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J Med Internet Res. 2006 Apr-Jun; 8(2): e10.
Published online Jun 23, 2006. doi:  10.2196/jmir.8.2.e10
PMCID: PMC1550698

Why Are Health Care Interventions Delivered Over the Internet? A Systematic Review of the Published Literature

Frances Griffiths, PhD, FRCGP,corresponding author1 Antje Lindenmeyer, PhD,1 John Powell, PhD, MFPHM,1 Pam Lowe, PhD,2 and Margaret Thorogood, PhD, FFPH1
2Aston University, Aston Triangle, Birmingham, UK
1Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
Frances Griffiths, Center for Primary Health Care Studies, Warwick Medical School, University of Warwick, Coventry, UK CV4 7AL, Phone: +0044 24 7652 2534, Fax: +0044 24 7672 8375, ku.ca.kciwraw@shtiffirg.e.f.
Reviewed by Elizabeth Murray

Abstract

Background

As Internet use grows, health interventions are increasingly being delivered online. Pioneering researchers are using the networking potential of the Internet, and several of them have evaluated these interventions.

Objective

The objective was to review the reasons why health interventions have been delivered on the Internet and to reflect on the work of the pioneers in this field in order to inform future research.

Methods

We conducted a qualitative systematic review of peer-reviewed evaluations of health interventions delivered to a known client/patient group using networked features of the Internet. Papers were reviewed for the reasons given for using the Internet, and these reasons were categorized.

Results

We included studies evaluating 28 interventions plus 9 interventions that were evaluated in pilot studies. The interventions were aimed at a range of health conditions. Reasons for Internet delivery included low cost and resource implications due to the nature of the technology; reducing cost and increasing convenience for users; reduction of health service costs; overcoming isolation of users; the need for timely information; stigma reduction; and increased user and supplier control of the intervention. A small number of studies gave the existence of Internet interventions as the only reason for undertaking an evaluation of this mode of delivery.

Conclusions

One must remain alert for the unintended effects of Internet delivery of health interventions due to the potential for reinforcing the problems that the intervention was designed to help. Internet delivery overcomes isolation of time, mobility, and geography, but it may not be a substitute for face-to-face contact. Future evaluations need to incorporate the evaluation of cost, not only to the health service but also to users and their social networks. When researchers report the outcomes of Internet-delivered health care interventions, it is important that they clearly state why they chose to use the Internet, preferably backing up their decision with theoretical models and exploratory work. Evaluation of the effectiveness of a health care intervention delivered by the Internet needs to include comparison with more traditional modes of delivery to answer the following question: What are the added benefits or disadvantages of Internet use that are particular to this mode of delivery?

Keywords: Internet, intervention studies, literature review

Introduction

The Internet is still a relatively new medium for seeking and delivering health care, although this use is increasing rapidly [1,2] and includes health information seeking [3], Internet-based peer support groups [4], online health consultations [5], and delivery of health interventions [6]. Some pioneer researchers have published studies that evaluate health interventions delivered directly to the users via the Internet for their ability to improve the health status of their users. In this paper we review their work, focusing on the reasons why these authors chose to use the Internet for delivery of a health care intervention. Our aim was to consolidate the findings from these early research papers to inform the development of future research. We include only health interventions in which the networking provided by the Internet is a component of the intervention. This is to distinguish them from other media such as print material, CD-ROM, and video. We reflect on the drivers to using the Internet for the delivery of health care. This paper does not review the outcomes of the interventions.

Methods

Identification of Studies

The initial identification of studies used five sources: three existing systematic reviews of eHealth interventions [7-9], a hand search of JMIR (vol 1(1) to vol 8(1)), and our own previous qualitative review of the literature concerning the Internet and consumer health information [10]. This latter review involved collation and identification of relevant literature through systematic searches of electronic bibliographic databases covering health and social sciences literature (1990 to December 2003, including Medline, HMIC, CINAHL, Sociological Abstracts, Sociofile, and Web of Science). We used search terms such as “Internet,” “electronic mail,” “computer communication networks,” and “health information,” “communication,” or “health informatics.” Two investigators reviewed the list to identify potentially relevant articles. We worked in pairs, reviewing the search results to identify relevant intervention studies. We did not set out to identify every published eHealth intervention paper, but aimed to search the majority of the available literature in a systematic way for a meaningful overview of the field.

