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Cited by 591Digital Mental Health InterventionsMobile Health and mHealth ApplicationsBehavioral Health and Interventions

A Behavior Change Model for Internet Interventions

Open access
Ritterband, Lee M., Thorndike, Frances P., Cox, Daniel J., Kovatchev, Boris P., Gonder-Frederick, Linda A.·2009·Annals of Behavioral Medicine
DOI 10.1007/s12160-009-9133-4PMC PMC2878721
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Abstract

BACKGROUND: The Internet has become a major component to health care and has important implications for the future of the health care system. One of the most notable aspects of the Web is its ability to provide efficient, interactive, and tailored content to the user. Given the wide reach and extensive capabilities of the Internet, researchers in behavioral medicine have been using it to develop and deliver interactive and comprehensive treatment programs with the ultimate goal of impacting patient behavior and reducing unwanted symptoms. To date, however, many of these interventions have not been grounded in theory or developed from behavior change models, and no overarching model to explain behavior change in Internet interventions has yet been published. PURPOSE: The purpose of this article is to propose a model to help guide future Internet intervention development and predict and explain behavior changes and symptom improvement produced by Internet interventions. RESULTS: The model purports that effective Internet interventions produce (and maintain) behavior change and symptom improvement via nine nonlinear steps: the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics. Website use leads to behavior change and symptom improvement through various mechanisms of change. The improvements are sustained via treatment maintenance. CONCLUSION: By grounding Internet intervention research within a scientific framework, developers can plan feasible, informed, and testable Internet interventions, and this form of treatment will become more firmly established.

Integrity signals

Registry

Crossref · 10.1007/s12160-009-9133-4

Cites

67 of 67 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 60 cited sources checked · 0 supported · 0 flagged

  • Premisecitation

    Environmental factors may either aid or obstruct people using a self-help treatment program.

    “The environment can provide support or serve as a barrier to individuals implementing a self-help treatment program [22].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Glasgow RE, Eakin EG. Issues in diabetes self-management. In: Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The Handbook of Health Behavior Change. 2nd ed. New York: Springer; 1998: 435.

      Not checked in the free run.

  • Premisecitation

    Environmental influences can affect all parts of the model in important ways.

    “In the Internet intervention model, environmental factors, similar to Glasgow’s “Pyramid of Influences,” [22] can impact each component of the model in potentially significant ways.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Glasgow RE, Eakin EG. Issues in diabetes self-management. In: Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The Handbook of Health Behavior Change. 2nd ed. New York: Springer; 1998: 435.

      Not checked in the free run.

  • Premisecitation

    Early studies indicate that certain website elements matter.

    “Although preliminary research has demonstrated the importance of some of these elements [24–26], additional work is necessary to determine the best use of each.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [24] Ritterband LM, Cox DJ, Gordon T, et al. The inclusion of audio, graphics, and interactivity in an internet intervention for pediatric encopresis. Child Health Care. 2006; 35: 47-59. source

      Not checked in the free run.

    • cites [25] Danaher BG, Boles SM, Akers L, Gordon JS, Severson HH. Defining participant exposure measures in web-based health behavior change programs. J Med Internet Res. 2006; 8: e15. source

      Not checked in the free run.

    • cites [26] Hurling R, Fairley BW, Dias MB. Internet-based exercise intervention systems: Are more interactive designs better? Psychol Health. 2006; 21: 757-772. source

      Not checked in the free run.

  • Interpretationreasoning

    Environmental factors influence behavior change, with family and community shaping actions via reinforcement.

    “Behavior change is also affected by environmental factors; family and the community can shape behaviors through positive or negative reinforcement.”
    Quote in the paperNot a substantial claim
  • Interpretationreasoning

    Finding the best combination of website elements is difficult because interventions, patients, systems, and technologies vary widely.

    “However, determining an optimal set of elements is complicated by the wide range of intervention types, patient populations, computing systems, and technologies as different elements of varying degrees will likely be necessary depending on the program focus area.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 64
  • The quote only partly states this claim. 2
  • May combine two claims. 30

  • Probably not a substantial claim: may not pass S1 (asserted). The quote only partly states this claim.

