The use of Web based interventions in improving well being

M-Health Interventions.
Evidence to demonstrate the capabilities for M - Health to deliver
high quality, low cost behaviour change for improving wellbeing
and long term condition self-management.

February 2013

Contents

The importance of good physical, mental and emotional health 3

The Evidence - How web based interventions improve wellbeing,
physical and mental health 5

Action – The case for creating an online health eco-system 10

References 12

Notes 13

2

www.icecreates.com together we can change our world

“Our Wellness or Wellbeing”

Promoting positive mental health and wellbeing
in the population is an important policy goal
amongst national and local organisations.

In recent years, there has been as experiencing positive relationships given to the idea that promoting
a discernible shift of focus and having a sense of purpose are positive mental health and wellbeing
all cited as important attributes in the population is an important
in the field of psychology of wellbeing. policy goal amongst national
from illness to wellness. and local organisations.
The emergence of positive There has long been held an
psychology and the science of assumption that by simply growing The strategy takes a
wellbeing has brought greater GDP, an increase in wellbeing will also population-wide perspective to
follow. More recently this has been improving mental health and
interest in establishing the challenged by governmental policies wellbeing as well as targeting those
underlying causes of the main as well as in the field of academic who are already experiencing mental
two elements that comprise research. Support for the importance health difficulties. This in part reflects
wellbeing: feeling and of the concept of wellbeing in its the direction of travel, moving away
functioning well. This includes own right has been shown by the from an understanding of mental
Prime Minister and the Deputy Prime health that focuses on targeted help
how we feel about ourselves, Minister, who have made it clear that for vulnerable groups and towards an
our future, and the world the Coalition Government’s success approach that balances promotion of
around us.1 will be measured by the nation’s positive mental health and wellbeing
wellbeing, not just by the state of the at a population level together with
Feelings of happiness, contentment, economy. The commitment to this treatment. The argument against a
enjoyment, curiosity and statement is evident in the Prime completely deficit-focused approach
engagement are characteristic of Minister recently tasking the Office to the delivery of services is based on
someone who has a positive view of for National Statistics to develop both financial considerations and the
their life. However, there is also wide a set of indicators that measure argument that focusing attention on
acknowledgement that an individual national wellbeing.1 those people who are experiencing
will inevitably experience negative mental health difficulties does not,
factors that impact on their lives.2 Further still, improving the mental in itself reduce the overall incidence
There is, also therefore, a focus health and wellbeing of the UK of vulnerability in the population.1
on the importance of sustainable population has been set as a
wellbeing, so that where an individual key objective by the Coalition
experiences painful emotions,he Government. In early 2011 the
or she has the capacity to manage Department of Health launched the
them. This is a skill which is essential mental health outcomes strategy,
for long-term wellbeing.3 Having No Health without Mental Health.4
some control over one’s life as well Here considerable prominence is

3


Good mental health and wellbeing is not
only confined across health, but is central
to our quality of life.

It is noted in this approach that the everyone can realise their potential to The following section of this paper
importance of good mental health flourish in the future. will explore the potential of online
and wellbeing is not only confined tools in supporting an individual to
across health, but as central to our The Centre for Wellbeing at the NEF self-manage their physical, mental
quality of life . Therefore impacting (the New Economics Foundation) and emotional health and wellbeing.
across a wide range of ‘non-health was commissioned by Foresight to
policy areas’ including education, look at the academic evidence and
training, employment and the develop key public health messages
importance of tackling some of concerned with how to promote and
the persistent problems that scar maintain positive mental health.
our society from homelessness, Five key messages: Five Ways to
violence and abuse, to drug use and Wellbeing3 were developed to reflect
crime4. This view is also reflected the kinds of behaviour, supported
in the public health white paper by academic evidence, that people
Healthy Lives, Healthy People,1 can undertake that may lead to
where for the first time equal improvements in their mental health
importance has been given to both and wellbeing.
physical and mental health.
They consist of the following five
The UK Government’s Foresight principles: ways to
programmei uses evidence and
analysis from a wide range of • Connect wellbeing:
disciplines to develop policy and
address key issues that will impact • Be active
on the opportunities and challenges • Take notice • Connect
facing the UK over the next 20 • Keep learning • Be active
years. The 2008 Mental Capital and
Wellbeing Project2 aims to identify • Give. • Take notice
the most important drivers of mental
Given this wider picture, it is a critical
• Keep learning
capital and wellbeing to highlight
where action is most important and responsibility for all working in public • Give.
how available resources can be better health and wellbeing to ensure
allocated. The project explores the that as wide a proportion of their
state of knowledge on promoting populations as possible have simple
and maintaining mental capital and access to interventions and services
wellbeing both now and in the future that support them to find their own
and what needs to be done paths to wellbeing.
to meet the challenges ahead, so that

i Foresight Programme http://www.bis.gov.uk/foresight

4


The Evidence - How web based
interventions improve wellbeing,
physical and mental health

The use of web based interventions in
health promotion, mental health and
condition management is increasing.

