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Patients with cardiovascular risk factors can reduce their risk of cardiovascular disease by increasing their physical activity and their physical fitness. According to the guidelines for cardiovascular risk management, health professionals should encourage their patients to engage in physical activity.
In this paper, we provide insight regarding the systematic development of a Web-based intervention for both health professionals and patients with cardiovascular risk factors using the development method Intervention Mapping. The different steps of Intervention Mapping are described to open up the “black box” of Web-based intervention development and to support future Web-based intervention development.
The development of the Professional and Patient Intention and Behavior Intervention (PIB2 intervention) was initiated with a needs assessment for both health professionals (ie, physiotherapy and nursing) and their patients. We formulated performance and change objectives and, subsequently, theory- and evidence-based intervention methods and strategies were selected that were thought to affect the intention and behavior of health professionals and patients. The rationale of the intervention was based on different behavioral change methods that allowed us to describe the scope and sequence of the intervention and produced the Web-based intervention components. The Web-based intervention consisted of 5 modules, including individualized messages and self-completion forms, and charts and tables.
The systematic and planned development of the PIB2 intervention resulted in an Internet-delivered behavior change intervention. The intervention was not developed as a substitute for face-to-face contact between professionals and patients, but as an application to complement and optimize health services. The focus of the Web-based intervention was to extend professional behavior of health care professionals, as well as to improve the risk-reduction behavior of patients with cardiovascular risk factors.
The Intervention Mapping protocol provided a systematic method for developing the intervention and each intervention design choice was carefully thought-out and justified. Although it was not a rapid or an easy method for developing an intervention, the protocol guided and directed the development process. The application of evidence-based behavior change methods used in our intervention offers insight regarding how an intervention may change intention and health behavior. The Web-based intervention appeared feasible and was implemented. Further research will test the effectiveness of the PIB2 intervention.
Dutch Trial Register, Trial ID: ECP-92
Developing a Web-based intervention requires a well-thought idea, but also a plan of how to design, implement, and evaluate the intervention. Intervention Mapping provides a framework for building high-quality interventions that are systematically planned, theory- and evidence-based, and take perspectives of end users and intermediaries into consideration [
In designing the intervention for this study, we focused on patients with cardiovascular risk factors. Cardiovascular risk factors increase the risk for cardiovascular disease, Type 2 diabetes, and overall mortality and morbidity [
This paper provides insight regarding the systematic development process of the Web-based Professional and Patient Intention and Behavior (PIB2) intervention to open up the “black box” of Web-based intervention development and support future development. The development of the behavioral change intervention should facilitate logic transparency, reproducibility, and diffusion of the intervention. The intervention sought to optimize behavioral coaching by health professionals and to encourage previously physically inactive patients with cardiovascular risk factors to become physically active, following cardiovascular risk management guidelines with a potential for implementation in cardiovascular inpatient and outpatient care [
The first step of Intervention Mapping is a needs assessment of the study population. The questions explored in the first step included: What is the problem? What are the causes? What behaviors are related to the problem? Are there detectable risk groups? The social-cognitive determinants that could explain intention and behavior were also studied [
Participants were health professionals and former students of the University of Applied Sciences, Utrecht, the Netherlands. Participants with at least a Bachelor’s degree in nursing or physiotherapy and who had consultations with patients with cardiovascular risk factors were invited to participate. Patients with at least one cardiovascular risk factor (abdominal obesity, high blood pressure, low high-density lipoprotein cholesterol, elevated triglycerides, and elevated blood glucose levels) and low physical activity levels were invited [
Intervention Mapping steps, design, implementation, and evaluation of the Professional and Patient Intention and Behavior (PIB2) intervention.
We undertook a separate planning process for health professionals because they perform different behaviors with different social-cognitive determinants related to the intention and behavior in question than their patients with cardiovascular risk factors do [
In the needs assessment for health professionals, we performed a literature review, held focus group interviews, and studied the social-cognitive determinants that explained intention and behavior. Focus group interviews with health professionals (n = 7) revealed that encouraging patients to become physically active was seen as an integral part of their daily practice and, although perceived as relatively easy to do, patient compliance was often a problem. In previous research, we studied through questionnaire the social-cognitive determinants of intention and behavior to encourage patients with cardiovascular risk factors to become physically active [
In the needs assessment for patients with cardiovascular risk factors, the literature showed various guidelines explaining the recommended levels of physical activity and physical fitness. In a previous study, we investigated physical activity and physical fitness in an adult population and found that the intensity of physical activity was especially important in reducing cardiovascular risk factors [
We defined the desired behavior of health professionals as encouraging behavior conducive to the health of patients. Health professionals should encourage patients with cardiovascular risk factors to become physically active at increasing levels of intensity as an extension of their professional behavior. This overall objective of extending professional behavior was specified in the health care professionals’ performance objectives. The performance objectives were directed at monitoring their encouraging behavior, formulating explicit plans to encourage their patients, and maintaining and habitually encouraging patients to prevent relapse (
Intervention Mapping step 2 performance objectives for health care professionals and patients with cardiovascular risk factors.
