Moving motivation Stolte, E.
2018
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Stolte, E. (2018). Moving motivation: Increasing physical activity in people aged 50 and over.
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Chapter 3
Design of an Internet-based
program with prompting to
motivate adults aged 50+ to
engage in physical activity
This chapter describes the design of an Internet-based motivational intervention for adults over 50 to become more physically active. An overview of the evidence on the topic of physical activity (PA) in this age group is provided along with the rationale for the design of the intervention (i.e., what, for whom, how and why). The aim is to inform intervention designers (who might benefit from the infor mation provided by from our intervention) and researchers (who might want to conduct a similar inter vention or compare the results of intervention studies). By providing a detailed description of the con tent of the intervention, we enhance its replicability and facilitate comparisons between its effective ness and that of intervention components in overview studies (Michie, Fixsen, Grimshaw, & Eccles, 2009). The design of the intervention program is based on the intervention mapping approach (Bartholo- mew, Parcel, Kok, & Gottlieb, 2006), which distinguishes six steps in systematically designing a theory- and evidence-based intervention. This chapter describes the results for the first four steps of this approach: 1. needs assessment, 2. matrices of change objectives, 3. selection of theory-based inter vention methods and practical applications, and 4. translation of methods and applications into an orga nized program. Step 5, adoption, implementation and sustainability of the program, and Step 6, evalua tion, are discussed in Chapters 4 to 6.
Step 1. Needs assessment: Physical activity and the target group
A needs assessment is the first step of the intervention mapping approach. We describe how older adults face health problems which can be attenuated by sufficient physical activity. Older adults can benefit substantially from physical activity because chronic conditions are most prevalent in this age group (American College of Sports Medicine [ACSM], 2009). Physical activity is related to attenuated functional decline and reduced risk of disabilities (Keysor, 2003; Miller, Rejeski, Reboussin, Ten Have, &
Ettinger, 2000) as well as to the prevention of falls, which constitute a major health risk in older age groups (Carter, Kannus, & Khan, 2001). In addition to physical health benefits, exercise has positive ef fects on mental health for older adults, as is well documented (ACSM, 2009). For example, physical activ ity is positively related to overall psychological wellbeing (ACSM, 2009), self-esteem and self-effi cacy (McAuley et al., 2005), cognitive functioning (ACSM, 2009), and reduced depression and anxiety (ACSM, 2009; Ross & Hayes, 1988) and negatively related to the development of dementia (ACSM, 2009).
Physical activity recommendations describe the minimal physical activity required for people to stay healthy. In 2000 (NNGB; Kemper, Ooijendijk, & Stiggelbout, 2000), the Dutch physical activity recom mendations stated that adults should engage in thirty minutes or more of moderately intense physical activity on at least five but preferably
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all days of the week. Adherence to the norm by Dutch people decreases with age: it is 61% for the 55-64 age group, 56% for the 65-74 age group, and 45% for people aged 75 and above (Hildebrandt, Bernaards, Chorus, & Hofstetter, 2013). Nevertheless, in the Netherlands, adherence to the recommendations increased from 42% to 48% in the 2000-2011 period among people aged 65 years or older (Hildebrandt, Bernaards, Chorus, & Hofstetter, 2013). This trend in the Dutch population of older adults shows that an increase in physical activity is possible, which is good news for health professionals, who have been actively focused on this topic for the past few decades.
The percentage of inactive older adults is declining but should be further reduced to achieve optimal health in the older population. Therefore, stimulation of physical activity in older adults is necessary to increase healthy aging, which is why the current intervention targets adults aged 50 years or older living in the Netherlands who want and need to be more physically active. The practical reason for choosing the lower limit of 50 years—and not, for instance, 55 or 65 years—was that a website targeting people over 50 years was used to recruit participants for part of the research. The specific choice for the lower limit of 50 years was arbitrary.
