before the intervention period, and 4 participants did not respond to the researchers’ telephone calls. Recruitment was continued until 20 participants fully completed the 5 intervention sessions.
In general, users stated that participating in the study and being involved in the intervention program raised awareness of their own behavior.
You are also made more aware, and that’s where it all starts.
It was just the fact that I was more aware because I had to take a moment for it.
Overall, the intervention website was perceived as user friendly and easy in use. Users highlighted the fact that it was clear and straightforward. In addition, the layout of the website was experienced as positive; it was simple and clear. Yet, some users would have liked a more colorful design.
Demographic characteristics of participants.
Characteristics | Particpants (N=20) | |
Men | 10 (50) | |
Women | 10 (50) | |
46.65 (16.65), 21-74 | ||
18-45 y, n (%) | 10 (50) | |
>45 y, n (%) | 10 (50) | |
Primary education | 1 (5) | |
Lower secondary education | 1 (5) | |
Higher secondary education | 8 (40) | |
College or university | 10 (50) | |
25.42 (4.99), 18.47-37.81 | ||
Not overweight, n (%) | 11 (55) | |
Overweight, n (%) | 9 (45) |
Users’ website data according to the 2 target behaviors (sedentary behavior and physical activity).
Website Data | Total (N=20) | Sedentary behavior (n=8) | Physical activity (n=12) | |
Number of users receiving feedback of not reaching the health norm, n (%) | 7 (35) | 6 (75) | 1 (8) | |
Time spent per session (min) | 6.67 | 6.74 | 6.59 | |
Number of users reading the extra tips, n (%) | 16 (80) | 6 (75) | 10 (83) | |
Number of users reading more about social support, n (%) | 14 (70) | 4 (50) | 10 (83) | |
Number of users taking the quiz, n (%) | 20 (100) | 8 (100) | 12 (100) | |
Mean score on the quiz (out of 5) | 4.4 | 4.71 | 4.08 | |
Number of users willing to monitor their behavioral change, n (%) | 15 (75) | 4 (50) | 11 (92) | |
Number of plans not achievable or instrumental, n (%) | 2 (2) | 2 (2) | 0 (0) | |
Total achievement | 39 (49) | 20 (63) | 19 (40) | |
Partial achievement | 37 (46) | 11 (34) | 26 (54) | |
Failure | 4 (5) | 1 (3) | 3 (6) | |
Adapt | 11 (14) | 5 (16) | 6 (12) | |
Maintain | 69 (86) | 27 (84) | 42 (88) | |
Session 2 | 8 (40) | 2 (25) | 6 (50) | |
Session 3 | 4 (20) | 2 (25) | 2 (17) | |
Session 4 | 7 (35) | 1 (13) | 6 (50) | |
Session 5 | 4 (20) | 2 (25) | 2 (17) |
I thought it was a very good website. Very clear. I always knew what to do, where to click.
It provided overview and was very clear. Nothing negative to mention. It was very easy, very simple. Yes, you could not do anything wrong I think.
I thought the layout was simple, but that didn’t bother me. I think it contributed to the clarity.
In line with that, users also stated that they would have liked more interaction on the website and more new content per session. For some users, the website was too repetitive and could have been more appealing. Yet, most of the participants were positive about the website and the initiative in general.
I think, if people will visit the website regularly, they will want to see something new every time though.
It is useful that you try to let people be physically active. You can think about it yourself, everything comes from you. There is no one telling you: ‘You have to do this if that happens’. You give yourself feedback.
Almost all participants experienced the intervention as personally relevant and appropriate. However, the website seemed less fitting for persons who considered themselves as being physically active or for individuals with a lack of motivation.
It is developed generation-independently, from 7 until 77 in a manner of speaking.
Normally, I am already physically active. In that way, the added value for me was minimal. Maybe the intervention is too restricted because it is assumed that people experience difficulties in being physically active.
Most users appreciated the time efficiency of the website. Some users would have liked a little more content and for other users, content could have been shown in even less internet pages.
That (cf. the length) was very reasonable. Certainly not too long. However, not too short either. I had expected a lot more questions and other things.