Target group | Performance objectives |
Health professionals | Monitor the encouragement of physical activity among patients with cardiovascular risk factors as a prerequisite for a physically active patient |
Formulate explicit plans to encourage physical activity among patients with cardiovascular risk factors | |
Identify solutions to diminish the barriers to encouraging physical activity among patients with cardiovascular risk factors | |
Formulate explicit plans to cope with difficult situations that occur while encouraging physical activity among patients with cardiovascular risk factors | |
Maintain and habitually encourage physical activity among patients with cardiovascular risk factors to prevent relapse | |
Patients with cardiovascular risk factors | Monitor cardiovascular risks linked to the intensity of physical activity |
Make explicit plans for physical activity | |
Identify solutions to diminish barriers to physical activity | |
Make explicit plans to cope with difficult situations that occur during physical activity | |
Maintain a lifestyle marked by physical activity to prevent relapse |
The performance objectives were linked with the social-cognitive determinants of intention and behavior as described in step 1. The link between performance objectives and social-cognitive determinants resulted in a matrix displaying the change objectives for health professionals (
Intervention Mapping step 2 (change objectives) performance objectives for health professionals linked to social-cognitive determinants risk perception, attitudes, and social influence.
Performance objectives health professionals | Risk perception and knowledge | Attitude and outcome expectations | Social influence and skills |
Monitors encouragement of physical activity among patients with cardiovascular risk factors as a prerequisite for a physically active patient | Describes the relationship between the professional behavior of encouraging physical activity and health outcomes for patients with cardiovascular risk factors; indicates that cardiovascular risk factors are related to the intensity of physical activity; reports relevant justifications for encouraging patients with cardiovascular risk factors to engage in physical activity | Feels positively about encouraging patients with cardiovascular risk factors to become physically active and the (health) benefits of physical activity; expects that physical activity will decrease cardiovascular risk factors | Describes others as supporting or encouraging patients with cardiovascular risk factors; asks for support; feels confident about handling negative social influence when encouraging patients with cardiovascular risk factors; performs skills necessary to encourage physical activity for cardiovascular patients |
Formulates explicit plans to encourage physical activity among patients with cardiovascular risk factors | Knows planning is important for encouraging patients with cardiovascular risk factors to engage in physical activity | Describes personal benefits for planning the encouragement of patients with cardiovascular risk factors to engage in physical activity | Feels confident in planning the encouragement of patients with cardiovascular risk factors to engage in physical activity in regard significant others |
Identifies solutions to diminish barriers to encourage physical activity among patients with cardiovascular risk factors | Recognizes negative feelings, thoughts, and actions regarding encouraging patients with cardiovascular risk factors to engage in physical activity that keep him/her from encouraging patients | Describes negative feelings, thoughts, and actions regarding encouraging patients with cardiovascular risk factors to engage in physical activity that keep him/her from encouraging patients | Discusses with colleagues the negative feelings, thoughts, and actions about encouraging patients with cardiovascular risk factors to engage in physical activity that keep him/her from encouraging patients |
Formulates explicit plans to cope with difficult situations that occur while encouraging physical activity among patients with cardiovascular risk factors |
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States that he/she is convinced of the importance of encouraging patients with cardiovascular risk factors to engage in physical activity |
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Maintains and habitually encourages physical activity among patients with cardiovascular risk factors to prevent relapse | Indicates that relapse is part of encouraging patients with cardiovascular risk factors to engage physical activity | States benefits of encouraging patients with cardiovascular risk factors to engage in physical activity in the short and long term; states that the best reaction to relapse is to restart | Handles negative social influence (to relapse) |
Intervention Mapping step 2 (change objectives) performance objectives for health care professionals linked to social-cognitive determinants self-efficacy and barriers.