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria were applied to the studies identified from the three sources described above. We included only peer-reviewed full research papers. We defined intervention studies as the use of information and communication technology to deliver a specific health intervention to a client or patient group. The study had to include a health-related outcome as part of evaluating the intervention, and the intervention had to include use of the networking provided by the Internet. Networked features included the use of email to contact a therapist, the use of chat rooms or bulletin boards by client/patient groups, or the transfer of personal health data via the Web between a health care site and personal network access (eg, between a clinic and patient’s home). Studies with no networked features, such as computer-based decision support systems delivered from a CD or interventions where there was no use of the Internet beyond delivery (ie, they could have been delivered by a CD), were excluded. A further key characteristic of the Internet is its accessibility via a networked computer anywhere and anytime. Hence, we excluded studies in which access to the intervention was provided only in the clinical setting as use of the intervention is restricted in place and time. It is also possible that effectiveness may be influenced by the clinical setting.

Our review focused on the use of the Internet for delivery of the interventions and therefore did not include non-Internet based telemedicine studies. The focus was on specific interventions for specific health problems, so we excluded interventions involving the provision of general Internet access such as home computers, Internet kiosks, or training in use of the Internet even if the outcomes included health related measures. We only included interventions in which the individuals using them were known to the health care professional or organization delivering the intervention to be sure that the participants were using their real identity and responding in a genuine way to the intervention. This cannot be ensured for a study that recruits participants solely via the Web, with no direct contact between investigators and participants. We excluded studies that solely involved the placing of health information on the Web for public access, even when there was opportunity for interaction or feedback.

Analysis

When there were several papers concerning the same intervention (eg, a pilot study followed by a full evaluation), we grouped these papers together and treated them as one study. For each study, all the reasons given for delivering the health care intervention on the Internet were listed. These were the reasons the authors of the papers gave for choosing the Internet as the mode of delivery, rather than post hoc reasoning given in the discussion of the study results. We then categorized the reasons; one study could be categorized in a number of different groups. Again, we worked in pairs, comparing results and resolving any discrepancies through further examination of the papers and discussion among team members.

Results

Types of Interventions

We found full evaluations of 28 interventions and a further 9 interventions for which only pilot work had been published (Multimedia Appendix). All the papers were from Europe, North America, or Australia. The interventions were aimed at a wide range of conditions, including cancer (3 studies), HIV/AIDS (3 studies), diabetes (3 studies), mental health (1 study), eating disorders (2 studies), and back pain (1 study). Some targeted health promotion issues such as smoking cessation (1 study), physical activity (1 study), and obesity (3 studies). Other interventions aimed to support caregivers, for example caregivers of people with Alzheimer’s disease (3 studies), stroke patient caregivers (1 study), new or young mothers (2 studies), and parents of children in intensive care (1 study). One intervention aimed at supporting rural women with chronic illness. One study reported the delivery of cognitive behaviour therapy (CBT) for a number of disorders, including headache, tinnitus, and panic disorders; two other studies reported CBT delivery for depression and one for post-traumatic stress disorder. Three interventions offered education and/or communication with specialist nurses for cardiac patients. Three interventions were specifically for young people or children: one for pain self management by children in hospital, one for those with cystic fibrosis, and one for the management of encopresis.

Reasons for Internet Delivery of Interventions

The reasons cited for using the Internet to deliver health interventions included the unique advantages of the Internet technology, reducing cost and increasing convenience for users, reducing health service costs, reaching isolated or stigmatized groups, timeliness of access to the Internet, need for user or supplier control of the intervention, and research-related reasons (Textbox).

Summary of findings

Reasons for Internet delivery:

  • Reducing cost and increasing convenience for users
  • Reduction of health service costs
  • Reduction of isolation of users
  • The need for timely information
  • Reduction of stigma
  • Increased user and supplier control of the intervention

Possible drawbacks of Internet interventions:

  • Potential for reinforcing the problems the intervention was designed to help
  • May overcome isolation of time, mobility, and geography, but may be no substitute for face-to-face contact

Elements of future evaluations:

  • Incorporate the cost not just to the health service, but also to users and their social networks
  • Be alert to unintended effects of Internet delivery of health interventions, and include a comparison with more traditional modes of delivery

Not all the studies in the early research papers mentioned the reasons for use of the Internet. Therefore, in the following analysis, the papers referenced are the papers for which the reason for Internet use was mentioned.