    Interpretationcitation

    The model proposes that online interventions that work yield and sustain changes in behavior and symptoms via nine nonlinear steps.

    “We hypothesize that effective Internet intervention programs will produce change in behaviors and reduce unwanted symptoms (as well as maintain improvement) via the following steps: the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics. Website use leads to behavior change via different mechanisms of change (e.g”
    Quote in the paperNot a substantial claim0 of 7 sources checked
    • cites [12] Rosenstock IM. Historical origins of the health belief model. Health Educ Monogr. 1974; 2: 328-335. source

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    • cites [13] Prochaska JO, DiClemente CC. The transtheoretical approach. In: Norcross JC, Goldfried MR, eds. Handbook of Psychotherapy Integration. New York: Basic Books; 1992: 300-334.

      Not checked in the free run.

    • cites [14] Lefebvre RC, Rochlin L. Social marketing. In: Glanz K, Lewis FM, Rimer B, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco: Jossey-Bass; 1997: 384-402.

      Not checked in the free run.

    • cites [15] Miller NE, Dollard J. Social Learning and Imitation. New Haven: Yale University Press; 1941.

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    • cites [16] Matarazzo JD, Weiss SM, Herd JA, Miller NE, Weiss SM, eds. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. New York: Wiley; 1984.

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    • cites [17] Casmir FL, ed. Building communication theories: A socio/cultural approach. Hillsdale: Erlbaum; 1994.

      Not checked in the free run.

    • cites [18] Fisher JD, Fisher WA. The information-motivation-behavioral skills model. In: DiClemente R, Crosby R, Kegler M, eds. Emerging Theories in Health Promotion Practice and Research. 2nd ed. San Francisco: Jossey Bass; 2002: 40-70.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Using a website drives behavior change via mechanisms like knowledge and motivation.

    “Website use leads to behavior change via different mechanisms of change (e.g., knowledge and motivation).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). The quote only partly states this claim.

    Interpretationreasoning

    Appearance dictates the program's appeal to the user.

    “This will, in part, dictate the program’s appeal to the user.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Website use and adherence are influenced by support and website characteristics.

    “which is influenced by support and website characteristics”
    • Also stated in: § Results · plain
      “which is influenced by support and website characteristics.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Treatment maintenance helps users keep the gains they have made.

    “treatment maintenance helps users maintain these gains.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    In weight loss programs, school lunch offerings can influence obese children's motivation.

    “Change mechanisms can be influenced by the support of the user’s school; for example, within a weight loss intervention, a school lunch program that makes nutritious lunches available can affect the motivation of obese children.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Laws restricting smoking can enhance smoking cessation outcomes.

    “For example, laws restricting smoking can enhance smoking cessation outcomes [23].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] Biener L, Abrams DB, Follick MJ, Dean L. A comparative evaluation of a restrictive smoking policy in a general hospital. Am J Public Health. 1989; 79: 192-195. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    User traits can function as predictors or be modified together with the target problem.

    “In fact, these user characteristics may serve as predictor variables [20, 21] or be targeted for change along with the identified problem.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [20] Magee JC, Ritterband LM, Thorndike FP, Cox DJ, Borowitz SM. Exploring the relationship between parental worry about their child’s health and usage of an Internet intervention for pediatric encopresis. J Pediatr Psychol. 2009; 34: 530-538. source

      Not checked in the free run.

    • cites [21] Tercyak KP, Abraham AA, Graham AL, Wilson LD, Walker LR. Association of multiple behavioral risk factors with adolescents’ willingness to engage in eHealth promotion. J Pediatr Psychol. 2009; 34: 457-469. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Changes in behavior influence physiology and target behaviors, which results in symptom improvement.

    “Behavior change impacts physiology and target behaviors to bring about symptom improvement”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    A user's traits, when shaped by their environment, influence how much they use and adhere to a website.

    “the user, influenced by environmental factors, affects website use and adherence”
    • Also stated in: § Results · plain
      “the user, influenced by environmental factors, affects website use and adherence, which is influenced by support and website characteristics.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The elements of a website shape how an Internet intervention is built and used.