Performance objectives for health professionals | Self-efficacy and skills | Barriers and skills to cope with barriers |
Monitors that encouragement of physical activity among patients with cardiovascular risk factors is a prerequisite for a physically active patient | Is confident about encouraging patients with cardiovascular risk factors to become physically active; demonstrates the skills necessary to encourage patients with cardiovascular risk factors to become physically active; demonstrates practical skills necessary to encourage physical activity among patients with cardiovascular risk factors |
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Formulates explicit plans to encourage physical activity among patients with cardiovascular risk factors | Describes when, where, and how they will encourage patients with cardiovascular risk factors to engage in physical activity |
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Identifies solutions to diminish barriers to encouraging physical activity among patients with cardiovascular risk factors |
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Handles situations that keep them from encouraging patients with cardiovascular risk factors to engage in physical activity |
Formulates explicit plans to cope with difficult situations that occur while encouraging physical activity among patients with cardiovascular risk factors | Demonstrates skills in daily planning for the encouragement of patients with cardiovascular risk factors to engage in physical activity | Incorporates difficult situations in daily planning for the encouragement of patients with cardiovascular risk factors to engage in physical activity |
Maintains and habitually encourages physical activity among patients with cardiovascular risk factors to prevent relapse | Is confident in his/her ability to encourage patients with cardiovascular risk factors to engage in physical activity; demonstrates that it is best to restart after relapse; evaluates encouraging behavior | Handles incidental situations that keep him/her from encouraging patients with cardiovascular risk factors to engage in physical activity |
In formulating our intervention objectives for patients, we defined the desired behavior as risk-reduction behavior assuming that if an intervention reduces the prevalence of risk factors, it can also reduce the prevalence of disease. Thus, not only should physical activity be encouraged for patients, but also the intensity of their physical activity, resulting in healthy behaviors for patients with cardiovascular risk factors [
Intervention mapping step 2 (change objectives) performance objectives for patients with cardiovascular risk factors linked to social-cognitive determinants risk perception, attitudes, and social influence.
Performance objectives for patients | Risk perception and knowledge | Attitude and outcome expectations | Social influence and skills |
Monitors their cardiovascular risk linked to the intensity of physical activity | Describes relationship between physical activity and health; describes their personal cardiovascular risk; describes that cardiovascular risk factors are related to the intensity of physical activity; indicate relevant reasons for physical activity | Feels positively about the (health) benefits of physical activity; expects that physical activity decreases cardiovascular risk factors | Describes significant others as supporting physical activity; asks for support; feels confident about handling negative social influence; performs social skills necessary for physical activity |
Makes explicit plans for physical activity | Knows planning is important for physical activity | Describes personal benefits of planning physical activity | Feels confident in planning physical activity in regard to social circumstances |
Patient identifies solutions to diminish barriers to physical activity | Recognizes negative feelings, thoughts, and actions about physical activity, cardiovascular risk factors, the body or self that keep him/her from engaging in physical activity | Describes negative feelings, thoughts, and actions about physical activity, cardiovascular risk factors, the body or self that keep him/her from engaging in physical activity | Discusses negative feelings, thoughts, and actions about physical activity, cardiovascular risk factors, the body or self that keep him/her from engaging in physical activity |
Makes explicit plans to cope with difficult situations that occur during physical activity |
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Expresses being convinced that physical activity is important |
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Maintains a lifestyle marked by physical activity to prevent relapse | Indicates that relapse is part of changing lifestyle physical activity | States the health benefits of physical activity in the short and long term; states that the best reaction to relapse is to restart | Feels confident about handling negative social influence (to relapse) |
Intervention mapping step 2 (change objectives) performance objectives for patients with cardiovascular risk factors linked to social-cognitive determinants self-efficacy, and barriers.
Performance objectives for patients | Self-efficacy and skills | Barriers and skills to cope with barriers |
Monitors their cardiovascular risk linked to the intensity of physical activity | Is confident about being able to perform physical activity; demonstrates the skills; shows practical skills necessary for physical activity |
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Makes explicit plans for physical activity | Describes when, where, and how they will engage in physical activity |
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Identifies solutions to diminish barriers to physical activity |
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Handles situations that keep him/her from engaging in physical activity |
Makes explicit plans to cope with difficult situations that occur during physical activity | Demonstrates skills in daily planning for physical activity | Incorporates difficult situations in daily planning for physical activity |
Maintains a lifestyle marked by physical activity to prevent relapse | Is confident about being able to perform physical activity; demonstrates that it is best to restart after relapse; evaluates physical activity behavior | Handles incidental situations that keep him/her from engaging in physical activity |
In step 3, we selected the theory-based methods (
Intervention mapping step 3 (theory-based methods) social-cognitive determinants linked to theoretical methods and their conditions.