In addition, the intervention was perceived as motivating and stimulating for behavioral change by most users. However, some users experienced problems putting their intention into action. Other users were not motivated enough to change their behavior.
It is stimulating to initiate behavior.
The website totally helped me, because I wasn’t exercising anymore at all and now I am exercising again. So it did work.
It is a very good initiative, but it is still difficult to translate it into action and actually move more or sit less. It seems evident, but it is not.
Users often mentioned that the difference between physical activity and sedentary behavior was not clear for them, which made the intervention more complex.
For me there was little difference. If you sit less, then you automatically move more, and if you move more, then you sit less. So I didn’t think it was clear.
All participants stated that being more physically active or less sedentary has benefits for both physical and mental health. Some participants believed in the benefits but indicated that they had not experienced the benefits because of the intervention.
I think it has an influence. I really believe it has, but I have not experienced it.
Accordingly, most users indicated that they did not learn new things through the intervention. They already knew the consequences of their behavior. They only had to be reminded to do something about it.
Learned new things? No. But it gave new insights, you take a moment to think about it.
The tailored feedback was highly appreciated by users. They recommended such feedback as the first step toward behavioral change. According to users, the feedback was personally tailored and made them aware that they had to change their behavior. Some users found that the feedback stimulated them actually to alter their behavior. Other users did not remember the feedback from the first session.
It was good to know where you are because you really don’t have a clue.
I thought it (cf. the feedback) was good. That way, you know where you are and where you can improve. And it is different for every person. So, it is more personal.
Action planning was experienced as highly motivating. Users appreciated the fact that they could plan their personal goals in a structured way by questions. Many users indicated that they actually performed their goal as planned.
I think it is important to plan this. Because everyone is busy and otherwise there is always something else coming up. If you don’t make it a goal or plan in your week, it will not occur or it will fade with time.
So putting my mobile phone further away (cf. in order to decrease sedentary time) is something that I do now.
Some users reported problems with action planning. They thought it was difficult to plan behavioral change a week in advance, especially when they had changing work hours. Furthermore, they preferred planning using a calendar rather than by questions. Other users found it difficult to plan behavioral change because they lacked the knowledge and inspiration about what to do. They wanted ready-to-use activity programs.
If you know what you want to do, but you do not put the words into action, then you fill this in. However, if someone knows he wants to be more physically active, but hedoes not know how exactly, then I think he will ask himself: “What should I do now?”
At the beginning I found it difficult to set up goals for myself.
Most users found it a good idea to think about barriers in advance and try to find solutions. However, many indicated that it was difficult to anticipate what could go wrong and how to overcome problems. Users expected the website to provide more guidance for this component.
What I really appreciated, is the fact that you were obliged to write down at least one barrier and how to cope with it. I had to take a bit of time to think about it, but in the end I always found one. The barrier component is the most powerful of the intervention.
Sometimes it was difficult. Because experiencing barriers is not difficult, but finding solutions is not always easy. Most of the time, the same barriers arose.
Barrier identification really was something else (cf. in comparison to action planning). You have to be able to think immediately about what hinders you. That was more difficult. And maybe there could have been more guidance from the website.
Many users misunderstood the purpose of self-monitoring and wrote down their plan in advance to remind them about it, but did not keep track of whether they executed the planned behaviors or not.
I always wrote it down in my diary, in color. That is definitely useful, otherwise you forget about it.
I had expected that I would be assisted to monitor my goals myself, to see how my sitting time changes. But I was not asked to write down my sitting time.
There were a few users who commented on the social support component. Some users found it very useful to involve others, whereas other users preferred to keep their behavioral change more private.
I also appreciated the more practical tips such as inviting neighbors or not exercising alone. I found it nice to read and I often took it into account.
I did not really like the social parts. I prefer to do this on my own.
The largest group of users found it useful to review their goals. Many users indicated that having to log in again was the most motivating part of the intervention.
The good thing was that it repeated itself every week. Another program ends after one session and then you have the tendency to put it aside. Since you had to log back in for five weeks, you wanted to do what they asked because they would ask if you did it.
