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Cited by 219Digital Mental Health InterventionsMobile Health and mHealth ApplicationsHealth Literacy and Information Accessibility

Web-Based Interventions for Behavior Change and Self-Management: Potential, Pitfalls, and Progress

Open access
Murray, Elizabeth·2012·Medicine 2.0
DOI 10.2196/med20.1741PMC PMC4084772
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Abstract

The potential advantages of using the Internet to deliver self-care and behavior-change programs are well recognized. An aging population combined with the increasing prevalence of long-term conditions and more effective medical interventions place financial strain on all health care systems. Web-based interventions have the potential to combine the tailored approach of face-to-face interventions with the scalability of public health interventions that have low marginal costs per additional user. From a patient perspective, Web-based interventions can be highly attractive because they are convenient, easily accessible, and can maintain anonymity/privacy. Recognition of this potential has led to research in developing and evaluating Web-based interventions for self-management of long-term conditions and behavior change. Numerous systematic reviews have confirmed the effectiveness of some Web-based interventions, but a number of unanswered questions still remain. This paper reviews the progress made in developing and evaluating Web-based interventions and considers three challenging areas: equity, effectiveness, and implementation. The impact of Web-based interventions on health inequalities remains unclear. Although some have argued that such interventions can increase access to underserved communities, there is evidence to suggest that reliance on Web-based interventions may exacerbate health inequalities by excluding those on the "wrong" side of the digital divide. Although most systematic reviews have found a positive effect on outcomes of interest, effect sizes tend to be small and not all interventions are successful. Further work is needed to determine why some interventions work and others do not. This includes considering the "active ingredients" or mechanism of action of these complex interventions and the context in which they are used. Are there certain demographic, psychological, or clinical factors that promote or inhibit success? Are some behaviors or some clinical problems more amenable to change by computer-based interventions? Equally problematic is the issue of implementation and integration of such programs into routine clinical practice. Many eHealth projects end when the research is concluded and fail to become part of mainstream clinical care. One way of addressing these challenges is to apply the Medical Research Council framework for developing, evaluating, and implementing complex interventions. This includes having a strong theoretical foundation, developing a proposed mechanism or pathway of action, ensuring that the evaluation adequately reflects this proposed pathway, and considering implementation from the beginning of the development process.

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review examines the potential, pitfalls, and progress of Web-based interventions for behavior change and self-management, focusing on three unresolved challenges: equity, effectiveness, and implementation. It argues that applying the Medical Research Council framework for complex interventions, together with greater use of theory, could help realize the field's potential.

Key findings

  • Web-based interventions have potential advantages in reach, accessibility, tailoring, and low marginal cost per user, but effect sizes in systematic reviews "tend to be small and not all interventions are successful."
  • Equity is unresolved: Internet penetration in 2011 was 11% in Africa, 24% in Asia, and 36% in Latin America/Caribbean; within the UK, access was 99% among households earning ≥£40,000 versus 43% at ≤£12,500, 95% among university graduates versus 31% among those who left school without graduating, <40% among those aged 65+, and 41% among those with work-limiting health problems or disabilities.
  • Effectiveness varies by outcome: reviews support effects for smoking cessation, alcohol reduction, safer sex, and physical activity, but a UK HTA review found little or no impact of adaptive e-learning on dietary behaviors and no impact on weight loss or BMI; CCBT is effective across mild-to-moderate depression, anxiety, OCD, and phobias, whereas non-CCBT emotional interventions (social networks, personal stories) lack robust evidence of benefit or harm.
  • A meta-analysis of ~85 studies covering >45,000 participants found that more extensive use of theory (particularly the Theory of Planned Behavior) and certain behavior-change techniques (eg, stress management, goal setting, action planning) were associated with larger effect sizes.

