CIN: Computers, Informatics, Nursing

& Vol. 32, No. 10, 504–511 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

F E A T U R E A R T I C L E

Practical Guidelines for Development of Web-Based Interventions WONSHIK CHEE, PhD YAELIM LEE, MSN EUNICE CHEE EUN-OK IM, PhD, MPH, RN, CNS, FAAN

BACKGROUND With recent technological advances in health-related fields, Web-based interventions began to receive attention for their high potential for healthcare and are frequently cited as alternate methods to traditional health education and support interventions.1 Web-based interventions have become popular mainly because of their easy accessibility with almost no limitation in time and place.1,2 Moreover, with a recent high funding priority on innovation of research, an increasing number of researchers began to develop and test various types of Web-based interventions in diverse areas including self-management education for older adults with type 2 diabetes,1 smoking cessation program for adolescents,2 and physical activity promotion of adults with metabolic syndrome.3 Web-based interventions in health-related areas could be categorized into education programs,1,4 decision support systems,5,6 support groups,7,8 and games.9–11 Education programs are targeted to provide a Web version of traditional education programs and access to the educational materials through the Internet.1,4 Decision support systems aim to support decision making related to health and illness (eg, pain management, hormone replacement therapy).5,6 Support groups provide a medium for users to share their experiences and opinions through the Internet and obtain peer support (eg, chat rooms, bulletin boards, e-mail, online discussion forums, and/or text messages).7,8 Games may provide educational aids to enhance skills and knowledge for users and to assist users’ decision making.9–11 These different types of Web-based interventions are not mutually exclusive; rather, they are combined in many cases.12,13 504

Despite a recent high funding priority on technological aspects of research and a high potential impact of Web-based interventions on health, few guidelines for the development of Web-based interventions are currently available. In this article, we propose practical guidelines for development of Web-based interventions based on an empirical study and an integrative literature review. The empirical study aimed at development of a Webbased physical activity promotion program that was specifically tailored to Korean American midlife women. The literature review included a total of 202 articles that were retrieved through multiple databases. On the basis of the findings of the study and the literature review, we propose directions for development of Web-based interventions in the following steps: (1) meaningfulness and effectiveness, (2) target population, (3) theoretical basis/program theory, (4 ) focus and objectives, (5) components, (6) technological aspects, and (7) logistics for users. The guidelines could help promote further development of Web-based interventions at this early stage of Web-based interventions in nursing. KEY WORDS Directions & Guidelines & Online intervention & Web-based intervention

Despite an increasing number of studies that aim to develop and use these different types of Web-based interventions, literature on how to develop the interventions is lacking. In general, there exist only several articles and book chapters on issues in Web-based research.14,15 Most of them focused on the issues in Web-based research methodology as a quantitative or qualitative descriptive data collection method.14,15 Therefore, in this article, we propose practical guidelines for development of Web-based interventions based on an Author Affiliations: School of Nursing (Drs W. Chee and Im, Ms Lee) and School of Engineering (Ms E. Chee), University of Pennsylvania, Philadelphia. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Eun-Ok Im, PhD, MPH, RN, CNS, FAAN, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA 19104 ([email protected]). DOI: 10.1097/CIN.0000000000000088

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empirical study and an integrated literature review. First, in the ‘‘Methods’’section, we concisely explain the empirical study and describe the approach used for the literature review. Then, based on the findings of the study and the literature review, we propose practical guidelines for development of Web-based interventions.

of the studies using content analysis. Detailed findings of the literature review are presented in the following section according to the steps proposed in the guidelines. The article retrieval and analysis process is summarized in Figure 1.