Most users expressed their interest in the extra tips and found them very useful. The tips were experienced as feasible and inspiring. Especially, the tip regarding “using prompts or cues” was often implemented. Some users indicated that more new tips during the sessions were needed. Reading success stories of other possible users was also perceived as of added value to the website, although some stated that the stories were too predictable.
The tips were very interesting because they were practically feasible. It were simple tips that were achievable.”
It is always motivating to see (cf. read) how someone else does it, then you also want to motivate yourself to do it.
The most helping was the note on the fridge. It made you aware to not forget about your plans that day.
Web-based interventions are increasingly used to alter health behaviors [
Besides investigating users’ opinions about self-regulation techniques, we also explored how they perceived the intervention in general. In comparison with the users of “MyPlan 1.0” [
This study revealed that most users were well aware of the benefits of increasing physical activity or reducing sedentary behavior; this was reported in the interviews. Users often mentioned that the intervention did not substantially increase their knowledge about the beneficial effect of a more active lifestyle, and this finding was corroborated by the high scores on the quiz, which aimed to provide information engagingly. Notwithstanding, users were interested in information and all completed the optional quiz. The findings indicate that further tailoring and offering more advanced information is recommended in this target population. In addition, previous research highlights the importance of providing new information tailored to the users’ needs [
Of particular interest to this study were the experiences and opinions of users about the self-regulatory strategies to bridge the intention-behavior gap. Key to our eHealth intervention were action planning and problem solving. Action planning consisted of formulating specific actions and planning about when and how they will conduct these behaviors. Action planning seemed to be feasible. Few users stated unachievable plans and many were able to reach their goals, at least, partially. However, thinking in advance about actions was experienced as difficult and effortful by users. Some stated that it was difficult to come up with specific actions or plan these actions a week in advance, and this is a good remark. An improvement may be to allow users to create and evaluate specific plans on a daily basis. Implementing such microcycles might offer users more guidance in creating instrumental and achievable plans on a daily basis.
The implementation of the technique “barrier identification/problem solving” was less feasible. Many users struggled with identifying barriers and finding solutions in advance, especially in the follow-up sessions in which they had to answer an open-ended question; this was communicated in the interviews and further corroborated by the analysis of the provided barriers and solutions at the website. Our results seem to be at odds with those of other studies. Sniehotta et al. [
In the interviews, some participants mentioned that the intervention may be of lesser use for individuals who are not ready for change yet, and this view is in line with various theoretical models of behavioral change, such as the Stages of Change Theory [
In addition, users indicated that the intervention might be of lesser use for individuals who already have a habit of being active. Inadvertently, many of our participants already had an active way of living. Their personal feedback on the questionnaire stated that they reached the health norm. We had opted not to exclude participants who reached the health norms. First, research has demonstrated that individuals often overestimate their activity levels when self-report measures of physical activity are used [
One of the strengths of this study was the diversity of the sample with an equal distribution of gender, age, educational level, and body mass index. Furthermore, having both users’ website data, as well as interview data, strengthened our conclusions. Finally, the perspective of users on the specific implementation of self-regulation techniques has not been often investigated. The most important limitation of this study was the fact that we did not investigate the participants’ actual levels of physical activity and sedentary behavior using validated methods. Consequently, we do not know whether our sample was more active than the general population. In addition, we were unable to assess the experiences of 4 users who quit the intervention. It may well be that their experience with the intervention was less positive. Furthermore, participants who were acquaintances of researchers might have had a more positive perception of the eHealth intervention. However, to limit this impact, these participants were always interviewed by a trained researcher they did not know.
In conclusion, this study reveals that behavioral change theories may be necessary but not sufficient to guarantee the efficacy in designing interventions. Equally important is the involvement of end users [
Implementation of the behavior change techniques in the website.
The Interview Guide.
Overview of the themes and subthemes.
Completed COREQ checklist.
International Physical Activity Questionnaire
The authors would like to thank Professor Dr Armand De Clercq for his support in developing “MyPlan 2.0.”
None declared.