Methods

  • Design: narrative review/commentary, not a systematic review; no search strategy, inclusion criteria, or formal synthesis method is reported.
  • Scope: synthesizes existing systematic reviews, meta-analyses, and trials across self-management of long-term conditions, health promotion, and mental health, plus policy and implementation literature.
  • Analysis: thematic discussion organized around equity, effectiveness (cognitive, behavioral, emotional outcomes, mechanism of action, cost-effectiveness), and implementation, with recommendations framed by the MRC complex interventions framework and normalization process theory.

Limitations

  • The paper states that a number of unanswered questions remain, including why some interventions work and others do not, what the "active ingredients" and effective dose are, and which demographic, psychological, or clinical factors promote or inhibit success; data on user characteristics and adherence are described as "confusing and contradictory."
  • The paper states there is a paucity of data on actual cost-effectiveness of Internet interventions and a paucity of comparative data on online peer-support services.
  • Evident from the text (not framed as a limitation by the author): this is a single-author narrative review without a documented systematic search or quality appraisal, so selection of cited evidence may be non-exhaustive and subject to author perspective.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2196/med20.1741

Cites

117 of 117 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 120 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Our own research on Web-based interventions supports concerns about equity, with disproportionately high numbers of users having a university degree.

    “Our own research on Web-based interventions supports these concerns about equity, with disproportionately high numbers of users having a university degree [29,30].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [29] source

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    • cites [30] source

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  • Interpretationreasoning

    Outside of carefully designed and executed studies, there is evidence that Web-based interventions tend to be used by more advantaged groups.

    “Unfortunately, outside of these carefully designed and executed studies, there is evidence that Web-based interventions tend to be used by more advantaged groups.”
    Quote in the paperSubstantial claim
  • Interpretationnone given

    The use of multimedia allows complex information to be presented in a simple format comprehensible even to those with low literacy skills.

    “Moreover, the use of multimedia (eg, video, audio, and graphics) allows complex information to be presented in a simple format comprehensible even to those with low literacy skills.”
    Quote in the paperNot a substantial claim
  • Interpretationreasoning

    Those with the most need have the least access.

    “In other words, those with the most need have the least access.”
    Quote in the paperSubstantial claim
  • Interpretationnone given

    Many eHealth projects end when the research is concluded and fail to become part of mainstream clinical care.

    “Many eHealth projects end when the research is concluded and fail to become part of mainstream clinical care.”
    • Also stated in: § Cost-Effectiveness and Implementation · plain
      “many interventions have not been widely disseminated.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 38
  • Classified as probably not a substantial claim. 36
  • The quote only partly states this claim. 1

  • May combine two claims.

    Interpretationnone given

    Most systematic reviews have found a positive effect on outcomes of interest, but effect sizes tend to be small and not all interventions are successful.

    “Although most systematic reviews have found a positive effect on outcomes of interest, effect sizes tend to be small and not all interventions are successful.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Internet penetration in Africa was estimated at 11%, 24% in Asia, and 36% in Latin America and the Caribbean in 2011.

    “Internet penetration in Africa was estimated at 11%, 24% in Asia, and 36% in Latin America and the Caribbean in 2011 [15].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] Internet World Stats: Usage and Population Statistics201112312012-08-11Internet usage statistics: the Internet big picturehttp://www.internetworldstats.com/stats.htm69q5RTCsT

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Web-based interventions could have two opposing impacts on health inequalities.

    “Web-based interventions could have two opposing impacts on health inequalities.”
    Quote in the paperSubstantial claim

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

    Interpretationnone given

    The behaviors of interest tend to be the same across healthy and unwell populations (healthy eating, physical activity, smoking cessation, moderating alcohol consumption, and practicing safer sex), but the levels of motivation may differ.

    “The behaviors of interest tend to be the same across both populations (ie, healthy eating, physical activity, smoking cessation, moderating alcohol consumption, and practicing safer sex), but the levels of motivation may differ.”
    Quote in the paperNot a substantial claim

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

    Interpretationnone given

    Interactivity is a major advantage of the Internet, both for users interacting with websites and entering personal information that allows tailoring, and for users interacting with one another through the Web.