Step 2. Programs change objectives
The second step in designing the intervention is to create matrices of change objectives. We used the knowledge available from the Active Plus project (van Stralen, Kok, de Vries, Mudde, Bolman, & Lechner, 2008) on useful intervention goals and specific change objectives for physical activity in older adults. To raise awareness and ensure the initiation and maintenance of PA norm adherence, we speci fied five performance objectives for the program, which were that older adults 1. know how much ac tivity is necessary to meet the Dutch PA recommendations, 2. know which activities they can integrate into their daily life in order to become more active, 3. are motivated to be more physically active (inten tion and effort), 4. monitor their PA, and 5. set goals and make specific plans to be more physically ac tive.
Step 3. Theoretical approach and practical applications
Step three of the intervention mapping approach is to select theory-based intervention methods and practical applications. The use of theory in intervention design is important for a proper foundation of intervention programs and may result in more effective interventions (Chase, 2015; Webb, Joseph, Yardley, & Michie, 2010). We used the two-phase approach to behavior change (Sniehotta, Scholz, &
Schwarzer, 2005). This approach describes the behavior change process as consisting of the intentional phase and the volitional or action phase, which both need to be addressed in a behavior change pro gram. The implication of applying the two-phase approach to a behavior change intervention is that part of the intervention should
aim at increasing the intention to be more active (i.e., the intentional phase), and part of the intervention should be aimed at increasing action (i.e., the action phase).
We used behavioral determinants from the TPB to target the intention to be more active. More specifically, the concepts of attitude (the degree to which a person has a favorable or unfavorable eval uation or appraisal of the behavior) and perceived behavioral control (perceived ease or difficulty of performing the behavior) (Ajzen, 1991) are used in the intervention to increase the intention to be ac tive. Behavioral determinants of the action phase of behavior change are behaviors that actively pursue a goal, also called self-regulatory behaviors (Sniehotta, Scholz, & Schwarzer, 2005). Goal setting, self-monitoring and action planning were chosen as behaviors to stimulate during the intervention in order to support the action phase. With action planning, people specify when, where and how to act in ac cordance with their goal intention (Sniehotta, Scholz, & Schwarzer, 2005).
Internet-based intervention
We chose to set up the intervention as a low-cost Internet-based intervention that required minimal personal contact between the older adult and the intervention administrator. More specifically, it was a self-guided Internet-based intervention provided for free to the target group. The description of the program stated that the program was self-guided without personal coaching and that participants should expect to be their own coach. In a review, Aalbers, Baars and Olde Rikkert (2011) found multiple stud ies showing that Internet-mediated interventions produced positive results for lifestyle change among people aged 50 years and older. Daily Internet use in the Netherlands increased from between 72% and 20% for the 55-65 to 75+ age groups in 2013 to between 82% and 28% for those age groups in 2016 (Statistics Netherlands, 2016). The growing Internet use in these groups indicates a growing potential to reach a large group of older adults using an Internet-mediated intervention. The most commonly re ported Internet activity for older adults is the use of email (in 2016, the prevalence was 89% for those aged 55-56, 77% for those aged 65-75, and 40% for those aged 75+). Looking up health information online is also common in Dutch older adults (in 2016, the prevalence was 63% for those aged 55-56, 51% for those aged 65-75, and 26% for those aged 75+). The use of these functionalities by these age groups indicates that they can be reached for health messages through the Internet and by e-mail.
Step 4. Translation into an organized program
Theoretical methods and applications need to be translated into an organized program, which is step four of the intervention mapping. Pre-existing and previously
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evaluated materials were used as much as possible. In Table 1 of Chapter 4 the content of the program is provided, specifying which be havioral determinants and performance objectives are targeted by the program components. The com ponents of the intervention program are as follows: two full-color informational brochures about physi cal activity targeted at older adults, online PA tips in the form of animated videos with corresponding text, an online PA plan, an online diary and email prompts. It is not necessary for participants to use all of the program content; the two brochures, for instance, had some overlapping content but were both included because with their differences in style, each could appeal to different people. We formulated an arbitrary target for the intended use of the program components that we think gives participants enough exposure to expect effects. The intended use is for participants to read at least one of the two brochures, fill out the PA plan, use the diary for at least three weeks and view at least half of the PA tips. Prior to the start of the intervention, we asked two people from the target group to provide us with feedback on the program materials. We chose an intervention duration of six weeks because we judged this as long enough to process the new information and to experiment with new activities and short enough to maintain participants’ attention to the program. The first week of the program consisted of the PA diary without other content: to assess change, it was necessary to establish a baseline. During the second week, information was provided; participants were prompted to fill out their PA plan, and they could use the Internet-based program to find advice and to plan PA until the end of the program.