PRACTICAL GUIDELINES FOR DEVELOPMENT OF WEB-BASED INTERVENTIONS

METHODS The proposed practical guidelines are based on (1) an empirical study through which a Web-based physical activity promotion program for Korean American midlife women (WPAPP) was developed and (2) an integrated literature review using multiple databases. The empirical study aimed to develop a Web-based physical activity promotion program for Korean American midlife women that incorporated the women’s cultural attitudes toward physical activity. We used the information mapping approach by Bartholomew et al16 to develop the program. The information mapping approach includes needs assessment as the first step. Thus, on the basis of the findings of previous studies (as needs assessment), we set ultimate intervention outcomes and targeted outcomes. Finally, we developed the program based on the findings of previous studies on significant predictors of Korean American midlife women’s physical activity. For example, educational sessions, online message boards, and online resources were structured based on quantitative findings on the significant predictors. The program was tailored to the cultural values, beliefs, and preferences of Korean American midlife women based on qualitative findings on the women’s cultural attitudes toward physical activity in the previous studies. During the research process, we discussed issues and/or concerns related to development of the program as a group and recorded the discussions as memos. Later, we analyzed the written memos using content analysis and identified issues and/or concerns related to development of the program. These findings were incorporated into the practical guidelines in the following section. For the systematic integrated literature review, the literature was searched using multiple electronic databases including PubMed, the Cumulative Index for Nursing and Allied Health Literature, and PsycINFO, over the period of 2003 to 2013. We retrieved a total of 6379 articles using combined keywords of online, Internet, or Web, and intervention. Only human subject study articles in English that were published within the past 10 years with abstracts available were included. Review articles, tutorials, and metaanalyses were excluded, and overlapping articles eliminated. Abstracts of the retrieved articles were reviewed to check if the articles met the inclusion and exclusion criteria for this literature review. Full texts of only 202 articles met the inclusion and exclusion criteria; they were sorted by content area, and analyzed by research process. Finally, we extracted themes reflecting similarities in the research process

The recommended steps could be skipped or repeated depending on the actual progress in the development process. The critical questions to ask in each step are summarized in Table 1.

Meaningfulness and Effectiveness First, researchers need to determine whether Web-based interventions would be a meaningful approach for their studies. The literature indicates that Web-based interventions have several strengths as interventions. These types of interventions would be meaningful for users with time and geographic restrictions1,17–19 because they make it possible for researchers to reach a large number of participants without any time and geographical limitations.20,21 In addition, Webbased interventions are meaningful for people with mobility and speech limitations, allowing them easy access to the

FIGURE 1. The literature retrieval and analysis process.

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T a b l e 1 Critical Questions to ask in Development of Web-based Interventions Steps Decide the meaningfulness and effectiveness of a Web-based intervention

Select the target population

Find a theoretical basis/program theory

Determine the focus and objectives of Web-based interventions

Decide the components of the Web-based intervention

Choose technological aspects

Decide logistics for users

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Critical Questions to Ask

Supporting References

How would a Web-based intervention be a meaningful approach for your study? Is it necessary to develop a Web-based intervention? Could a traditional intervention work better than a Web-based intervention? Who is the target population? Why do you choose this specific target population?

Kelechi et al, 201022; Huang et al, 200718; Park and Kim, 201119 Bond et al, 20061; Randi Schoenfeld et al, 201020; Bosak et al, 200921 Davis et al, 201227; Fichter et al, 201226; Hansen et al, 201225 Gerdprasert et al, 201141; Lin and Wang, 200939; Hudson et al, 200340; Yamagishi et al, 200742 Lin and Wang, 200939; Hudson et al, 200340; Bosak et al, 20103 Kuo et al, 200930; Kazer et al, 201149; Hudson et al, 200340; Hansen et al, 201225 Im et al, 201050; Kim and Kang, 200617; Yoo et al, 200346

Do you need a theoretical basis/program theory to guide development of your intervention? Do you need to develop a program theory that can guide development of your intervention? Why do you choose this specific theoretical basis/program theory? What would be the focus of your intervention (eg, any specific practice areas, specific diseases)? What would be the objectives of your intervention? What are the predictors/factors that your intervention aims to incorporate in the design? What are the components of your intervention that are needed to achieve the objectives? Why are these specific components needed? Can your research funding pay possible high cost of developing a Web-based intervention? Do you have enough time to prepare, organize, maintain, and update the content of a Web-based intervention? Do you have enough time to review, consider, adopt, and use new technologies? Do you or your research team have adequate technical expertise and experience? What are the exact steps that users would go through? How would you maintain the consistency of the intervention? How would you control the users’ actual usages of the intervention? What are the strategies that you will use to prevent dropouts?

Kazer et al, 201149; Scharer et al, 200924; Grim et al, 201147; Nahm et al, 201012; Nahm et al, 200948 Jacobi et al, 201251; Van Straten et al, 200823; Kelechi et al, 201022 Cantrell and Conte, 20087; Jaganath et al, 201254; Edlich et al, 200465; Huang et al, 200718 Chen et al, 201145; Kuo et al, 200930; Huang et al, 200718 Hurling et al, 200756; Crenshaw et al, 201055; Chen et al, 201145; Toscos et al, 201157 Hurling et al, 200756; Crenshaw et al, 201055; Chen et al, 201145 Park et al, 200952; Whittemore et al, 201058; Bosak et al, 200921 Whittemore et al, 201058; Khatony et al, 200960; Kim and Kang, 200617; Park and Kim, 201119 Chen et al, 201145; Park et al, 200952; Chuang et al, 201031 Chen et al, 201145; Lin et al, 201166 Lin and Wang, 200939; Whittemore et al, 201058; Huang et al, 200718 Coˆte´ et al, 201163; Yoo et al, 200346; Yamagishi et al, 200742 Whittemore et al, 201058; Huang et al, 200718; Park et al, 200952 Huang et al, 200718; Bosak et al, 200921; Bond et al, 20061; Khatony et al, 200960