Unique Advantages of the Internet Technology

There were 13 interventions studied [6,11,16,20,24,32,35, 37,41,45,52,57,60,67,71-73] for which the reason for Internet use was connected with the nature of the technology: reaching many people with just one posting, easy storage of large amounts of information, ease of updating information, providing personalized feedback, and the possibilities of broadband and video transmission. Two of these 13 studies [57,16] expressly valued the Internet for its ability to reach a maximum number of people at minimum cost. All these studies also give other reasons for Internet use.

Reducing Cost and Increasing Convenience for Users

Reducing cost and increasing convenience for the user was given as a reason for delivery over the Internet in 20 of the interventions studied [20-23,29,32,39,43-48,50,52,53,56-58, 60-63,65,66,75]. These studies targeted a range of health issues. Various aspects of increased convenience to the user were mentioned, including saving the user time, requiring less effort from the user, being more accessible, and not requiring the user to attend a particular facility. One US study [43], reporting an intervention for women with breast cancer, stated users’ lack of money for a second opinion as one of the reasons for Internet delivery. Two studies advocated use of the Internet as it may reduce the loss of users from their maintenance programs for obesity [46,47].

Reducing Health Service Costs

By using Internet delivery, 14 of the interventions studied [11,12,14,15,24,28-30,39,41,42,46,48, 57,58,60,65,67,68,72-75] aimed to reduce costs to health services or address a lack of provision. Of these, two studies, one on linking parents with their low-birth-weight babies in intensive care [41], and the other on the management of encopresis [60], specified reduction in health service cost as a reason for Internet use. The cost of service provision was also given as a reason by a number of other studies, but with slightly different emphases. One study saw the Internet as a cost-effective way of delivering an intervention to encourage physical activity in a broad range of people in many places [58]. Five of the interventions studied gave a lack of health service resources as their reason, two citing a lack of practitioners in CBT [11,12,42] and the others a lack of support for caregivers of those with Alzheimer’s disease [24,39] and AIDS [28-30]. All the above studies discussed a general lack of these services. None of the studies gave a specific localized service failure as the reason for Internet delivery, but two mentioned service failure more generally. One study [60] gave the lack of physicians trained in the treatment of encopresis as the reason for Internet delivery, while another study [67] aimed to reduce barriers to nutrition education due to general practitioners’ lack of skills and time. The authors of one other study [48] argued for Internet delivery because patients with diabetes have been found to have poor control despite specialist care, and their control may become even worse after the devolution of diabetes care to primary care services.

In six of the interventions studied, researchers wanted to avoid the cost to the health service of providing the intervention face-to-face, including psychological interventions for the treatment of depression [42], eating disorders[71-75],obesity [46-66], lack of physical activity [57,58], and a range of conditions (headache, tinnitus, panic attacks, and insomnia) [11-13].The authors of the latter intervention studied also argued that Internet delivery increases access to an otherwise costly therapy [14,15]. Another study [19] explicitly addressed inequalities of health care, suggesting that Internet delivery helped to overcome inequalities of access to health services.

Reaching Isolated Groups

Dimensions of isolation were given as reasons for using the Internet in 13 of the interventions studied [18,19,21,25-30, 33,34,37,43,49,52,53,75]; 5 stated geographical isolation as their reason. These studies included interventions for rural women with chronic disease [33] or diabetes [34], an intervention for women with breast cancer [43], a cognitive behavioral program for eating disorders [75], an intervention for people with post-traumatic stress disorder [53], and an intervention for children with cystic fibrosis [52]. The authors of the latter study also mentioned the advantage of providing peer support without the risk of cross infection that can be life threatening for children with cystic fibrosis.