The purpose of each intervention component is described along with accompanying behavior change techniques (BCT). A BCT is “an observable, replicable, and irreducible component of an interven tion designed to alter or redirect causal processes that regulate behavior; that is, a technique is pro posed to be an ‘active ingredient’ (e.g., feedback, self-monitoring, and reinforcement)” (Michie et al., 2013, p. 82). A BCT taxonomy, with each technique numbered, was created to establish more uniform reporting of intervention content in the field of behavior change (Michie et al., 2013).
For example, the online PA plan contains BCT action planning (BCT 1.4).
Brochures. Two existing paper brochures provided information on physical activity and health with the purpose to increase knowledge, positive attitudes, perceived behavioral control and motivation to become more active. See Table 1 for the behavioral change techniques used in the brochures. Two different brochures were used because they were targeted at different groups. The brochure of the Unie KBO/NISB Consult is targeted at older people, with big letters, a puzzle and pictures of people who ap pear to be older than 65. The brochure of the Dutch Heart Foundation is less age specific. It includes
pictures of younger and older people, and it has more text and smaller letters than the other brochure. As participants were provided both brochures, the information should be informative for participants of a wide range of ages.
PA tips. In addition to the brochures, the PA tips conveyed health information. Twelve animated videos, approximately one minute long, were created with the web-based program goanimate.com. Animation characters, one male and one female, presented an equal number of PA tips. This delivery mode was chosen to make the information more appealing and easier to digest than plain text. In the pilot phase, some participants could not sufficiently follow the audio, which was created with text- to-speech software included in the animation software. To facilitate understanding of the spoken text, it was added separately in a text box below the video (not as subtitles) after the pilot phase.
Half of the tips were based on behavioral determinants of the intentional phase, targeting atti tude, motivation and perceived behavioral control (tip numbers 1, 3, 4, 5, 7, and 11; Table 2). The other half were based on behavioral determinants in the behavioral phase and further encouraged partici pants to keep track of their activity, set goals and use reminders (tip numbers 2, 6, 8, 9, 10, and 12; Ta ble 2). PA tips were categorized into four overall themes, each containing three tips. Six out of the twelve PA tips were aimed at the action phase of change; for instance, they encouraged participants to use reminders such as post-its in their own environment (BCT, 7.1 prompts/cues). Figure 3 at the end of this chapter shows an example of a PA tip.
PA plan. An online PA plan was designed by adapting a PA plan for older adults available on the website of an elderly association (Unie KBO). The PA plan contains several steps in which participants can set goals (what to achieve and when, BCT goal setting, 1.1/1.3), choose specific activities (sports, recrea tional, household, transportation) and then plan when, where and how (BCT 1.4, action planning) they will conduct these activities (Sniehotta, Scholz, & Schwarzer, 2005) (Figures4a and 4b at the end of this chapter provide a screenshot of the online PA plan in Dutch with an explanation in English).
PA diary. An online PA diary was developed in which participants can fill out the number of minutes spent doing specific physical activities for each day during six weeks. The diary automatically adds up the number of minutes for each day and the total number of minutes per activity in a week. An element of feedback was added after the pilot phase of the program in the form of a traffic light color that signaled whether the total amount of activity reached the norms. The online diary has the goal
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of stimulating participants’ self-monitoring of their PA behavior (BCT 2.3, registering behavior) in order to make them aware of any discrepancy between their behavior and PA norms and to enable them to track their progress in increasing PA. Figures 5a, 5b and 5c provide a screenshot of the online PA diary.