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interventions.22 Researchers indicated the meaningfulness of the interventions in approaching isolated/marginalized people with stigmatized conditions (eg, human immunodeficiency virus [HIV], depression, heavy drinking) and underserved people including racial/ethnic minority groups and residents of rural areas. They supported the meaningfulness of the interventions in dealing with issues that could be discussed better without disclosing identities (eg, sexual health, sexual abuse).23–28 Moreover, Web-based interventions provide flexibility for users to control content, time, location, speed, and learning schedule.21,29–31 They allow the researchers to easily update and modify the content of the interventions32,33 and to use various multimedia functions (eg, sound, image, and animations) in order to attract potential participants.18,19 Subsequently, some studies reported the effectiveness of Web-based interventions in facilitating users’ learning experience,21,29–31 which could be another meaningful use of the interventions. Researchers also need to determine whether a Web-based intervention is an effective approach over other approaches for their specific research topic and target population. Sometimes, a traditional intervention would work better than a Web-based intervention. In that case, development of a Webbased intervention could be a source of problems because of its inherent characteristics and restrictions. For example, a researcher could use easy accessibility of Web-based interventions in order to overcome the difficulties in gathering people for a specific education program in a specific geographical area (eg, community center). A researcher could use a Web-based intervention for people diagnosed with a stigmatized condition who are frequently hidden in communities and for adolescent and/or young adults who feel comfortable using the Internet. However, for a community intervention for elderly that requires direct face-to-face interactions, a Web-based approach may not work better than a traditional approach (eg, face-toface education). In the WPAPP study, a Web-based approach was essential to reach Korean American midlife women across the country in dispersed areas. This approach was selected because it was difficult to get midlife women, including Korean American midlife women, together in community settings for various reasons (eg, lack of childcare, social support, difficulties in transportation, and busy schedules).34–38 Thus, a Web-based approach that does not require physical attendance but has high flexibility and accessibility was necessary for the WPAPP study. In a previous study of the research team,1 Asian American midlife women including Korean American midlife women preferred Web-based physical activity promotion programs to traditional physical activity promotion programs because of their perceived usefulness of the programs. They preferred the self-controllability and easy accessibility of Web-based programs. However, they were concerned about the lack of face-to-face interactions in the interventions. Furthermore, Asian American (including Korean American) women indicated the necessity of culture-

specific content and structure of Web-based programs. The women thought that the source of the information would be more important than the medium of the information (eg, Web based, booklet, or face-to-face). Thus, the WPAPP incorporated these components that the women indicated in the previous study (eg, message boards to increase interactions, culture-specific exercise, the use of education materials from scientific authorities).

Target Population The next step in developing a Web-based intervention is to select the target population of the intervention. The target populations of the Web-based interventions in the literature included women, adults, and college students.39–43 A quarter of the Web-based interventions were aimed at women,39 about a quarter of the interventions aimed at adults,3,40,43 and approximately 12% of them aimed at college students.42 In the WPAPP study, the target population was Korean American midlife women, who were chosen because (1) Korean Americans represented one of the largest subethnic groups that we recruited in our previous studies; (2) they are the most rapidly growing group in the US44; (3) the research team had extensive experience with this group in previous studies; (4) they are culturally homogeneous group that has rarely interbred with other groups until recently22; and (5) Koreans are one of the ethnic minority groups who use the Internet more than any other.29,45

Theoretical Basis/Program Theory As in non–Web-based intervention studies, a theoretical basis/program theory is needed to guide development of Web-based interventions. Indeed, the literature review shows that a specific theoretical framework(s) was used in a half of the Web-based intervention studies. The theoretical framework(s) were (1) the self-regulation theory,25 (2) the selfefficacy model,30,31 (3) the transtheoretical model,17,39,46 (4) the social cognitive theory,12,47,48 (5) the Lazarus and Folkman theory,24 (6) the Mishel uncertainty in illness theory,49 and (7) the transitions theory.40 In the WPAPP study, a program theory derived from the Midlife Women’s Attitudes Toward Physical Activity (MAPA) theory was used to guide the development process. The MAPA theory50 was developed based on an integrated literature review and an empirical study on midlife women’s attitudes toward physical activity. The theory was adopted for development of the WPAPP because it clearly delineates the major concepts to consider in increasing the physical activity of midlife women. We identified the target variables of the WPAPP among the major variables considered in the theory and focused on the variables in the program development.