As identified in the recent From a patient perspective, web-
government policy Healthy Lives, based interventions can also be
Healthy People 5 and No Health highly attractive because they can
without Mental Health,4 there is a maintain privacy; and in recent years
need to improve the mental health the accessibility and convenience
and wellbeing of the UK population of obtaining information online has
and keep people well. Both policies increased significantly.10
focus on the importance of mental
as well as physical health, giving
equal weight to each concept. It More and more individuals are
is widely acknowledged also that now online. It is now estimated
there is a need to promote self- that globally, there are more than a
management for patients with long- total of 1.8 billion internet usersii
term conditions, such as diabetes, of which 61% access it daily
heart disease or arthritis. Effective compared to 54% watching TV
self- management programmes daily and 36% listening to the
have been shown to reduce health radio.iii By 2015 it is thought that
care costs and improve quality of nearly 3 billion people will be
life across a range of conditions.1 using the internet, a figure
that is more than 40% of the
The use of web based interventions world’s projected population.iv
in health promotion, mental health
and condition management is
increasing. This is largely due to the
potential to combine the scalability of
public health with the effectiveness
of personalised, individually tailored
interventions that have low marginal
costs per additional user.

iihttp://royal.pingdom.com/2012/01/17/internet-2011-in-numbers/
iiihttp://www.digitalstrategyconsulting.com/intelligence/digital_intelligence102010.htm
ivhttp://www.bbc.co.uk/news/technology-13613536

5


Individual and Household Internet Access
(UK) at a glance:

• In 2012, 21 million households in Great Britain had an internet connection
representing 80% of households, up from 77 % 2011 and 57 % in 2006.

• In 2012, 67% of adults in Great Britain used a computer every day.v

• Nine out of ten adults aged 35-44 have internet access at home.vi

• Twenty six per cent of adults aged over 75 have internet access at home.

• Households with two adults aged 16-24 years old and those households with
children are more likely to have internet access.

• The percentage of adults who go online everyday has increased across all
age groups since 2006, with the largest increase has been amongst those
individuals aged over 55 years.

Figure 1: Households with Internet Access

90
80
70
60
50
40 Per cent
30
20
10
0
2001

2011
1998
1999
2000

2002
2003
2004
2005
2006
2007
2008
2009
2010

2012

Base: UK households from 1998 to 2004. Great Britain Households from 2005 to 2012.v

v
ONS (2012) http://www.ons.gov.uk/ons/rel/rdit2/internet-access-quarterly-update/2012-q3/stb-iaqu.html
Offcom 2011 http://media.ofcom.org.uk/2011/08/04/a-nation-addicted-to-smartphones/
vi

6


The number of UK adults aged over 50
consuming social media on their
mobile has risen by 52% year on year.

The use of information and The web has increasingly become
communication technology an open arena where people meet,
(e-health) is expected to lead discuss their ideas, and engage in
to improvements in health dialogue with each other . Users
continue to spend more time in social
care quality, primarily through
media than in any other category of
effective communication and website. Social networks and blogs
efficiency. now account for around 25% of all
time spent online in the UK.vii Social
Web based interventions are also media has increasingly become a
built for inclusion. Health information mainstream vehicle for information
can be presented in an accessible and and experience sharing.
comprehensible format
(in bite-sized chunks using video
graphics and audio) and be made
readily available at the moment
of need. This approach is helping
to address health literacy levels in
communities across the UK. • More than 1 billion users of Facebook
Web based interventions can interact
with the user by providing tailored • 145 million users of twitter
healthcare advice and by enabling
users to communicate together. • 60 million profiles on LinkedIn
There is a real opportunity here to
provide an online platform and the
forms of interactivity for individuals • More than 12 billion videos viewed per month
to connect online, much like social on YouTube
networking sites. These can then be
used to provide formal behaviour
change support, decision support • Mums are 40% more likely to use mobile social
and peer support. Increased social networking tools than the average smartphone
support has been found to be an ownervii
important component in sustaining
behaviour change.13
• The number of UK adults aged over 50
consuming social media on their mobile has
risen by 52% year on year.