Table 1. Behavioral change techniques (BCT number*) in brochures
Behavioral change tech nique Brochure Unie KBO/NISB Brochure Dutch Heart Foundation Instructions on how to perform the
behavior (4.1)
Information on Dutch PA norm and example exercises
Information on Dutch PA norm Information about health consequences
(5.1)
PA and chronic disease and disa bility;
diabetes, arthritis and heart disease, bone health, memory, balance
PA and effects on the heart, choles terol, managing body weight, sleep, bone health, diabetes
Describe emotional (or affective) consequences of behavior (5.6)
PA and the role of endorphins in creating positive affect
Benefits of physical activity for energy levels, stress reduction, relaxation and feeling younger
Demonstration of behav ior (6.1) Use of brief personal stories with pictures as role models; men tioning their favorite activities
Use of role models with personal sto ries and pictures; explaining how they became more active and how it made them feel
Self-monitoring of behav ior (2.3) Schematic representation with bullets to
be colored for each ten minutes of PA
* Numbering of behavior change techniques is based on the behavior change taxonomy by Michie et al. (2013)
Table 2. Overview of topics of the PA tips (number and name of behavioral change techniques) General topic
How, where and when 1. Examples to demonstrate that a variety of activities contribute to PA norms (4.1, instruction on how to perform the behavior)
2. Using your own environment by using prompts/notes (7.1, prompts/cues)
3. Explanation of the PA norm (4.1, instruction on how to perform the behavior)
Planning 4. Gradually build up PA and listen to your body (4.1, instruction on how to perform the behavior)
5. Plan activities together with others (3.1, social support, 6.1, demonstra tion of behavior)
6. Adapting a PA plan based on ex perience (1.5, review behavior goals, 1.6, discrepancy between current behavior and goal, 1.7, review out come goals) Staying motivated 7. Advantages of being more
physi cally active. (5.1, information about health consequences, 5.6, describe emotional (or affective) consequences of behavior)
8. Registering physical activity (2.3, self-monitoring of behavior)
9. Reminder to use the PA plan (1.4, action planning)
Creating habits 10. Rewarding yourself for progress towards being more physically active (10.7, self-incentive)
11. Look up more information from sources on the Internet
12. Creating habit (8.3, habit for mation)
Email prompts. In Internet-based programs, reminders are part of a system component called di alogue support, which influences the effectiveness of programs for behavioral outcomes (Oinas-Kukko nen & Harjumaa, 2009). We used prompts sent by email (BCT, 7.1, prompts, cues) as a specific interven tion strategy. The prompts support the action phase by providing cues that remind participants of their goals, motivate them over time and increase adherence to the intervention (Abraham &
Sheeran, 2003; Kelders, Kok, Ossebaard, & Van Gemert-Pijnen, 2012). Email prompts were designed as basic messages containing a message title with the name of the participant and the message that a new PA tip was avail able online. Corresponding to the email prompts, a new PA tip would appear on the personal page of the participant. The reason the emails were matched with new information in the form of a PA tip was to stimulate behavior change over time and make the prompts relevant for participants to pay attention to. Because of the restrictions of the website used, it was not possible to change the messages over time or to add a link to the new information.
The intervention website
The Internet-based program components were integrated by two IT developers into a website with a simple layout in order to make it user friendly. The content of the website was managed by the researcher, who could also manage the random allocation of the respondents into the control and ex perimental groups and plan the start of the intervention program for participants through a separate page behind a login. After the pilot phase, an extra page was added for the researcher with the registra tion of all automated emails that were sent by the program, which enabled checking for technical prob lems. The homepage provided general information about the intervention program and the research, including a link to a registration form.
Every potential participant was required to read the information about the study before registering. The obligatory information was based on guidelines provided by the medical ethical research board. Additionally, a question and answer page was available. The Internet-based intervention content was delivered through the personal part of the website, for which a login was available for participants. Instructions with the timeline of the intervention and what was expected from participants were provided both in a written letter and online. Figure 1 and Table 3 describe the func tionalities of the intervention website. The schematic representation of the homepage in Figure 1 shows how the information provided to participants about the program was distributed over several pages. Table 3 gives a brief description of each functionality. In Figure 1, the functionalities that were publicly available on the
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website are shown in the column on the left. The column on the right shows the per sonal part of the website, which was password protected and only accessible for participants after they finished the registration process. The arrows represent links from one page to another within the web site. Within each column, the overview of functionalities on the home page and the personal page are listed on the left side in black boxes, and the pages on which these functionalities were available are listed on the right side in blue boxes. For instance, on the homepage, the ‘sign in’ functionality leads people to their personal page after entering their email address and password.