    “Interactivity is a major advantage of the Internet, both for users interacting with websites and entering personal information that allows the site to tailor the information or services offered to that specific user, and for users interacting with one another through the Web.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In 2011, Internet access among those aged 65 or over was <40%, and among those with health problems or disabilities that limited work, access was 41%.

    “In 2011, Internet access among those aged 65 or over was <40%, and among those with health problems or disabilities that limited the kind or amount of work able to be done, access was 41% [28].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] source

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

    Interpretationnone given

    From a patient perspective, Web-based interventions can be highly attractive because they are convenient, easily accessible, and can maintain anonymity/privacy.

    “From a patient perspective, Web-based interventions can be highly attractive because they are convenient, easily accessible, and can maintain anonymity/privacy.”
    Quote in the paperNot a substantial claim

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

    Interpretationnone given

    Many of the potential benefits of Web-based interventions have yet to be realized.

    “Many of these potential benefits have yet to be realized.”
    Quote in the paperNot a substantial claim

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

    Interpretationnone given

    An almost unlimited amount of information can be stored on the Web, yet it can be presented in an accessible and comprehensible format, in bite-size chunks, using video, graphics, and audio, and is available at the moment of need.

    “An almost unlimited amount of information can be stored on the Web, yet it can be presented in an accessible and comprehensible format, in bite-size chunks, using video, graphics, and audio, and is available at the moment of need.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Initial results of CCBT for somatic problems are promising, but many of the trials have been relatively small.

    “Although initial results are promising, further work is needed because many of the trials have been relatively small [44-47].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [44] Andersson, G, 2002, Psychosom Med source

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    • cites [45] source

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    • cites [46] source

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    • cites [47] source

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

    Interpretationnone given

    Numerous systematic reviews have confirmed the effectiveness of some Web-based interventions.

    “Numerous systematic reviews have confirmed the effectiveness of some Web-based interventions, but a number of unanswered questions still remain.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    External constraints that may prevent health-promoting activities include poor housing, poor working conditions, and poverty.

    “External constraints that may prevent health-promoting activities include poor housing, poor working conditions, and poverty [24].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [24] source

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  • May combine two claims.

    Premisecitation

    Older people and people with disabilities or long-term illnesses are less likely to have Internet access.

    “Of greater concern, older people and people with disabilities or long-term illnesses are less likely to have Internet access.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] source

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  • May combine two claims.

    Premisecitation

    In 2011, Internet access among people with household incomes of £40,000 or more was 99%, whereas it was only 43% among people with household incomes of £12,500 or less.

    “In 2011, Internet access among people with household incomes of £40,000 or more was 99%, whereas it was only 43% among people with household incomes of £12,500 or less (half the national median income).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] source

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  • May combine two claims.

    Interpretationreasoning

    Access is necessary-but not sufficient-for benefiting from Web-based interventions.

    “Moreover, access is necessary—but not sufficient—for benefiting from Web-based interventions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Among people with a university degree, Internet access was 95%, whereas access was only 31% for those who left school without graduating.

    “Similarly, among people with a university degree, access was 95%, whereas access was only 31% for those people who left school without graduating.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [28] source

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  • May combine two claims.

    Premisecitation

    Some researchers have demonstrated that Internet interventions can be used by and can benefit severely disadvantaged groups, including homeless drug users, single teenage mothers, and vulnerable elderly people.

    “Some researchers have undertaken impressive work, demonstrating that Internet interventions can be used by and can benefit severely disadvantaged groups, including homeless drug users [25], single teenage mothers [26], and vulnerable elderly people [27].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [25] Cashen, MS, 2002, Comput Inform Nurs source

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    • cites [26] Dunham, PJ, 1998, Am J Community Psychol source

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    • cites [27] Heyn Billipp, S, 2001, Public Health Nurs source

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

    Premisecitation

    Computerized cognitive behavioral therapy (CCBT) was first developed for use with people experiencing mental health problems such as depression and anxiety.