    “These elements dictate the development and use of an Internet intervention.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Links between environment and other model parts can be identified, measured, and assessed to understand the environment's overall effect.

    “Connections between environment and other components of the model can be identified, measured, and evaluated to provide critical information regarding the overall impact of the environment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Deconstruction studies using computer and Internet programs have already been started by some researchers.

    “Some researchers have already begun conducting these important deconstruction studies with computer and Internet-based programs [31–33]”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [31] Greist JH, Marks IM, Baer L, et al. Behavior therapy for obsessive-compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. J Clin Psychiatry. 2002; 63: 138-145. source

      Not checked in the free run.

    • cites [32] Wright J, Wright A, Albano AM, et al. Computer-assisted cognitive therapy for depression: Maintaining efficacy while reducing therapist time. Am J Psychiatry. 2005; 162: 1158-1164. source

      Not checked in the free run.

    • cites [33] Tate DF, Jackvony EH, Wing RR. A randomized trial comparing human e-mail counseling, computer-automated tailored counseling, and no counseling in an Internet weight loss program. Arch Intern Med. 2006; 166: 1620-1625. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Research indicates that external support may improve adherence and outcomes for many disorders, but this is not always found.

    “There is research indicating that external support of the application may improve adherence and outcomes for many disorders [33, 47, 50]; however, this is not always found to be the case [48, 49]”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [33] Tate DF, Jackvony EH, Wing RR. A randomized trial comparing human e-mail counseling, computer-automated tailored counseling, and no counseling in an Internet weight loss program. Arch Intern Med. 2006; 166: 1620-1625. source

      Not checked in the free run.

    • cites [47] Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychol Med. 2007; 37: 319-328. source

      Not checked in the free run.

    • cites [50] Christensen H, Griffiths KM, Korten AE, Brittliffe K, Groves C. A comparison of changes in anxiety and depression symptoms of spontaneous users and trial participants of a cognitive behavior therapy website. J Med Internet Res. 2004; 6: e46. source

      Not checked in the free run.

    • cites [48] Andersson G, Lundström P, Ström L. Internet-based treatment of headache: Does telephone contact add anything? Headache. 2003; 43: 353-361. source

      Not checked in the free run.

    • cites [49] Klein B, Austin D, Pier C, et al. Internet-based treatment for panic disorder: Does frequency of therapist contact make a difference? Cogn Behav Ther. 2009; 38: 100-113. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    A site's look may promote first and ongoing use and boost engagement.

    “Although this issue may seem unimportant, appearance may be critical as it likely encourages initial (and continued) use of the website and may increase overall engagement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Website usage is influenced by user characteristics, environmental factors, the website itself, and support.

    “Usage is affected by the user characteristics, environmental factors, the actual website, and support.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    There is a large need for psychological services for insomnia; about one third of adults report insomnia symptoms and about 10% meet diagnostic criteria for an insomnia disorder.

    “For example, there is a huge need for psychological services for the treatment of insomnia, a significant health problem with one third of the adult population reporting symptoms of insomnia and approximately 10% meeting diagnostic criteria for an insomnia disorder [53–56].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [53] Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders, an opportunity for prevention? JAMA. 1989; 262: 1479-1484. source

      Not checked in the free run.

    • cites [54] Mellinger GD, Balter MB, Uhlenhuth EH. Insomnia and its treatment. Prevalence and correlates. Arch Gen Psychiatry. 1985; 42: 225-232. source

      Not checked in the free run.

    • cites [55] Ohayon MM. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev. 2002; 6: 97-111. source

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    • cites [56] Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry. 1997; 154: 1417-1423. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Symptom improvement and maintenance of gains is the goal of most Internet interventions.

    “Symptom improvement (and then maintenance of these gains) is the goal of most Internet interventions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisenone given

    Some interventions are purely self-guided, while other researchers have developed semi-self-guided applications that require clinician assistance.