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Focus and Objectives The researchers need to determine the focus of their interventions. The literature review indicates that Webbased interventions have been developed with a focus on diverse practice areas of nursing. Approximately 40% of the Web-based interventions were for management of specific diseases (eg, eating disorder,51 diabetes mellitus,1,17 cancer,49 depression,23 metabolic syndrome,3 hypertension,52 asthma,44 venous ulcers,22 and chronic obstructive pulmonary disease29). More than 30% of the interventions were for disease prevention and health promotion (eg, screening for hepatitis B,53 prevention of osteoporosis,12,20 prevention of obesity,45 and prevention of hip fracture48). Approximately 12% of the Web-based interventions were targeted to provide social support for early female survivors of childhood cancer7 and adults with diabetes 60 years or older. In addition, Web-based interventions were developed to train peer leaders in HIV prevention,54 and to support parenting,40 breastfeeding,18 newborn care,30 and nursing education.9,31,41 On the basis of the decided focus, researchers need to set objectives of the interventions. In the WPAPP study, we selected six determinants of the target behavior (predictors of Korean American midlife women’s physical activity) for the program development based on the findings from previous studies on Korean American midlife women’s attitudes toward physical activity and their physical activity experiences. The determinants included three modifiable factors (attitudes, selfefficacy, and perceived barriers) and three nonmodifiable factors (employment, number of children, and acculturation level). We focused on only the three modifiable factors in the program development because they could be modified through a Webbased program. Accordingly, the program has four objectives: (1) to address physical activity–related issues/concerns in such a way that it enables the women to gain peer support from other Korean American midlife women with similar experiences (to improve self-efficacy and perceived barriers); (2) to obtain reliable, accurate, and adequate information related to physical activity and strategies to safely increase physical activity (to improve attitudes); (3) to enhance their resources and help them, their spouses, and their family members by relieving their physical activity-related concerns (to improve self-efficacy and perceived barriers); and (4) to promote physical activity in their daily lives (to improve attitudes and self-efficacy).

Components The next step is to determine the components of the Webbased intervention that will be developed.45,55 The WPAPP has three components: (1) an interactive online message board, (2) interactive online educational sessions, and (3) online resources. These components were decided based on the program theory that was mentioned above. The program theory emphasizes providing support/coaching and 508

information/knowledge through the WPAPP to change attitudes, self-efficacy, social influences, and perceived barriers. The interactive online message board provides a mechanism through which participants can share their own physical activity experience and receive support/coaching from peers and healthcare providers.56,57 The message board consists of a discussion board, multimedia upload functions (as in Facebook), and physical activity log functions, with daily monitoring by an RN under the supervision of a family physician. Interactive online educational sessions (users can choose the contents and ask questions and/or provide feedback by clicking buttons on the menu) provide information/knowledge about topics related to the three modifiable factors. The contents of the educational sessions include benefits of physical activity (to improve attitudes and self-efficacy); physical activity guidelines (to improve self-efficacy and perceived barriers); various short videos related to physical activity by the National Institutes of Health (NIH) (subtitled in Korean) (eg, Exercise, Sleep, and Cancer Risk) (to improve attitudes and self-efficacy); office exercises (to improve self-efficacy and perceived barriers); tips to increase physical activity in busy daily schedule (to improve perceived barriers); and examples of exercises that can be easily done without specific equipment (to improve self-efficacy and perceived barriers). The content of the educational sessions comes from reports and short videos by scientific authorities (eg, the NIH consensus statements on physical activity). The online resources include 17 Web links to online resources related to the modifiable factors only from scientific authorities. Because Asian American midlife women including Korean American midlife women regarded the accuracy of the information/knowledge as the most important aspect of a Web-based program in the previous study,1 the educational sessions and online resources were intentionally chosen from those by scientific authorities that had already been validated.