In other studies, the cause of the isolation was not geographical. One [28-30] stated the isolation of people living with HIV/AIDS as a reason for Internet delivery. Several studies cited the isolation of caregivers who were unable to easily go out, such as those living with an Alzheimer’s sufferer [21,25-27] and young mothers with children at home [37]. The physical immobility of individuals, including fatigue and disability, was mentioned in interventions focused on people with HIV/AIDS [28] or breast cancer [43] and on children with cystic fibrosis [52].

Several studies mentioned that Internet delivery enabled users to be in contact with people with similar health issues and so receive support. The implication was that this would be unlikely to happen otherwise as the condition was rare or restricting, for example, children in pain [49], children with cystic fibrosis [52], young mothers [37], people living with AIDS [28-30,43], and people with type 2 diabetes [18,19].

Reaching Stigmatized Groups

The researchers of 11 interventions saw the Internet as a way of reaching people suffering from conditions that caused them to feel embarrassed or stigmatized [18,19,22,24, 28,30,31,37,43,45,46,57,60,73-75]. The anonymity of Internet delivery was a reason for using the Internet in the following interventions: an intervention for mental health problems [31], in which the authors considered stigma to be a problem; an intervention for people living with type 2 diabetes [18,19], in which the authors suggested that anonymity prevented people from being judged on the basis of their appearance; two interventions to improve the self-care of people living with AIDS [28,30,45]; an intervention for young women at risk of eating disorders [73-75]; and a support intervention for young mothers [37]. Three studies suggested that Internet delivery avoids embarrassment about the health issue for which the intervention was used. One of these was for breast cancer [43], the second referred to embarrassment about failure to lose weight in an obesity intervention [46], and the third was aimed at child encopresis [60]. One study of a support system for caregivers of patients with Alzheimer’s disease [22,24] and one study of an intervention to encourage physical activity [57] suggested that Internet delivery encourages openness of communication.

The Timeliness of Access to the Internet

Several interventions [12,21,22,25,28-30,37,43] mentioned the need for timely information and advice as a reason for Internet delivery, including interventions to support Alzheimer’s caregivers [21,22,25], people with AIDS [28-30], young mothers [37], those with breast cancer [43], headache sufferers [12], and an intervention encouraging physical activity [57,58]. The suggestion was that people need information or advice at a time of crisis, for example, when their child is ill or when they are making a decision such as a change in treatment or their own behavior. The continuous access provided by the Internet was seen as helpful in these situations.

User Control of the Intervention

Many authors advocated use of the Internet because users could take control of the intervention [11,21,32,37,45,48,58,60, 63,67,72,74], tailoring the information they received to their own needs. This included interventions for Alzheimer’s caregivers [21], those with HIV/AIDS [45], a glucose modeling tool for type 1 diabetes [48], and an intervention promoting physical activity [58]. Other studies advocated use of the Internet because users could use the intervention at their own pace. These included CBT for depression [32] or tinnitus [11], an educational program for cardiac patients [63], peer support interventions providing young mothers with support [37] or facilitating weight loss [67], an intervention for those at risk of eating disorders [72,74], and an intervention for encopresis [60].

Supplier Control of the Intervention

For some interventions that delivered CBT as a self-help program, the Internet was seen as a potentially appropriate mode of delivery for such a structured, evidence-based intervention [12-15,32,42,57, 58,66,71-74]. One author stated that Internet delivery was superior to professional psychologists in delivering structured and standardized interventions [42]. However, in delivering these structured programs, the studies supplemented the standardized intervention through individualized email feedback, tailored information, online peer support, or a combination of the three.

Research-Related Reasons

Almost all authors justified the evaluation of Internet-delivered interventions by saying that they need evaluating or adapting for specific populations. Six studies give this as their only reason [38,40,54,55,59,61]. Most studies give examples of successful Internet-delivered interventions to support their own research. However, one study gives, as its only reason for Internet-delivered intervention, that the intervention or a similar intervention had been useful in other studies [40]. One study [54] questions whether face-to-face and online support groups for those with breast cancer would work together, and gives this question as the only reason for delivering the intervention via the Internet.

A few studies did not give a research-related reason for evaluating an Internet-delivered intervention. These studies were descriptive accounts of an intervention [33,48,51] or were evaluating the use of an Internet-delivered intervention that was in response to a specific health service–related problem [60].