    “An alternative approach has been the use of computerized cognitive behavioral therapy (CCBT), which was first developed for use with people experiencing mental health problems such as depression and anxiety [42,43].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [42] Proudfoot, J, 2004, Br J Psychiatry source

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    • cites [43] Proudfoot, J, 2003, Psychol Med source

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  • May combine two claims.

    Premisecitation

    The Internet is now widely available in the developed world, with more than 90% penetration in Sweden, approximately 80% penetration in the United Kingdom, Australia, and the United States, and approximately 60% in Europe as a whole.

    “The Internet is now widely available in the developed world, with more than 90% penetration in Sweden, approximately 80% penetration in the United Kingdom, Australia, and the United States, and approximately 60% in Europe as a whole [15].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Internet World Stats: Usage and Population Statistics201112312012-08-11Internet usage statistics: the Internet big picturehttp://www.internetworldstats.com/stats.htm69q5RTCsT

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    Changing dietary behaviors appears to be more challenging, with a recent systematic review for the UK Health Technology Agency finding little or no impact of adaptive e-learning technologies across a wide range of dietary behaviors and no impact on weight loss or body mass index.

    “Changing dietary behaviors appears to be more challenging, with a recent systematic review for the UK Health Technology Agency finding little or no impact of adaptive e-learning technologies across a wide range of dietary behaviors and no impact on weight loss or body mass index [39].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [39] source

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  • May combine two claims.

    Interpretationcitation

    Although small changes in behavioral outcomes have been demonstrated for people with long-term conditions, these have not converted into improved clinical outcomes.

    “Although small changes in behavioral outcomes have been demonstrated, these have not converted into improved clinical outcomes [31].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] source

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

    Interpretationreasoning

    These two forms of interactivity can be used to provide formal behavior change support, decision support, and peer support.

    “These two forms of interactivity can be used to provide formal behavior change support, decision support, and peer support.”
    Quote in the paperSubstantial claim

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

    Interpretationreasoning

    The impact of Web-based interventions on health inequalities remains unclear.

    “The impact of Web-based interventions on health inequalities remains unclear.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    Internal, or psychological, constraints (eg, low self-efficacy or an external locus of control) may also play a part in preventing users from acting on information.

    “Internal, or psychological, constraints (eg, low self-efficacy or an external locus of control) may also play a part.”
    Quote in the paperNot a substantial claim

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

    Interpretationnone given

    The motivation of people with a long-term condition differs from those without a diagnosis of a health problem because the need for change is both more immediate and more personal.

    “It can be postulated that the motivation of people with a long-term condition differs from those without a diagnosis of a health problem because the need for change is both more immediate and more personal.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Characteristics of the intervention that may improve adherence include a strong theoretical foundation, perceived personal relevance, perceived effectiveness, tailoring, persuasive technologies, credibility, social networking, and regular "push factors" including human support and/or periodic prompts.

    “Characteristics of the intervention that may improve adherence to the intervention include a strong theoretical foundation [41], perceived personal relevance to the user [65,66], perceived effectiveness [67,68], tailoring [69,70], persuasive technologies [71], credibility [72,73], social networking [74,75], and regular “push factors” including human support [76-78] and/or periodic prompts (eg, by”
    Quote in the paperSubstantial claim0 of 6 sources checked
    • cites [41] source

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    • cites [65] source

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    • cites [66] source

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    • cites [76] source

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    • cites [77] source

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    • cites [78] source

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  • May combine two claims.

    Interpretationnone given

    One way of ensuring an intervention is used by large numbers of people is to integrate it into routine health services, but this has been rarely done to date.

    “One way of ensuring an intervention is used by large numbers of people is to integrate it into routine health services, but this has been rarely done to date.”
    Quote in the paperNot a substantial claim

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

    Interpretationcitation

    Many researchers have found that women, older people, and well-educated people are all more likely to demonstrate adherence to Web-based interventions than males, younger people, and less-educated people.