    “While some interventions are purely self-guided applications, other researchers have developed semi-self-guided applications that require clinician assistance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    People may approach and use Internet interventions differently from other treatments, so user expectations are important.

    “People may approach and use Internet interventions differently than any other form of treatment, and it is critical to take into consideration user expectations [45].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] Christensen H, Mackinnon A. The law of attrition revisited. J Med Internet Res. 2006; 8: e20. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The Internet intervention model can be used to test how adherence affects behavior change and how other factors affect adherence.

    “The Internet intervention model lends itself to testing the impact of adherence on behavior change, as well as testing how other factors influence adherence.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Personalization and tailoring are central to Internet interventions and may be among the features that set them apart from other self-help programs.

    “The elements of personalization and tailoring are critical to Internet interventions and could be considered some of the primary elements distinguishing Internet interventions from other self-help programs.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Knowing which core parts everyone needs and which extra modules only some need can lead to more efficient, effective, and relevant treatments.

    “Identifying which core components of treatment are necessary for everyone, as well as determining which additional modules are needed by only some users, can help provide treatments that are more efficient, effective, and relevant.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    In the model, support directly affects system development because it must be built into the application design.

    “Support also directly impacts the development of the system (website), as this component needs to be implemented into the design of the application.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted). May combine two claims.

    Interpretationcitation

    It is hypothesized that message source and style affect user engagement and other change mechanisms, such as gaining knowledge and motivation.

    “These are hypothesized to impact user engagement and other mechanisms of change, including acquisition of knowledge and motivation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Incorporating support increases time, effort, and finances and can greatly reduce the ability to disseminate Internet interventions on a large scale.

    “Costs must also be considered [9] as the incorporation of any support increases the time, effort, and finances to implement an Internet intervention and can significantly reduce the ability to disseminate this type of intervention on any grand scale.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Tate DF, Finkelstein EA, Khavjou O, Gustafson A. Cost effectiveness of Internet interventions: Review and recommendations. Ann Behav Med. 2009. doi: 10.1007/s12160-009-9131-6 . source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Many user characteristics can be modified through intervention use and can serve as mechanisms of change.

    “It is important to note that many of the user characteristics can be modified through intervention use and serve as mechanisms of change.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Behavioral prescriptions aim to raise commitment and improve adherence.

    “These prescriptions are part of the treatment and are also designed to increase commitment and boost adherence.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Some researchers have used personalized e-mails and telephone support to increase adherence.

    “Some researchers have been incorporating personalized e-mails and telephone support as methods of increasing adherence [47–49].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [47] Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychol Med. 2007; 37: 319-328. source

      Not checked in the free run.

    • cites [48] Andersson G, Lundström P, Ström L. Internet-based treatment of headache: Does telephone contact add anything? Headache. 2003; 43: 353-361. source

      Not checked in the free run.

    • cites [49] Klein B, Austin D, Pier C, et al. Internet-based treatment for panic disorder: Does frequency of therapist contact make a difference? Cogn Behav Ther. 2009; 38: 100-113. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Some users may expect to complete only a limited part of a program to meet their needs, while others may plan and need to complete the full treatment.

    “Users may expect to complete a limited subset of a program to satisfy their needs, whereas other users may plan and need to complete the full treatment offered.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] Christensen H, Mackinnon A. The law of attrition revisited. J Med Internet Res. 2006; 8: e20. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    Personalization and tailoring likely engage users further and may increase their desire to use the system.

    “It likely also further engages the user and may increase the individual’s desire to use the system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    An Internet intervention should still meet some minimum requirements of effectiveness.

    “The application should, however, meet some minimum requirements of effectiveness [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Tate DF, Finkelstein EA, Khavjou O, Gustafson A. Cost effectiveness of Internet interventions: Review and recommendations. Ann Behav Med. 2009. doi: 10.1007/s12160-009-9131-6 . source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationcitation

    Because the Internet contains much misinformation, offering accurate, clear, and simple information is essential for effective and well-received applications.