Other Reasons

The following reasons, alongside others mentioned above, were also given for delivery of an intervention via the Internet:

  • poor information received by patients from health professionals [48]
  • novelty [57,58]
  • attractiveness of the Internet to young people and children [51]
  • online communication as one of the main forms of communication used by young people [60]

Discussion

We have reviewed many pioneering studies evaluating Internet use for the delivery of health care interventions and found a variety of reasons for delivering interventions through the Internet. All the interventions have been, or could be, delivered by other means. For example, support groups for isolated individuals can use more established means of communication such as telephones and post, and therapeutic programs can be delivered face-to-face. The key differences between non-Internet delivered interventions and those delivered via the Internet relate to time and place. For example, Internet support groups enable quick communication between many isolated individuals, and Internet-delivered therapeutic interventions can be taken up at any time and anywhere with Internet access.

Our literature search strategy was designed to systematically identify the majority of eHealth intervention studies meeting our inclusion criteria. However, as a qualitative analysis that aimed to explore the motivations for delivering such interventions online, it was not necessary to undertake an exhaustive search for every single eHealth study ever published in any language. This contrasts with the methodology of quantitative meta-analysis, which requires the identification of all possible studies to produce one summary result. We believe that our qualitative thematic approach met our objective and was both rigorous and repeatable. Qualitative methods of research synthesis are a relatively new area and can be very valuable in identifying lessons for future work, particularly as they do not focus solely on the results on previous studies, but also consider other factors such as the researchers’ motivations. Our criteria for inclusion and exclusion of studies were designed to maintain the focus of the review on the added value from use of the Internet. Hence, they took account of the key characteristics of the Internet, particularly its networking potential and accessibility. Thus, our criteria differed from definitions of eHealth, for example, by excluding telemedicine [76] and general public access [77].

At this early stage of development, researchers should give careful thought to the reasons for using the Internet for any particular intervention. We should try to understand the unique advantages and disadvantages of Internet delivery of health care and in what circumstances Internet use could contribute most effectively to improving health. For example, why might speedier communication and flexibility of location enhance the effectiveness of the intervention? Answers may include, for example, overcoming inequalities of access to health services or encouraging openness of communication. However, to clarify the added contribution of Internet delivery over more traditional forms of delivery, evaluations should include a direct comparison between Internet-delivered interventions and those delivered by the most effective of available conventional means. Such evaluations will enable us to understand the effect of the real differences between the interventions. Few studies in our review undertook such a direct comparison.

Failing to undertake such a direct comparison may result in the failure to identify and quantify situations where face-to-face delivery is better than Internet delivery. For example, among the many studies of structured behavioral programs using Internet delivery, only one intervention [46,47] compared the benefits of this delivery method with time-intensive face-to-face therapy, and another compared it with a classroom-based intervention [70,72]. A systematic review comparing the effectiveness of Web-based and non-Web–based interventions [9] included, apart from the above two interventions, no other trials in which Web-based interventions had been compared to intensive face-to-face interventions. Undertaking an evaluation of Internet-delivered intervention without comparison may inappropriately encourage a reduction of the availability of the effective face-to-face intervention. This would work against the original motivation of the research to increase access to an effective intervention.

The design, delivery, and evaluation of an Internet-delivered intervention also need to consider the following questions: What may be the unintended harmful consequences of Internet delivery? What may be the negative effects of speedier communication and flexibility of location? For example, it is possible that providing low-cost Internet-based support for groups that are not currently provided with adequate support, such as caregivers of those with Alzheimer’s disease, may reinforce the low priority of these groups for health and social services and thus increase their isolation. Providing an intervention via the Internet for individuals living with a health problem they feel is stigmatized could have the unintended consequence of the issue being less talked about outside the anonymity of the Internet and thus reinforcing the stigma (see Textbox). Although identifying such unintended consequences was not an aim of this study, it was notable that we did not identify any reports of such consequences in the papers reviewed.

Evaluations of Internet-delivered interventions should aim to ensure that they include both the benefits and potential harms of the mode of delivery for all those affected by it. For example, an economic evaluation should include not only the cost of the Internet intervention, but also costs to health services, specific services, users, and their social networks. The studies reviewed rarely included an evaluation of such indirect costs.