    “Although many researchers have found that women, older people, and well-educated people are all more likely to demonstrate adherence to Web-based interventions than males, younger people, and less-educated people [65,66,68,69]”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [65] source

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    • cites [66] source

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    • cites [68] source

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    • cites [69] Wangberg, SC, 2008, Patient Prefer Adherence

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  • May combine two claims.

    Interpretationcitation

    Although there are some interventions that have been used by very large numbers of people, many interventions have not been widely disseminated.

    “Although there are some interventions that have been used by very large numbers of people [82,83], many interventions have not been widely disseminated.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [82] source

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    • cites [83] source

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  • May combine two claims.

    Interpretationcitation

    There is a paucity of data on actual cost-effectiveness of Internet interventions, making it difficult to determine their actual, versus potential, cost-benefits.

    “There is also a paucity of data on actual cost-effectiveness of Internet interventions [17,34], making it difficult to determine their actual, versus potential, cost-benefits.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [17] source

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    • cites [34] source

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  • May combine two claims.

    Interpretationcitation

    Even when an intervention is effective, the main costs tend to be incurred during development, with relatively low marginal costs per additional user, so that any cost-benefit relies on achieving large numbers of users.

    “Even when an intervention is effective, the main costs tend to be incurred during development, with relatively low marginal costs per additional user, so that any cost-benefit relies on achieving large numbers of users [17].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] source

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

    Interpretationcitation

    A similar methodological approach focusing on persuasive features found considerable use of persuasive techniques, but the authors were unable to conclude whether specific techniques were associated with effectiveness.

    “A similar methodological approach, but focusing on the use of persuasive features and mechanisms embedded in Web-based interventions, found considerable use of persuasive techniques. However, the authors were unable to conclude whether specific techniques were associated with effectiveness [63].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [63] source

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  • May combine two claims.

    Interpretationcitation

    Qualitative data suggest that users find personal experiences helpful in reaching decisions, but there are less data available about whether and how such narratives impact emotional or clinical outcomes.

    “Qualitative data suggest that users find such “personal experiences” helpful in reaching decisions [55], but there are less data available about whether and how such narratives impact emotional or clinical outcomes [56].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [55] source

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    • cites [56] source

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  • May combine two claims.

    Interpretationcitation

    Attrition from Web-based interventions is a phenomenon that has been observed frequently and may undermine effectiveness.

    “Attrition from Web-based interventions is a phenomenon that has been observed frequently [64] that may undermine effectiveness.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [64] source

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

    Interpretationnone given

    An intervention has to be effective before it can be cost-effective.

    “The potential cost-effectiveness of Internet interventions is highly appealing, but an intervention has to be effective before it can be cost-effective.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Implementation of eHealth has proved problematic in most countries, with numerous reports of delay, budget overspends, and occasional severely negative impacts on the quality and effectiveness of care.

    “Implementation of eHealth has proved problematic in most countries, with numerous reports of delay, budget overspends, and occasional severely negative impacts on the quality and effectiveness of care [84,85].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [84] Department of HealthNational Audit Office20062012-08-11LondonThe Stationery OfficeThe National Programme for IT in the NHShttp://www.nao.org.uk/publications/0506/department_of_health_the_nati.aspx?alreadysearchfor=yes69q5utIU3

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    • cites [85] source

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  • May combine two claims. The quote only partly states this claim.

    Interpretationreasoning

    Data on user characteristics and adherence are confusing and contradictory.

    “Data on user characteristics are confusing and contradictory.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    Differences in target populations, target behaviors, target outcomes, or differences in the content or delivery of the interventions themselves may explain why some interventions work better than others.

    “This may be because of differences in target populations, target behaviors, target outcomes, or differences in the content or delivery of the interventions themselves.”
    Quote in the paperSubstantial claim

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

    Interpretationcitation

    Others have found no association between adherence and age, gender, or education level.

    “others have found no association between adherence and age, gender, or education level [80,81].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [80] source

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    • cites [81] source

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  • Classified as probably not a substantial claim.