Determinant | Theory-based method | Considerations for use | Conditions and strategies |
Risk perception, knowledge | Risk communication, risk perception | Requires knowledge about the relationship between (health) problem and (risk vs nonencouraging) behavior | Encourage thinking about individual risk and personal vulnerability |
Attitude, outcome expectations | Decisional balance | Requires consideration and evaluation of behavior | Encourage listing pro and cons of changing the behavior in the short and long term |
Social influence and skills | Resistance to social pressure | Requires social-skill enactment with feedback | Encourage to resist social pressure |
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Mobilizing others for social support | Requires a network that can potentially support health behavior | Encourage to seek social support |
Perceived behavioral controland skills | Guided practice | Requires subskill enactment with feedback | Encourage subskills practice |
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Action planning | Requires specification of when, where, and how to act | Planning behavior change, making a behavior change plan |
Barriers and skills to cope | Coping planning | Requires identification of high-risk situations and the practice of coping responses | Put into practice behavior change |
In a systematic review and meta-analysis, it was found that the number of behavioral change techniques applied had a positive impact on the total effect size of the intervention [
A Web-based behavioral change intervention was considered the most appropriate intervention. The intervention aimed to motivate health care professionals to encourage physical activity among their patients and to extend their professional behavior. The intervention also aimed to improve risk-reduction behavior in patients with cardiovascular risk factors. The intervention was not developed as a substitute for face-to-face contact between the health professional and the patient, but as an additional instrument to optimize health services [
Several tests and interviews were conducted with experts and members of the target groups (health professionals and patients) to verify the match between intervention components, the performance and change objectives, theory-based methods, conditions for use, and strategies. The PIB2 intervention embeds 5 modules, each comprising a sequential set of screens on the website (
In module 1, the health professionals encouraged the patient to become and stay physically active. Module 1 was designed to invite the patient to participate in the intervention (to use the intervention based on the mutual exchange of information between the health professionals and the patient) paralleling the performance and change objectives, the methods, conditions, and strategies (
After the assessment, the health professionals began coaching the patient with cardiovascular risk factors through a process of behavior changes to become and to stay physically active. In the process of behavior change, the 7 theory-based methods, conditions, and strategies were put into practice through 7 different website screens. The process of behavior change started with risk perception by encouraging the patient to think about individual cardiovascular risk and personal vulnerability, and the relationship between physical activity and cardiovascular risk. This was followed by listing the pros and cons of changing (or not changing) their behavior in the short and long term, and encouraging the patient to describe what his/her personal pros and cons are to becoming (or not becoming) physically active in the short and long term. After this, the patient was encouraged to resist social pressure and to seek social support, and to practice the necessary subskills. The process of behavior change ended with planning the behavior change by making a behavior change plan and putting the behavior change into practice. The patient was encouraged to specify when, where, and how to become physically active in a plan. When the patient started to put the physical active lifestyle into practice, high-risk situations should be detected and the practice of coping responses was encouraged.
A feedback system measured the progress of the patient’s cardiovascular risk factors, physical activity levels, and the process of behavior change. The patient’s profile was displayed while the health professional was working with the patient. The health professional provided the patient with physical activity recommendations based on research [
Module 2 was the health professionals’ support system. The support system was parallel to the website screens of module 1 (
Module 3 facilitated the professional to become a motivating and encouraging health professional (
Module 4 consisted of a forum directed at health professionals. Health professionals could use the forum to share experiences with other health professionals who also used the PIB2 intervention and find solutions for specific problems pertaining to the coaching of patients (
Module 5 facilitated the patient to look back at the plans he made in conjunction with the health professionals in module 1 (
The health professionals could use all the modules of the PIB2 intervention with a log-in code. However, patients could only access module 5 with their log-in code. Health professionals could access background information on the PIB2 intervention and specific information for each module. Information on physical activity, physical fitness, general physical activity devices, making an activity plan, and cardiovascular risk factors were accessible. For patients, information about the PIB2 intervention with specific information on only module 5 was available. Background information and a response form for members of the general public visiting the website was also available.