Although the Internet can overcome isolation of time, mobility, and geography, it may be a poor substitute for face-to-face contact with real people. The balance between use of the Internet and face-to-face contact should be carefully considered in each circumstance. This applies to structured interventions such as CBT as well as to more flexible interventions such as peer-to-peer support. In designing an evaluation, researchers should be aware that Internet-based contact may be providing something different than face-to-face contact and should seek to assess these potentially different effects (see Textbox).

A number of studies gave no reason for use of the Internet as the mode of delivery beyond stating that it exists and needs evaluating. Now that the field of Internet- delivered interventions is established, future researchers should carefully consider how the networking provided by Internet delivery may enhance the effect of an intervention. This should involve exploratory work and more explicit use of existing theory and modeling [78].

The pioneering researchers who undertook the studies reviewed in this paper were often looking to the Internet for a way to help resolve some of the current difficulties and dilemmas of health care. These included the provision of equal access to health care, limitations on resources for health care, changing roles of health professionals, and changing needs for particular skills. Exploring the possible benefits of using the Internet to address these issues is important, but it is also important to make a meaningful comparison between using the Internet and using other more traditional ways of addressing the issues. Future research will hopefully shed more light on the benefits and disadvantages of Internet use particular to this mode of delivery.

Acknowledgments

The authors acknowledge the support of the Warwick West Midlands Primary Care Research, and the UK Department of Health, which support their academic posts.

Abbreviations

AIDS
acquired immunodeficiency syndrome
CBT
cognitive behavior therapy
HIV
human immunodeficiency virus