    Premisecitation

    The MRC framework suggests a phased approach, with early work (Phases 0 to 2) consisting of systematic literature reviews, theoretical work, modeling studies, qualitative studies, studies to confirm the proposed pathway of action and identify appropriate intermediary outcomes, and pilot studies to optimize both the intervention and the trial parameters.

    “It suggests a phased approach, with early work (Phases 0 to 2) consisting of systematic literature reviews to identify what is already known, theoretical work to establish an appropriate theoretical foundation, modeling studies to establish potential rate-limiting steps and population impact, qualitative studies to determine acceptability and feasibility, studies to confirm (or deny) the proposed”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [91] Anderson, R, 2008, BMJ source

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    • cites [92] source

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

    Interpretationcitation

    Phase 4 (implementation) studies are needed both to establish how best to implement the intervention into routine practice and to determine whether the benefits shown in the trial manifest outside the trial environment, and can also identify unintended adverse effects.

    “Phase 4 (implementation) studies are needed both to establish how best to implement the intervention into routine practice and to determine whether the benefits shown in the trial manifest outside the trial environment. Phase 4 studies can also identify unintended adverse effects [90,91].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [90] MRC Health Services and Public Health Research BoardMedical Research Council2000042012-08-11LondonMedical Research CouncilA Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Healthhttp://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC00337269q6M4rBF

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    • cites [91] Anderson, R, 2008, BMJ source

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

    Interpretationreasoning

    The Medical Research Council (MRC) framework for developing, evaluating, and implementing complex interventions offers an appropriate framework for research on Web-based interventions.

    “Therefore, the Medical Research Council (MRC) framework for developing, evaluating, and implementing complex interventions offers an appropriate framework for research on Web-based interventions.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [90] MRC Health Services and Public Health Research BoardMedical Research Council2000042012-08-11LondonMedical Research CouncilA Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Healthhttp://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC00337269q6M4rBF

      Not checked in the free run.

    • cites [91] Anderson, R, 2008, BMJ source

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

    Interpretationnone given

    Application of theory is likely to enhance the effectiveness and success of implementation initiatives.

    “Application of theory is likely to enhance the effectiveness and success of implementation initiatives.”
    Quote in the paperNot a substantial claim

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

    Premisenone given

    An alternative approach used in the mental health field is "facilitated access" in which use of the intervention is monitored and supported by a health care worker or therapist.

    “An alternative approach used in the mental health field is “facilitated access” in which use of the intervention is monitored and supported by a health care worker or therapist.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Kraft has advised researchers to consider the use of an intervention as the first behavior change to target.

    “Kraft [97] has advised researchers to consider the use of an intervention as the first behavior change to target.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [97] source

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  • May combine two claims.

    Interpretationreasoning

    Achieving large numbers of users often requires implementing and integrating interventions into routine health care, but this has proved difficult to date.

    “Achieving large numbers of users often requires implementing and integrating interventions into routine health care, but this has proved difficult to date.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The precursor to NPT, the normalization process model (NPM), originated from a large body of work on eHealth and was developed to explain the observation that many eHealth initiatives failed to embed into routine practice.

    “The precursor to NPT, normalization process model (NPM), originated from a large body of work on eHealth and was developed to explain the observation that many eHealth initiatives failed to embed into routine practice [112,113].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [112] source

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    • cites [113] source

      Not checked in the free run.

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

    Premisereasoning

    Early phase studies aim to optimize both the intervention and the evaluation, with a view to ensuring that a final Phase 3 trial will provide a definitive answer.

    “These early phase studies aim to optimize both the intervention and the evaluation, with a view to ensuring that a final Phase 3 trial will provide a definitive answer.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    This provides empirical support for the proposed "pathway of action" of the intervention.

    “This provides empirical support for the proposed “pathway of action” of the intervention.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    If an intervention has been designed to cause changes in self-efficacy and outcome expectancies, it is important that the evaluation determines whether changes in these proximal outcomes occur as well as whether the target behavior changes.