Nielsen (2011) http://cn.nielsen.com/documents/Nielsen-Social-Media-Report_FINAL_090911.pdf
vii

7


Web based tools and trackers have been
successfully used to assist all individuals
in adopting healthy behaviours.

There are two main populations to
target for behaviour change in this Online web based interventions The success of online tools to support
sense: have been shown to work in a variety behaviour change relating to the
of health settings and formats. management of long term conditions
• healthy people who are Interactive Health Communication viii
and lifestyle factorsix has been also
engaging in unhealthy Applications (IHCAs) are computer- been documented. In recent years
behaviours likely to based, usually web-based, there has been an increase of online
result in future physical information packages for patients tools and trackers to help individuals
health problems that combine health information monitor their lifestyle related
with social support, decision support, behaviours and receive personalised
• people who are currently or behaviour change support. In a tips and feedback to help them
unwell and need to change study1 identifying 24 randomised achieve their goals.x Research has
their health behaviours to control trials involving 3739 suggested that using tools to break
prevent further deterioration participants IHCAs appeared to have down large goals into smaller, more
of their health status.10 largely positive effects on users, in manageable parts may help patients
that users tend to become more better manage long-term diseases
Web based interventions and online knowledgeable, feel better socially such as diabetes.
tools can also be used to assist supported, and may have improved
self-management for individuals behavioural and clinical outcomes
with long term conditions. In this compared to non-users. Specifically,
instance, these could be made up the use of IHCAs was shown to
of reminders and prompts to assist demonstrate a positive increase in The use of
with medication management knowledge, social support, clinical
and provide the infrastructure to outcomes and self-efficacy. IHCAs was
manage interactions with health
professionals. Web based interventions have
shown to
also been shown to work through demonstrate a
Online tools and trackers have systematic reviews concerning
been successfully used to assist specific behaviours such as smoking positive increase
all individuals in adopting healthy cessation, reducing alcohol in knowledge,
behaviours such as healthy eating, consumption, safer sexual behaviours
exercising more, stopping smoking and increasing physical activity. social support,
and reducing alcohol intake. The In particular, web-based, tailored,
effectiveness of internet-based interactive smoking cessation
clinical
interventions has been proven to be interventions have been found to be outcomes and
enhanced by the use of additional effective compared with untailored
methods of communicating with booklet or e-mail interventions and self-efficacy.
participants, especially the use of shown to demonstrate higher levels
SMS text messages.16 of user satisfaction.2

http://www.newswise.com/articles/behavioral-strategies-may-help-control-chronic-diseases
viii

ix
http://trainingforthehealthcareworkforce.blogspot.co.uk/2012/12/can-mobileapps-help-people-lose-weight.html?m=1
x
http://my.drinkaware.co.uk/users/sign_up

8


Research has also demonstrated including anxiety, moderate The majority of the supportive replies
the potential for more structured depression and phobias.2 Qualitative fell into the category of emotional
behavioural-led weight loss websites data also suggests that alternative support, followed in order by
to produce greater weight loss and to using CCBT, social networks and informational and tangible support.
maintain a greater loss than self-help personal stories may be used to Programme evaluation revealed
commercial websites. Using goals provide emotional and informational changes in the level of parenting
and smaller tasks that get patients to support by reading about ‘someone stress with mothers who participated
their ultimate goal step-by-step has like them’ who has had a similar regularly in this CMSS community
also been found to be useful for goals experience3 managing their health or more likely to report a decrease
like weight loss and exercising several a specific condition. in parenting stress following the
times a week. Using online tools and intervention.
trackers to provide feedback such Web based interventions and online
as progress charts, physiological support have been shown to be Specific sub population groups in
calculators, and journals has been particularly effective within certain which web based interventions have
shown to be the best predictor of population groups. The use of also been shown to work included
weight loss, whilst an individual is computer mediated social support severely disadvantaged groups such
losing weight. The “social support” (CMSS) networks for single mothers as drug users. Projects to develop
factor such as web chats and with young infants concerned with and implement electronic access
biographical information has been parenting issues has been shown to to information on HIV/AIDS and
shown to be the best predictor during be particularly effective. The network resources have been shown to be
maintenance. Overall, weight loss operated 24 hours per day over a successful in the USA.15
in an online weight control program period of 6 months, permitting public
has been found to be most positively message exchanges, private e-mail,
related to dynamic web features that and text-based teleconferencing for
provided feedback, support, and as many as 8 participants at any one
motivation to participants1. time.