    “Given that there is a significant amount of misinformation on the Internet [34], providing accurate, clear, and simple information is critical to creating and delivering efficacious applications that will be well-received.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] Eysenbach G, Powell J, Kuss O, Sa ER. Empirical studies assessing the quality of health information for consumers on the World Wide Web: A systematic review. JAMA. 2002; 287: 2691-2700. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Behavior change is typically necessary for symptoms to improve.

    “Behavior change is typically necessary for the symptoms to improve.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Without human involvement, Internet interventions can serve as many people as the computer servers are scaled to support.

    “Without human involvement, Internet interventions can serve as many people as the computer servers are scaled to support.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    Regardless of how an intervention is delivered, users bring a set of user characteristics, and their use is shaped by influences such as environment and support.

    “Regardless of the delivery mechanism, users approach the intervention with a set of user characteristics, and use of that intervention is shaped by various influences including the environment and support.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Symptoms are specific to the problem and treatment application.

    “Obviously, the symptoms are specific to the problem and treatment application.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Behavior change and symptom improvement occur through various mechanisms of change.

    “Ultimately, behavior change and symptom improvement occur via various mechanisms of change.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Testing offers a way to teach or emphasize particular content.

    “Testing also provides a method to teach (or highlight) specific content that can be presented through the use of multiple choice or true/false questions with corrective feedback.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Different delivery elements offer distinct ways to present content, potentially affecting system use through engagement, usability, and enjoyment, and possibly influencing mechanisms of change.

    “Each of these elements provide a different way of delivering content that may impact use of the system due to the individual’s engagement, usability, and enjoyment of the program, as well as potentially impacting specific mechanisms of change.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    As the need for external support decreases, the reach of Internet interventions increases exponentially.

    “As the needs of external support are reduced, the reach of Internet interventions exponentially increases.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Feedback can act as an important type of reinforcement.

    “Providing feedback can serve as a significant form of reinforcement.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    For most Internet interventions, symptom improvement is the ultimate success measure, and it is usually determined by behavior change.

    “While the ultimate measure of success of most Internet interventions is symptom improvement, this is usually dictated by the occurrence of behavior change.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Reinforcement is used to motivate users to learn and advance through the program.

    “Reinforcement is utilized to help motivate the user to learn and progress through the program.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The benefits of an Internet intervention, such as widespread use and accessibility, may far outweigh reduced effectiveness compared with the gold standard.

    “The benefits of such a system, including widespread use and accessibility, may far outweigh reduced effectiveness compared to the gold standard.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Because Internet interventions can be used in different ways, usage data are harder to interpret; an apparent dropout or nonadherent user may have achieved success with a low treatment dose.

    “Given these different uses of an Internet intervention, it is much more difficult to make sense of usage data, as someone who appears to be a “dropout” or nonadherent user may actually be someone who obtained “success” with a low treatment dose [45].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [45] Christensen H, Mackinnon A. The law of attrition revisited. J Med Internet Res. 2006; 8: e20. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Contracts and written instructions are known to improve behavior change.

    “Behavioral contracts, concerning what the patient is willing to do (and when), and written instructions are known to enhance behavior change [27].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Cox DJ, Tisdelle DA, Culbert JP. Increasing adherence to behavioral homework assignments. J Behav Med. 1988; 11: 519-522. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Environmental influences can affect users after they have started using the system, potentially affecting adherence midway through the program.

    “For example, it is possible that environmental influences impact users after they have begun using the system, thus potentially impacting users’ adherence midway through the program.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The model proposes that people enter an Internet intervention with user characteristics shaped by environmental factors.

    “The model for Internet interventions proposes that individuals approach an Internet intervention with a set of user characteristics that are influenced by environmental factors.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    User characteristics affect website use.

    “The user characteristics in turn impact their use of the website.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Website use is also affected by website characteristics, adherence to the site, and program support.

    “Website use is also influenced by website characteristics, adherence to the site, and support offered by the program to assist users in their use of the intervention.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    User characteristics may predict website use and ultimate symptom improvement, and evaluating them could help developers tailor interventions.

    “For example, user characteristics may predict use of the website, as well as ultimate symptom improvement, and evaluating these user variables (e.g., disease severity, readiness for change) could help future developers tailor the intervention accordingly.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    The environment affects all components of the model.