There, they find several functionalities, one of which is a ‘to do box’, which provides links to online questionnaires and the PA diary. Figure 2 at the end of this chapter shows a screenshot of the homepage.
Figure 1. Schematic representation of the functionalities of the intervention website Note. Black boxes represent functionalities, which are further described in Table 3. Grey boxes represent pages within the specified page area (within homepage or personal page). Arrows represent a link to another page of the website.
Homepage
Sign in
General introduction General info Sign up or invite friends For who?
Questions
Contact
Registration form Information about the study Form to invite friend
Q & A about participating Contact form
Personal page Sign out Home To do box
Questionnaires PA diary form Instructions PA plan form PA tips Overview of diaries
Change password Change personal info Questions
Contact Profile PA Plan
List of PA tips Past PA diaries
Table 3. Description of content of intervention website
Homepage Information available to anyone visiting the website Sign in Access to intervention content through email address and password General introduction Video and text explaining the purpose of the website
General info Information about the study
Sign up or invite friends Button to invite friends and button to sign up
For who? Those aged 50+, who want to be more active and are able to check email regularly Questions Button leading to page with Q&A about program and study
Contact Button leading to contact form Personal page
Sign out Sign out of personal page links back to homepage
Home Back to homepage
To do box Introduction and exit video and links/buttons to weekly questionnaire and PA diary
PA plan Buttons leading to PA plan (page with online form to make a PA plan. Print function and backup of brochures as a download available) and instructions page on PA plan
List of PA tips Clickable list of links to PA tips (animated videos and written texts) Past PA diaries Overview of past diaries, each clickable to see the whole week Questions Button leading to page with Q&A about program and study Contact Button leading to contact form
Profile Buttons to change password or personal info (email address or name) PA diary Online PA diary form for a week with explanation. Print function available
Approval for testing the intervention from the medical ethics committee
A research plan for testing the intervention was written. When setting up the research for this thesis, we used the guidelines for social science research from the Central Committee on Research In volving Human Subjects (Centrale Commissie Mensgebonden Onderzoek; CCMO), based on the Medical Research involving Human Participants Act (CCMO, 2001). A series of steps was taken to receive ap- proval to conduct the studies presented in this thesis (Chapter 4 to 6). First, the administrative board of the Medical Ethics committee of the Vrije Universiteit Medical Center (VUmc) conducted a preliminary check in April 2012 to assess whether the proposed research fell under the Medical Research involving Human Participants Act. The decision was that the evaluation of the intervention did not fall under the act, while the proposed randomized control trial did fall under this act and needed to receive full ethics approval by the committee. The assessment was possible after the research committee of the faculty of Social Sciences, Vrije Universiteit, reviewed the research plan. This committee accepted the proposal after one revision based on their comments in January 2013. In 2013, the full research protocol, includ ing
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all questionnaires and documentation on procedures for informed consent, were submitted and reviewed by the VUmc Medical Ethical Committee. The committee decided that this study did not fall under the Medical Research involving Human Participants Act. It did not require registration and could be carried out as planned following standard regulations.
Discussion
This chapter describes the rationale for, and the design process of, the content of an Internet-based PA program for people 50 years and older. In a stepwise process, specific objectives for the pro gram were chosen, after which behavior change theories were used to choose behavioral determinants to target. These behavioral determinants are targeted by behavior change techniques incorporated into components of the intervention program. The result is an Internet-based program with a PA diary, plans, tips, and email prompts, as well as paper brochures. The description of the program components along with the screenshots serves three aims. First, the detailed description of program components and its intended goals informs us on what we need to test when we implement the intervention program to the test. The results from the pilot, evaluation and effect studies are needed to decide which components for an intervention setup for older adults are effective.