    “Thus if an intervention has been designed to cause changes in self-efficacy and outcome expectancies, it is important that the evaluation determines whether changes in these proximal outcomes occur as well as whether the target behavior changes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The MRC framework advises the use of a theoretical framework for development of the intervention, and this advice is supported by the empirical literature which demonstrates that theoretically informed Web-based interventions are more likely to be effective than those without a theoretical foundation.

    “The MRC framework advises the use of a theoretical framework for development of the intervention, and this advice is supported by the empirical literature which demonstrates that theoretically informed Web-based interventions are more likely to be effective than those without a theoretical foundation.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [41] source

      Not checked in the free run.

    • cites [62] source

      Not checked in the free run.

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

    Premisecitation

    Eysenbach has argued that researchers need to document and publish the content of interventions just as they should document both the planned and actual level of engagement by participants with interventions under evaluation.

    “Eysenbach [64] has argued that researchers need to document and publish the content of interventions just as they should document both the planned and actual level of engagement by participants with interventions under evaluation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [64] source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Theories offer generalizable frameworks that can apply across different settings and individuals, the opportunity for incremental accumulation of knowledge, and an explicit framework for analysis.

    “Theories offer us generalizable frameworks that can apply across different settings and individuals, the opportunity for incremental accumulation of knowledge, and an explicit framework for analysis [95].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [95] Clinical Effectiveness Research Agenda GroupImplementation Science20092012-08-11LondonDepartment of HealthAn Implementation Research Agenda. A report prepared for the High Level Group on Clinical Effectivenesshttp://www.implementationscience.com/content/4/1/18/additional/69q6Wnw1Z

      Not checked in the free run.

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

    Premisecitation

    Kraft advocates "tunnelling," or highly tailored pre-determined routes through the intervention, coupled with numerous proactive contacts by the intervention to the user delivered through SMS, email, or automated phone calls.

    “He advocates “tunnelling,” or highly tailored pre-determined routes through the intervention, coupled with numerous proactive contacts by the intervention to the user delivered through short message service (SMS), email, or automated phone calls [98,99].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [98] source

      Not checked in the free run.

    • cites [99] source

      Not checked in the free run.

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

    Premisenone given

    Researchers interested in developing a Web-based behavior-change intervention have a wide range of psychological theories from which to choose.

    “Researchers interested in developing a Web-based behavior-change intervention have a wide range of psychological theories from which to choose.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    The eHealth Implementation Toolkit (e-HIT) is aimed specifically at eHealth interventions and has been developed for use by managers and other staff charged with implementing eHealth initiatives.

    “A similar toolkit, the eHealth Implementation Toolkit (e-HIT), is aimed specifically at eHealth interventions and has been developed for use by managers and other staff charged with implementing eHealth initiatives (ie, implementers) [120-122].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [120] source

      Not checked in the free run.

    • cites [121] source

      Not checked in the free run.

    • cites [122] source

      Not checked in the free run.

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

    Premisecitation

    The MRC framework has been highly influential, with many additional publications on applying, extending, and revising the framework.

    “It has been highly influential, with many additional publications on applying, extending, and revising the framework [92-94].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [92] source

      Not checked in the free run.

    • cites [93] source

      Not checked in the free run.

    • cites [94] source

      Not checked in the free run.

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

    Interpretationreasoning

    Only when both the intervention and the trial parameters have been optimized and the mechanism of action has been well defined, should researchers proceed to a Phase 3 randomized controlled trial to establish the effectiveness of the intervention.

    “Only when both the intervention and the trial parameters have been optimized and the mechanism of action has been well defined, should researchers proceed to a Phase 3 randomized controlled trial to establish the effectiveness of the intervention.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    The MRC framework was first published in 2000 and revised in 2008.