Intervention Mapping step 4 (intervention) flowchart of the intervention.
In step 5 of Intervention Mapping we developed a plan to facilitate implementation of the intervention (
Intervention Mapping step 5 (adoption and implementation plan) and step 6 (evaluation plan).
Group | Design | |||||
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Intervention group 1 | T1 Preintervention | T2 Start intervention, continuous measurement | T3 End intervention at 12 months |
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Control group A | T1 Preintervention I |
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T2 Preintervention II | T3 Start intervention, continuous measurement | T4 End of the intervention at 24 months |
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Intervention group 2 | T1 Preintervention | T2 Start intervention, continuous measurement | T3 End of the intervention at 12 months |
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Control group B |
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T1 Preintervention | T2 Start intervention, continuous measurement | T3 End of the intervention at 24 months |
The website was designed from the bottom up, beginning with determining the data needed to measure the effectiveness of the Web-based intervention [
The effect evaluation will be performed to verify whether the PIB2 intervention was successful in extending the encouraging behavior of health professionals (if methods, conditions, and strategies to use these methods were successfully applied to change performance and change objectives). The effect evaluation will also be performed to verify whether the intervention was successful in strengthening the physical activity behavior of patients with cardiovascular risk factors (if we attained their performance and change objectives). For patients, the main outcome measure was improvement in cardiovascular risk profiles (if patients decreased their number of cardiovascular risk factors by at least one risk factor and/or decreased their levels of cardiovascular risk factors at the end of the intervention). The process evaluation will be performed during implementation of the PIB2 intervention through the collection of data on the use and usability of the PIB2-intervention modules.
This paper describes the systematic development process of the Web-based PIB2 intervention to disclose the black box of Web-based interventions and support future Web-based intervention development. Intervention Mapping step 1, the needs assessment for health professionals, indicated that we could state the problem that they do not always encourage patients with cardiovascular risk factors to become and/or stay physically active. The outcome measure for health care professionals was to extend their professional behavior. For patients at risk for cardiovascular disease, we could state the problem that they had low intentions toward, and inadequate levels of, physical activity and physical fitness. The outcome measure for patients with cardiovascular risk factors was to expand their risk-reduction behavior. Intervention Mapping step 2 resulted in matrices with specific performance and change objectives, for both health professionals and patients, linked with important social-cognitive determinants. Intervention mapping step 3 resulted in the linking of important social-cognitive determinants of intention and behavior, performance and change objectives with theory-based methods, and conditions and strategies to use these methods based on results of previous studies [
Changing intentions and behavior among both health professionals and patients is a complex process with many inhibiting factors. By assessing the needs of both health professionals and patients, we defined important and changeable social-cognitive determinants. Using evidence-based behavior change techniques in the development process of the intervention was important because they provided insight regarding how social-cognitive determinants of health professionals and patients’ may be changed. It proved difficult in Intervention Mapping step 3 (theory-based methods and strategies) to tune in on both groups, health professionals and patients with cardiovascular risk factors. Also in Intervention Mapping step 4, the development of the Web-based intervention made this complicated. We designed a prototype of the website, and it took many revisions, especially for the modules directed at health care professionals, before completion. The ease-of-use of the website for the selected methods proved complicated, as was the interaction between modules. Although influencing the professional behavior for health professionals and the physical activity behavior for patients with cardiovascular risk factors is difficult to achieve, the Intervention Mapping protocol provided us with tools to handle this complicated process.
Although it is easy to conclude that when you want to change the health-related behavior of patients it is a prerequisite that health professionals are able to handle the process of behavior change, this proved difficult. Choosing a Web-based intervention showed many opportunities to handle this complicated process, in our view more than any other method, but it proved difficult to make the website easy to use without having to explain everything.
Furthermore, although we carefully developed and tested the Web-based intervention in close cooperation with health professionals and patients with cardiovascular risk factors, much of its success depends on its feasibility and usefulness in the health professionals’ daily practice and on whether there is sufficient time and expertise to use the intervention during the consultation period.
Consolidated Standards of Reporting Trials
Professional and Patient Intention and Behavior
short questionnaire to assess health-enhancing physical activity
The authors would like to thank Ir Lex Verheesen for his contribution in the development of the website.
None declared.