Second, the description can give other interven tion designers an idea of which type of intervention elements, such as an online PA plan, might benefit this age group.
Third, researchers who want to compare the results from this intervention to other in terventions can use the description to assess how intervention components match their definition of intervention techniques and how the application of techniques used in this intervention might differ from the use of the same technique in a different intervention.
The intervention is set up as a multicomponent intervention. This is the outcome of a stepwise process of incorporating several theoretical concepts into the intervention techniques. A systematic review of Internet-mediated lifestyle interventions found that multicomponent health interventions work better than interventions with only one component (Aalbers, Baars, & Olde Rikkert, 2011). As the compo nents of a multicomponent program interact with one another, it is hard to establish which com ponents contribute to what extent to the effectiveness of the program. By describing each component, it becomes easier for other researchers to compare the effectiveness of programs and their elements (Michie, Fixsen, Grimshaw, & Eccles, 2009). Moreover, by evaluating participants’ experiences with every component, we
want to contribute to the knowledge of what type of online intervention compo nents appeal to this target group. This is described in Chapter 5, which entails participants’
evaluation of the program.
The design of the program was the outcome of a structured process, but the type and quantity of techniques and design can be altered. For example, prompts could be sent at a different frequency, in clude new information or be sent through different means, such as text messages. There is no evidence yet on what type of prompts are best; a recent review by Alkhaldi et al. (2016) found small positive re sults in general but an insufficient amount of research to conclude anything about the best type or pre ferred frequency of prompts. There are also functionalities that might be useful but were not included in this intervention, partly because of limited resources. Regarding the development and use of technol ogy, it is now possible and probably more convenient to use apps for smartphones or tablets in addition to or instead of a PC-based website intervention. Future interventions might want to take advantage of the possibilities of smartphones to stimulate behavior change over time. The use of a smartphone app has consequences for the design, as it can display very few intervention features at once, and care needs to be taken that the visual design suits the target group. A combination of an Internet-based interven tion with prompts by means of a smart phone app seems to be a good option. Personal coaching or per sonalization of content is not used in the current intervention and may have added value. Part of the advantage of using a self-guided intervention without personal coaching is that it costs less. The person- alization of content in the form of tailoring can be effective if the right information for personalization is known (Aalbers, Baars, & Olde Rikkert, 2011). Tailoring can be automated more easily than personal coaching and is therefore an easier option for Internet-based interventions. Another approach that is often used in Internet interventions is to stimulate online networking, which creates a possibility for social support. A meta-analysis (Laranjo et al., 2014) found an overall positive effect of social networking sites on health behavior change. Participants’ uptake of social support tools, such as forums, as part of an intervention website is usually low and increases costs, as these tools often need the attention of a professional (Aal bers, Baars, & Olde Rikkert, 2011). It seems that the use of standalone social media such as Facebook groups is a more cost-effective approach (Aalbers, Baars, & Olde Rikkert, 2011). In sum, some options to consider when designing a similar Internet-based program are to add intervention techniques using mobile tech nology, to use automated tailoring and to consider variations in prompting messages.
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Figure 2. Screenshot of the homepage of the Internet-based program
Note. This screenshot gives an impression of the design of the website. The content is from the version used in the main trial just after the regis tration closed.
Figure 3. Screenshot of a PA tip.
Note. Translated text: It is more fun and also more motivating to engage in physical activities with others. It gives you an extra incentive to stick to your intentions. You can arrange an activity with a friend or neighbor. You can also use the websites www.50plusnet.nl or www.beweegmaatje.nl to find others with whom you can engage activities. Think for a moment who you could ask to engage in an activity with you and how you can get to know more people for this purpose.
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Figure 4a. Screenshot of the first two steps of the online physical activity planning tool (in boxed arrows an explanation is added
Figure 4b. Screenshot of the third step of the online physical activity planning tool
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Figure 5a. Screenshot of part 1 of the physical activity diary
Figure 5b. Screenshot of part 1 of the Physical activity diary after pilot, with feedback in the form of traffic light colors.
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Figure 5c. Part 2 of the physical activity diary