Technological Aspects The next step is to choose technological tools. Researchers need to consider the possible high cost of developing a Webbased intervention before choosing technological tools.52,58 Frequently, development of the interventions incurs a high cost, which is not feasible in small grant projects. The literature review indicated that researchers needed to put more time (time-consuming) to develop Web-based interventions compared with traditional interventions.58 The studies indicated that researchers were frequently burdened by the time needed to prepare, organize, maintain, and update the content of interventions and by the time needed to review, consider, adopt, and use the new technology.31 Whittemore et al58 reported that they needed $85 000 to develop and implement a Web-based intervention. However, studies confirmed that the cost required for intervention implementation

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was usually lower than medical costs such as fees for medical consultation and for a clinic visit.21 Moreover, researchers reported that Web-based interventions could be cost-effective because they lower costs related to in-person education.19,33,59 In addition, Web-based interventions could lower healthcare providers’ workload.17,19,60 Researchers also need to consider the necessity of technical expertise. The literature indicated that the research teams who developed Web-based interventions needed technical experts, such as Web developers and programmers, to develop and maintain the Web sites.58,61 In the WPAPP study, we had an engineering team who was actually in charge of all technological aspects of the development process of the WPAPP. This way, the research team could have adequate expertise and experience in technological aspects of the program development at a minimum cost. The WPAPP used specific information architecture and includes menus based on the three components. Presentation styles (eg, colors, designs, and menus) were tailored to Korean culture based on the feedback from Korean American participants of previous studies.62

Logistics for Users The next thing to consider in development of a Web-based intervention is how to set logistics for users. The literature indicated that researchers hardly had control of the users’ actual usages of the interventions due to few-face-to-face interactions. The lack of controllability could be problematic in terms of intervention implementation. At the planning stage of the interventions, researchers need to consider developing step-by-step details on intervention implementation (eg, how many times the participant will be required to visit the Web site).39,58 For example, in the study by Whittemore et al,58 the researchers identified the patterns of their Web site usages by counting the number of participant log-ins and the number of sessions that the participants navigated and used/completed. A unique strength of Web-based interventions is their consistency in intervention implementation.63 Web-based interventions could provide consistent content to their users regardless of healthcare providers’ busy schedules in clinical settings46 and deliver standardized and consistent education/content to users.42 Thus, in the development process, setting the consistency in intervention implementation through programming and close monitoring is essential. In the WPAPP study, we set specific logistics for users based on the logical flow of the WPAPP usages. When a user logs in the project Web site, she is given the three components and asked to choose one. She is allowed to move forward and backward and to choose other options at her convenience. If she chose the online message board, she would be linked to the board and she could post any messages in any format (eg, stories, poem, essay), interact with other participants using

multimedia functionality, and monitor her own physical activity using physical activity log functions. If she chose the online educational sessions, she would be given all the choices of the educational sessions categorized into the modifiable factors and asked to go through the session(s) of her choice within 1 hour per session. If she chose the online resources, she would be given the 17 Web links and allowed to use the resources in the links of her choice. Her activities were automatically recorded in the servers, and the online records monitored by the research team. Creative and innovative strategies to prevent dropouts need to be considered at the planning stage of Web-based intervention studies. The literature indicated that researchers rarely had control of users’ actual completion of the interventions.64 Researchers had little control over the users’ access to other Web sites (to prevent contamination), and they rarely identified nonverbal cues.8,19 The reliability/ credibility of the data provided by users largely depended on the users’ willingness and honesty.52 Partially because of this low controllability, high dropout rates in Web-based interventions were frequently reported. The main reasons of the dropouts in the literature were as follows: The users did not want to complete the intervention21; they could easily leave the Web site1; and/or they did not like the use of technology.60 Thus, high dropouts of the participants in Web-based interventions could be an issue to consider when developing and evaluating an intervention. Using specific motivation strategies—such as electronic gift certificates, Web links to online resources, or online professional consultation—could reduce dropouts during the intervention implementation. Indeed, in the WPAPP study, we incorporated all the motivation strategies mentioned above to minimize possible dropouts.

CONCLUSION In this article, we proposed practical guidelines for the development of Web-based interventions based on an empirical study and a systematic integrative literature review. First, researchers need to decide how a Web-based intervention would be meaningful and effective in approaching their research topics and target populations. Second, they need to select their target populations. They need to find a theoretical basis/program theory for their interventions and decide the focus and objectives of their interventions. On the basis of the focus and objectives, researchers need to select components of their interventions and choose technological aspects. Finally, they need to decide the logistics for users and include strategies to promote the users’ participation. These guidelines have several limitations because they are based on only one empirical study, although the findings from a systematic integrative literature review are also incorporated. Through further research and practice developing

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and using Web-based interventions, researchers need to continuously examine and add directions for development of the interventions that are not identified in this article. We hope the guidelines that are proposed in this article could help promote further development of Web-based interventions at this early stage of Web-based interventions in nursing.

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Practical guidelines for development of web-based interventions.

Despite a recent high funding priority on technological aspects of research and a high potential impact of Web-based interventions on health, few guid...
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