Appendix 1

Summary table of reviewed studies

AuthorYearRefCountryHealth ConditionDescription of InterventionNetworked FeaturesReasons Given by Authors for Using Internet
Andersson2004[11]SwedenTinnitusCBT for headache, tinnitus, panic disorder, insomnia:
6-module online self-help program based on cognitive behavioral therapy with email support from a trained therapist
Participants complete online progress reports; therapist responds by emailAdvantage of technology
Cost for health services
User control of intervention
Headache
Andersson2003[12]
Tinnitus
Cost for health services
Supplier control of intervention
Timely information/advice
Panic disorder
Andersson2002[13]
Panic disorder
Carlbring2001[14]
Supplier control of intervention
Headache
Carlbring2003[15]
Insomnia
Cost for health services
Supplier control of intervention
Strom2000[16]
Cost for health services
Supplier control of intervention
Strom2004[17]
Advantage of technology
Research related only
Barrera2002[18]United StatesType 2 diabetesD-net: Internet-based self management program for type 2 diabetes with online feedback, professionally moderated but peer-directed message board, and access to professional coachMessage boards, chat facility (peer-to-peer and peer-to-professional)Reaching isolated groups
Reaching stigmatized groups
Glasgow2003[19]
Cost for health services
Reaching isolated groups
Reaching stigmatized groups
McKay2002[20]
Advantage of technology
Cost for users
Bass1998[21]United StatesAlzheimer’s diseaseComputerLink for Alzheimer’s caregivers: information, communication, and resource center with nurse-led online support group (message board) with email facility, decision support system, encyclopedia, and links to quality websitesMessage boards, email facility (peer-to-peer and peer-to-professional)Cost for users
Reaching isolated groups
Timely information/advice
User control of intervention
Brennan1991[22]
Cost for users
Reaching stigmatized groups
Timely information/advice
Brennan1992[23]
Brennan1994[24]
Cost for users
Brennan1995[25]
Advantage of technology
Cost for health services
Reaching stigmatized groups
Casper1995[26]
McClendon1998[27]
Reaching isolated groups
Timely information/advice
Reaching isolated groups
Reaching isolated groups
Brennan1991[28]United StatesHIV/AIDSComputerLink for people living with AIDS: information, communication, and resource center with nurse-led online support group (message board) with email facility, decision support system, encyclopedia, and links to quality websitesMessage boards, email facility (peer-to-peer and peer-to-professional)Cost for health services
Reaching isolated groups
Reaching stigmatized groups
Timely information/advice
Brennan1994[29]
Flatley-Brennan1998[30]
Cost for users
Cost for health services
Reaching isolated groups
Timely information/advice
Cost for health services
Reaching isolated groups
Reaching stigmatized groups
Timely information/advice
Chang2001[31]United StatesMental healthMental health support for Asian-American men: online support group moderated by Asian-American counselorMessage boardsReaching stigmatized groups
Christensen2002[32]AustraliaDepressionMoodGym: online self-help program based on cognitive behavioral therapyParticipants complete online feedback sheetsAdvantage of technology
Cost for users
User control of intervention
Supplier control of intervention
Christensen2004[6]
Advantage of technology
Cudney2000[33]United StatesChronic illnessWomen to Women: nurse-led online support group for rural women with chronic illness; 1 subgroup with diabetes onlyMessage boards, email and chat facility to other peers and nurseReaching isolated groups
Reaching isolated groups
Smith2001[34]
Delgado2003[35]CanadaHeart diseaseHeart failure Internet communication toolEmail between patients and health professionalsAdvantage of technology
Research related only
Wu2005[36]
Dunham1998[37]CanadaYoung mothersSupport for young mothers: peer-led online support groupMessage boards, email facility, and teleconferencingAdvantage of technology
Reaching isolated groups
Reaching stigmatized groups
Timely information/ advice
User control of intervention
Feil2003[38]United StatesSmoking cessationSmoking cessation: Web-based structured intervention and support program hosted by a para-professional ex-smokerMessage boards, email and ask-an-expert facilityResearch related only
Glueckauf2003[39]United StatesAlzheimer’s diseaseSupport for Alzheimer’s caregivers: Web- and phone-based caregiver education and support programVideo-linked classes, peer-to-peer chat, and message boardsCost for users
Cost for health services
Reaching isolated groups
Gomez2002[40]United Kingdom/ SpainHIV/AIDSSelf-monitoring tool for people with AIDS: Web-based recording and feedback system to enable self-care at homeEmail ask-an-expert function based on patient-entered dataResearch related only
Gray2000[41]United StatesLow-body-weight infantsBabyCareLink: education and communication tool for parents of children in intensive careReports/images of child, parent- ICU staff communicationAdvantage of technology
Cost for health services
Greist2000[42]United States/ United KingdomDepressionCOPE: Web-based (computer-enabled interactive voice re­sponse system) cognitive behavioral therapy for depressionSends records and emergency signals to clinicianCost for health services
Supplier control of intervention
Gustafson1993[43]United StatesBreast cancerCHESS: integrated information, referral, decision, and social support program for women with breast cancerFacilitated online support group, ask-the-expert functionCost for users
Reaching isolated groups
Reaching stigmatized groups
Timely information/advice
Gustafson2001[44]
Cost for users
Gustafson1999[45]United StatesHIV/AIDSCHESS: integrated information, referral, decision, and social support program for people with AIDSFacilitated online support group, ask-the-expert functionAdvantage of technology
Cost for users
Reaching isolated groups
Reaching stigmatized groups
User control of intervention