Web based interventions have been During the 6 month intervention, the
shown to be effective in mental network was accessed over 16,670
as well as physical health and times and descriptive analyses of the
lifestyle related behaviour change. messages exchanged on the network
Interventions based on computerised disclosed that 98% of the replies to
cognitive behavioural therapy (CCBT) concerns posted in the public forum
have been shown to be acceptable, provided positive social support.
effective and cost-effective across
a range of mental health problems

The use of computer mediated social
support (CMSS) networks for single
mothers with young infants concerned
with parenting issues has been shown
to be particularly effective.

9


Action – the case for creating
an online health eco-system

At its most effective, the online environment
can be a driving force behind building a truly
asset-based community.
The Medical Research Council Please see our next white paper on At its most effective, the online
(MRC) suggests that all successful behavioural theories and behaviour environment can be a driving force
web-based interventions will have change to highlight the key behind building a truly asset-based
a strong theoretical foundation constructs and how they address community – by empowering people
for developing, evaluating each behavioural determinant of and communities to realise their own
and implementing complex a web based intervention. potential and sense of responsibility
interventions. Theoretical to each. We believe that an effective,
frameworks for the intervention We believe that web based co-created and community-owned
should be selected and used in both interventions are an essential tool in health eco-system is the ideal
development and evaluation, the promoting and facilitating wellbeing, starting point to build resilience and
key constructs of the theory must by harnessing the power of social sustainability within communities,
be identified and consideration and digital media to connect people and to create a culture of wellbeing
given to how the intervention will together, both virtually and in the and mutual support.
act on these constructs. real world.

At ICE, we provide a theoretical
underpinning to all our behavioural
change research and interventions.
Naturally, therefore, this also
underpins all of our web-based
intervention work.

10


The Empowered Connected Citizen

Technology, Human
cloud,
sustainable needs,

me
networks, activities
apps, and
sensors behaviour
and data

At its most effective,the online
environment can be a driving
force behind building a truly
asset-based community .

11


The UK Government’s Digital Service Design Principlesxi should
form the basis of any effective online health eco-system:

1. Start with needs
2. Do less 
3. Design with data 
4. Do the hard work to make it simple 
5. Iterate. Then iterate again 
6. Build for inclusion 
7. Understand context 
8. Build digital services, not websites 
9. Be consistent, not uniform 
10. Make things open: it makes things better.

It is by employing such an approach that
public health professionals and organisations will
create sustainable, needs-led online resources
that will facilitate the culture of wellbeing and
community support that will help people to live
longer, healthier, happier lives.

xi https://www.gov.uk/designprinciples

11


References
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neweconomics.org/publications/ bis.gov.uk/assets/biscore/corporate/
five-ways-to-wellbeing Accessed 4th migratedD/ec_group/116-08-FO_b 12
Rebecca A. Krukowski, et al (2008)
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Relationship Between Web Features
2
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computerised cognitive-behavioural
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Review SRX-2: Psychological Supporting People with Long primary care: randomised controlled
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Mental Capital and Wellbeing Project Leeds, UK: Department of Jepson R, Hunt K, Ziebland S, et
[Online]. Available at: www.foresight. Health; 2005 Jan 05. [Online] al. (2011) How information about
gov.uk/Mental%20Capital/SR-X2_ Available at: http://www.dh.gov. other people’s personal experiences
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No health without mental health: 2012. 15
Cashen MS, Sklar BM, Nguyen
a cross-government mental HH, Just M, Galzagorry G, Bakken
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Available at: http://www.dh.gov. Individuals.[Online] Available city community church: lessons
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10

Nazareth I.(2005) Interactive Health
5
Department of Health (2012) Communication Applications for
Healthy lives, healthy people: people with chronic disease.[Online]
our strategy for public health Available at: http://www.ncbi.nlm.
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en/Publicationsandstatistics/
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PublicationsPolicyAndGuidance/
DH_121941 Accessed 14th November
2012.

12


Notes

13


For more information about the models and
methodologies presented in this white paper
please contact:

Stuart Jackson on: 07970 226 640
or email: stuart@icecreates.com
Joy Spalding on: 07540 412 305
or email: joy.spalding@icecreates.com
Zerina McCarthy on: 07715 121 391
or email: zerina.mccarthy@icecreates.com

together we make a difference

The use of Web based interventions in improving well being

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