    “The environment affects all components of the model, and measuring these influences is important to understanding the impact of the environment on the user, usage of the system, change mechanisms, changing of behaviors, symptom improvement, and treatment maintenance.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Examining website use may provide the most meaningful information to researchers, clinicians, and users.

    “Examining website use is another distinctive aspect to the model, potentially providing the most meaningful information to researchers, clinicians, and users.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Each component, area, and element of the model can be examined and measured.

    “Measurement indicates that each component, area, and element of the model can be examined and measured.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Relapse prevention can avert deterioration, maintain successes, and enhance maintenance of behavior change and symptom improvements.

    “However, relapse prevention can be used to avert deterioration and maintain successes and can be used to enhance the maintenance of behavior change and symptom improvements [59].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [59] Marlatt GA, George WH. Relapse prevention and the maintenance of optimal health. In: Shumaker SA, Schron EB, Ockene JK, McBee WL, eds. The Handbook of Health Behavior Change. 2nd ed. New York: Springer; 2004: 33-58.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    It is critical to measure mechanisms of change, behavior change, symptom improvement, and treatment maintenance to determine whether Internet interventions deliver effective treatments.

    “While not unique to Internet interventions, it is critical to also measure the mechanisms of change, behavior change, symptom improvement, and treatment maintenance components to determine the ability of Internet interventions to deliver effective treatments.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The model depicts a recurrent cyclical process.

    “To clarify, the model depicts a recurrent cyclical process.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Relapse prevention information is included to help users reduce the chance of problems returning and to develop plans for future problems.

    “Relapse prevention information is incorporated in order to help the user reduce the possibility of problems returning and develop plans to address future problems should they occur.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    By drawing on multiple disciplines and established theories, the model helps conceptualize, identify, and measure factors likely to contribute to behavior change and symptom improvement in Internet interventions.

    “By drawing on multiple disciplines and previously established theories and models, this model enables us to conceptualize, identify, and measure the factors likely to contribute to behavior change (and symptom improvement) in Internet interventions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    A model's usefulness is determined by how well it can be evaluated.

    “The usefulness of any model is determined by how well it can be evaluated, and the current model and its components can be operationalized and measured in numerous ways.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Treatment success is maintained through relapse prevention.

    “Treatment success is maintained through relapse prevention.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    The model is an oversimplification of how Internet interventions produce behavior change.

    “First, the model is an oversimplification of how Internet interventions produce behavior change.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Addressing adherence problems, such as with stepped care, and measuring adherence changes can yield information that extends beyond Internet-delivered treatment programs.

    “Building in ways of addressing problems with adherence, such as stepped care approaches, and measuring the resulting changes in adherence can provide information and understanding that reaches beyond that of treatment programs delivered via the Internet.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    The model is not meant to be unidirectional; steps can repeat or occur out of order.

    “Despite this linear depiction, however, the model is not conceptualized as a unidirectional process. Instead, steps can be repeated or even occur out of order.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    The model predicts that website use leads to behavior change through mechanisms of change, and that behavior changes lead to symptom improvement.

    “The model then predicts that website use leads to behavior change via various mechanisms of change and that the behavior changes result in symptom improvement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationreasoning

    Mechanisms of change, behavior change, and symptom improvement may all affect user characteristics, which then continue to affect these processes.

    “Furthermore, the mechanisms of change, behavior change, and symptom improvement may all have an impact on user characteristics which in turn continue to affect these processes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Dismantling a program and identifying which treatment elements produce positive change should lead to more efficient but still effective programs using only necessary ingredients.

    “Dismantling the program and determining which treatment elements help result in positive change should lead to more efficient yet still highly effective programs utilizing only the necessary ingredients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    The model extends knowledge about the development, testing, and usage of Internet interventions and has clinical and research implications.

    “This model extends our knowledge about the development, testing, and usage of Internet interventions and has both important clinical and research implications.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    The model identifies components of an Internet intervention and presents their relationships to explain and predict behavior change and symptom improvement across interventions.