Harvey-Berino2002[46]United StatesWeight lossWeight loss program: Web-based weight maintenance program following classroom-based weight loss interventionMeetings with video-linked educator, chat room, message board, email facilityCost for users
Cost for health services
Reaching stigmatized groups
Harvey-Berino2002[47]
Cost for users
Hejlesen2000[48]DenmarkType 1
diabetes
DIASNet: Web version of online modeling device used for self-management, communication, and educationCan be jointly used by patients and health professionalsCost for users
Cost for health services
User control of intervention
Poor info from professionals
Holden2002[49]United StatesPain in childrenStarbrightWorld: commercially developed interactive computer network for hospitalized childrenPeer-to-peer emails, video links, chat rooms, bulletin boardsReaching isolated groups
Hudson1999[50]United StatesYoung mothersSocial support for young mothers: nurse-led email network providing health information and supportEmail network (peer-to-peer and peer-to-nurse)Cost for users
Reaching isolated groups
Iafusco2000[51]ItalyType 1
diabetes
Support group for teenagers with type 1 diabetes: chat room with weekly meetings moderated by diabetologistChat roomAttractive to young people
Johnson2001[52]United StatesCystic fibrosisTeen Central: online support group for teenagers with cystic fibrosisModerated message boards, free “graffiti wall,” email facilityAdvantage of technology
Cost for users
Reaching isolated groups
Lange2003[53]Nether-landsPost-traumatic stress disorderInterapy: Internet-based cognitive behavioral writing program for people suffering from post-traumatic stressCommunication with therapists who read submitted writings and tailor standardized feedbackAdvantage of technology
Cost for users
Reaching isolated groups
Lieberman2003[54]United StatesBreast cancerSupport group for women with breast cancer: electronic support group led by experienced cancer support facilitatorWeekly sessions, newsgroup, 24-hour chat room facilityResearch related only
Lorig2002[55]United StatesBack painSupport group for back pain: email discussion group with 2 professional moderators and 3 content expertsEmail listservResearch related only
Mahoney1998[56]United StatesAlzheimer’s diseaseReach for TLC: computer-mediated voice mail system to provide support and education for caregiversVoice mail bulletin board, ask-the-expert facilityCost for users
Marshall2003[57]United States/ AustraliaPhysical activityPhysical activity program: online, workplace-based interactive behavioral change programEmail based on motivational stage and personalized goalsAdvantage of technology
Cost for health services Reaching stigmatized groups
Timely information/advice
Supplier control of intervention
Novelty
Napolitano2003[58]
Cost for users
Cost for health services
Timely information/advice
User control of information
Supplier control of information
Novelty
Pierce2002[59]United StatesStrokeCaring-Web: nurse-led Web-based support group for caregivers of stroke victimsEmail contact to nurse, email listserv (peers and nurse)Research related only
Ritterband2003[60]United StatesEncopresisU-Can-Poop-Too: Web-based enhanced toilet training for children with encopresis and their parentsPersonalized homepage, follow-up sessions based on modules completed Cost for users
Cost for health services
Reaching stigmatized groups
User control of intervention
Attractive to children
Robinson2001[61]United KingdomBulimiaE-mail therapy for bulimia: email treatment conducted by 2 clinicians experienced in eating disordersParticipants emailed diaries to which therapists respondedResearch related only
Ross2004[62]CanadaHeart diseaseWeb-based Online Medical Record: access to records and communication tool for patients with congestive heart failureMessaging system between patients and cardiac nursesCost for users
Southard2003[63]Heart diseaseWeb-based educational program: nurse-led educational program for secondary prevention of heart diseaseMessaging between patients and nurses/dietitiansCost for users
User control of intervention
Takahashi1999[64]JapanSmoking cessationQuit Smoking Marathon: smoking cessation program delivered through daily guidance emailsMessage forum for participants, doctors and ex-smokersNone – description only
Tate2001[65]United StatesWeight lossWeight loss program: Web-based behavioral weight loss program with email follow-up for those at risk of diabetesMessage board; participants submit diaries and weight; counselors respond by emailCost for users
Advantage of technology
Cost for users
Cost for health services
Supplier control of intervention
Tate2003[66]
Verheijden2004[67]NetherlandsWeight lossWeight loss program: peer support intervention to reduce fat consumption in those at risk of heart diseaseBulletin board for peer-to-peer communication and social supportAdvantages of technology
Cost for health service
User control of intervention
Winzelberg2003[68]United StatesBreast cancerSupport group for women with breast cancer: Web-based social support group moderated by mental health professionalMessage board with weekly discussion topicCost for users
Supplier control of intervention
Dev1999[69]United StatesEating disordersStudent Bodies: CD-ROM behavioral program plus Web-based counselor-led support group for students at risk of eating disordersModerated weekly discussion group (message board or email)Research related only
Research related only
Celio2000[70]
Advantage of technology
Cost for health services
Supplier control of intervention
Winzelberg1998[71]
Winzelberg2000[72]
Advantage of technology
Cost for health services
User control of intervention
Supplier control of intervention
Zabinski2001[73]
Zabinski2001[74]
Advantage of technology
Cost for health services
Reaching stigmatized groups
Supplier control of intervention
Zabinski2003[75]
Cost for health services
Reaching stigmatized groups
User control of intervention
Supplier control of intervention
Advantage of technology
Cost for users
Cost for health services
Reaching stigmatized groups
Reaching isolated groups

Footnotes

Conflicts of Interest:

None declared.

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