    “This framework was first published in 2000 [90] and revised in 2008 [91].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [90] MRC Health Services and Public Health Research BoardMedical Research Council2000042012-08-11LondonMedical Research CouncilA Framework for Development and Evaluation of RCTs for Complex Interventions to Improve Healthhttp://www.mrc.ac.uk/Utilities/Documentrecord/index.htm?d=MRC00337269q6M4rBF

      Not checked in the free run.

    • cites [91] Anderson, R, 2008, BMJ source

      Not checked in the free run.

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

    Interpretationnone given

    Use of an appropriate theoretical framework (eg, NPT and its associated tool kit) may help researchers work through implementation issues in a structured fashion.

    “Use of an appropriate theoretical framework (eg, NPT and its associated tool kit) may help researchers work through implementation issues in a structured fashion.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    Better descriptions of Web-based interventions in the published literature, including clear descriptions of the theoretical approach used, how it was operationalized, and the likely pathway of action and active components, will facilitate improved research designs to evaluate interventions because important mediators or proximal outcomes will be clearly specified.

    “This will facilitate improved research designs to evaluate interventions because important mediators or proximal outcomes will be clearly specified.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    The application of the MRC framework for development, evaluation, and implementation of complex interventions, together with a greater use of theory, could help address the challenges of equity, effectiveness, and implementation in eHealth.

    “It has argued that the application of the MRC framework for development, evaluation, and implementation of complex interventions, together with a greater use of theory could help address these challenges.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Normalization is important for sustainability.
62 of 62

  • The paper relies on this without support.

    Normalization is important for sustainability.

    “Normalization is important for sustainability.”
1 of 1

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?

  • The Few Touch application was equipped with neither "push" factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles.

    “The application was equipped with neither “push” factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles, which are advocated for long-term usage, according to relevant studies [62-65].”

    From Long-Term Engagement With a Mobile Self-Management System for People With Type 2 Diabetes (2013) · cites this paper as [65]

  • Relevant studies advocate push factors and an advanced decision support system providing feedback based on accumulated data and other personal profiles for long-term usage.

    “The application was equipped with neither “push” factors nor an advanced decision support system providing feedback based on accumulated data and other personal profiles, which are advocated for long-term usage, according to relevant studies [62-65].”

    From Long-Term Engagement With a Mobile Self-Management System for People With Type 2 Diabetes (2013) · cites this paper as [65]

Cites

Flagged first, then by citations

Research works printed but not linked: 5

  1. Corbin, JM, 1998, Unending Work and Care: Managing Chronic Illness at Home (Jossey Bass Social and Behavioral Science Series)
  2. Wangberg, SC, 2008, Patient Prefer Adherence, 2, 57
  3. 10.1267/meth03040366 · DOI
  4. 10.1267/meth03040297 · DOI
  5. Rasu, RS, 2010, Am J Manag Care, 16, e98

Cited by

Sorted by citations

Related

Authors
Murray, E.
Affiliations
University College London (GB)
Corresponding author
Murray, Elizabeth
ORCID
Murray, Elizabeth
Venue
Medicine 2.0
Publisher
JMIR Publications Inc.
Published
2012-08-14
Volume
1
Issue
2
Pages
e3
ISSN
1923-2195 (ISSN-L)
DOI
10.2196/med20.1741
PMC
PMC4084772
OpenAlex
W1990682749
Semantic Scholar
9df2e6a2abb5681b956d48cd0444286309af5d22
Cited by
219
References
117
Citations by year
2026: 9 · 2025: 9 · 2024: 7 · 2023: 15 · 2022: 16 · 2021: 20 · 2020: 13 · 2019: 15 · 2018: 13 · 2017: 33 · 2016: 25 · 2015: 25 · 2014: 12 · 2013: 6 · 2012: 1
FWCI
19.86
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Medicine 2 0 (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Topics
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Health Sciences › Health Professions › General Health Professions › Health Literacy and Information Accessibility
Keywords
online intervention, e-health, behavior change, self-management, chronic disease, self-care, digital divide, health disparities, implementation, complex interventions, MRC framework, mechanism of action, scalability, health care costs

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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 by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

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