    “This model of Internet interventions helps identify the various components of an Internet intervention and presents the relationships among the various components in an effort to explain and predict behavior change and symptom improvement across interventions.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The Internet intervention model enables the field to turn knowledge about behavior into useful strategies for health enhancement.

    “The Internet intervention model enables the field to do just that.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Determining which aspects of a treatment application are used may reveal the most helpful treatment components.

    “Determining which aspects of a treatment application are utilized may uncover the most helpful aspects of treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    The current model and its components can be operationalized and measured in many ways.

    “The usefulness of any model is determined by how well it can be evaluated, and the current model and its components can be operationalized and measured in numerous ways.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    Measuring the support component will improve understanding of usage and adjunctive assistance.

    “Measuring the associated support component will contribute to a greater understanding of usage and adjunctive assistance.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    Users will keep using the Internet intervention as they change behaviors and experience symptom improvement, which changes their user characteristics and affects continued use.

    “Users will continue to use the Internet intervention even as they change behaviors and experience symptom improvement, which will cause changes in their user characteristics, which will impact their continued use of the system, and so on.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Premisecitation

    It is critical for clinicians and researchers to understand how health behavior changes and to turn that knowledge into useful strategies for health enhancement.

    “It is critical for clinicians and researchers to understand how health behavior changes and to transform that knowledge about behavior into useful strategies for health enhancement [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Glanz K, Lewis F, Rimer B. Linking theory, research, and practice. In: Glanz K, Lewis F, Rimer B, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. San Francisco: Jossey-Bass; 1997: 19-35.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Evaluating different aspects of the website is essential for predicting and explaining behavior change through Internet interventions.

    “Although evaluating different aspects of the website (e.g., color, layout, organization) is a time-intensive undertaking, it is essential in helping to predict and explain behavior change via Internet interventions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Simplification aids understanding and use but does not capture every aspect of intervention processes.

    “Although simplification encourages understanding and facilitates use, such brevity fails to capture all aspects of intervention processes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationnone given

    Some elements must be included in all Internet interventions, such as understandable content, while other elements and amounts will vary for different treatments and populations.

    “Clearly, some elements will need to be incorporated into all Internet interventions (e.g., understandable content); however, different elements (and varying amounts of these elements) will be necessary for diverse treatments and populations.”
    Quote in the paperNot a substantial claim
79 of 79

  • The paper relies on this without support.

    Many Internet interventions have not been grounded in theory or developed from behavior change models.

    “To date, however, many of these interventions have not been grounded in theory or developed from behavior change models”

  • The paper relies on this without support.

    No overarching model to explain behavior change in Internet interventions has yet been published.

    “and no overarching model to explain behavior change in Internet interventions has yet been published.”

  • The paper relies on this without support.

    There has been no published theoretical model underlying these programs.

    “Although there has been a recent proliferation of Internet health interventions [1, 4, 10], there has been no published theoretical model underlying these programs.”

  • The paper relies on this without support.

    We are unaware of literature documenting how technology, specifically the Internet, can be used to promote behavior change and subsequent symptom improvement with an underlying theoretical model.

    “Although various books provide recommendations for effective website design [19], we are unaware of literature documenting how technology, specifically the Internet, can be used to promote behavior change and subsequent symptom improvement with an underlying theoretical model.”

  • The paper relies on this without support.

    Feasibility and efficacy data have been established in Internet intervention research, but true effectiveness studies are needed.

    “While feasibility and efficacy data have been established in Internet intervention research, true effectiveness studies are needed.”

  • The paper relies on this without support.

    Any type of prevention or treatment program can fit within the website and website use components of the model.

    “In a sense, the website and website use components of this model could be considered a “black box” in that any type of prevention or treatment program could fit here.”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Practitioners recommended incorporating vignettes featuring parents and children with EBSA, as they enhance knowledge retention and motivation.

    “Practitioners recommended incorporating vignettes featuring parents and children with EBSA, as they enhance knowledge retention, and motivation (Ritterband et al., 2009).”

    From Intervention for school anxiety and absenteeism in children (ISAAC): Co-designing a brief parent-focused intervention for emotionally-based school avoidance. (2024) · cites this paper as Ritterband et al., 2009

    The Website section says a vignette may help a user learn and understand a concept and may increase motivation. It presents these as possible effects in Internet interventions, not established improvements in knowledge retention or effects demonstrated for parents and children with EBSA. The practitioners’ recommendation appears to be the citing authors’ finding, rather than a finding attributed to this source. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The idea that a website's quality and design affect adherence and outcomes has generally lacked rigorous testing.

    “It is believed that the quality and design of websites can influence adherence and outcomes (24), although this belief has generally not been rigorously tested.”

    From Behavioral Intervention Technologies: Evidence review and recommendations for future research in mental health (2013) · cites this paper as [24]

  • Little is known about the fundamental experience of participating in an Internet-based intervention and about the dimensions through which this experience engages a participant's mental health.

    “However, little is known about the fundamental experience of participating in an Internet-based intervention, and even less is known about the dimensions through which this experience engages a participant’s mental health.”

    From Adolescent and parent experiences with a primary care/Internet-based depression prevention intervention (CATCH-IT) (2011) · cites this paper as [19]

  • Internet-adapted therapies have added benefits of convenience, privacy, and the ability to provide full-spectrum care to patients in remote areas.

    “with the added benefits of convenience, privacy, and providing clinicians with the ability to provide a full-spectrum of care to patients even in remote areas [29; 48].”

    From Internet-enhanced management of fibromyalgia: A randomized controlled trial (2010) · cites this paper as [48]

  • Patients benefit as they can access self-management information in private and at their own convenience over the long term, an important consideration for a chronic condition.

    “Patients also benefit as they can access self-management information in private and at their own convince over the long term–which is an important consideration when managing a condition that by definition is chronic [48].”

    From Internet-enhanced management of fibromyalgia: A randomized controlled trial (2010) · cites this paper as [48]

Cites

Flagged first, then by citations

4 of the 71 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Petty RE, Cacioppo JT. Motivational factors in consumer response to advertisements. In: Geen RG, Beatty WW, Arkin RM, eds. Human Motivation. New York: Allyn and Bacon; 1984: 418-454.
  2. US Department of Commerce. A Nation Online: How Americans are Expanding their Use of the Internet. US Department of Commerce. Washington: Government Printing Office; 2002.

Cited by

Sorted by citations

Related

Authors
Ritterband, L. M., Thorndike, F. P., Cox, D. J., Kovatchev, B. P., & Gonder-Frederick, L. A.
Affiliations
University of Virginia Health System (US)
Corresponding author
Ritterband, Lee M.
ORCID
Venue
Annals of Behavioral Medicine
Publisher
Oxford University Press (OUP)
Published
2009-08
Volume
38
Issue
1
Pages
18-27
ISSN
  • 0742-5554 (ISSN-L)
  • 0883-6612
  • 1532-4796
DOI
10.1007/s12160-009-9133-4
PMC
PMC2878721
OpenAlex
W2161380409
Cited by
591
References
71
Citations by year
2026: 13 · 2025: 22 · 2024: 22 · 2023: 45 · 2022: 29 · 2021: 45 · 2020: 50 · 2019: 43 · 2018: 48 · 2017: 33 · 2016: 48 · 2015: 31 · 2014: 53 · 2013: 34 · 2012: 37
FWCI
29.00
Type
journal article
Language
en
Open access
Locations
  • Annals of Behavioral Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health
  • National Institute of Mental Health (R34 MH70805, R34MH070805)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD028160)
Topics
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Social Sciences › Psychology › Applied Psychology › Behavioral Health and Interventions
Keywords
online intervention, behavior change models, online health interventions, mechanisms of change, medication adherence, maintenance therapy, symptom improvement, website characteristics, user support, environmental factors, behavioral medicine
MeSH terms
Behavior Therapy, Computer Simulation, Evaluation Studies as Topic, Humans, Models, Psychological, Therapy, Computer-Assisted, User-Computer Interface, Internet

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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