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Chronic diseases are the principal cause of morbidity and mortality worldwide. An increased consumption of vegetables and fruit reduces the risk of hypertension, coronary heart disease, stroke, and cancer. An increased fruit and vegetable (FV) intake may also prevent body weight gain, and therefore indirectly affect type 2 diabetes mellitus. Insufficient physical activity (PA) has been identified as the fourth leading risk factor for global mortality. Consequently, effective interventions that promote PA and FV intake in a large number of people are required.
To describe the systematic development of an eHealth intervention, MyPlan 1.0, for increasing FV intake and PA.
The intervention was developed following the six steps of the intervention mapping (IM) protocol. Decisions during steps were based upon available literature, focus group interviews, and pilot studies.
Based on needs assessment (Step 1), it was decided to focus on fruit and vegetable intake and physical activity levels of adults. Based on self-regulation and the health action process approach model, motivational (eg, risk awareness) and volitional (eg, action planning) determinants were selected and crossed with performance objectives into a matrix with change objectives (Step 2). Behavioral change strategies (eg, goal setting, problem solving, and implementation intentions) were selected (Step 3). Tablet computers were chosen for delivery of the eHealth program in general practice (Step 4). To facilitate implementation of the intervention in general practice, GPs were involved in focus group interviews (Step 5). Finally, the planning of the evaluation of the intervention (Step 6) is briefly described.
Using the IM protocol ensures that a theory- and evidence-based intervention protocol is developed. If the intervention is found to be effective, a dynamic eHealth program for the promotion of healthy lifestyles could be available for use in general practice.
Chronic diseases, such as cardiovascular disease, type 2 diabetes, and cancer, are the principal cause of morbidity and mortality worldwide, representing 68% of all deaths [
In this study, a dynamic eHealth intervention, MyPlan 1.0, was developed that targets self-regulation processes to increase PA and FV intake. To enhance reach and use, the intervention will be implemented in general practice. To ensure that MyPlan 1.0 is theory and evidence based, as well as feasible for implementation in general practice, the intervention mapping (IM) protocol was used as the planning model for the intervention [
The IM protocol consists of the following six steps: (1) needs assessment, (2) development of matrices of change, (3) selection of theory-based methods and practical applications, (4) description of the program production, (5) development of a program adoption and implementation plan, and (6) completion of an evaluation plan [
In Step 1, a planning group was established to ensure that the intervention targets important factors to increase effectiveness and sustained used of the eHealth intervention. Based on the needs assessment, we also selected the target behaviors in Step 1.
In Step 2, we adopted self-regulation theories to determine the intervention content and to formulate performance objectives. Different statements were formulated about how participants may achieve the intervention goals. These statements are specific actions that have to be taken by participants and are called performance objectives [
In Step 3, theory-based methods that can modify the selected determinants to achieve the performance objectives were determined. Matching methods were selected based upon the results of systematic reviews that summarized the effectiveness of behavior change methods for healthy eating and physical activity interventions. We also took into account the summary list published by Bartholomew et al [
In Step 4, an intervention plan was developed, based on the selected methods and practical applications. Previous programs that were effective were used as examples [
In Step 5, the implementation of the intervention was planned. Support by general practitioners has been shown to improve the use and the effect of computer-tailored programs [
The aim of this paper was to describe the intervention development. It is therefore not a research protocol of the trial, which is reported at ClinicalTrials.gov (trial registration number: NCT02211040). Therefore, in Step 6, we only specify the evaluation design and briefly describe the evaluation plan. We briefly describe the decisions made during each step of the IM protocol in the results section.
The planning group consisted of six researchers from different health disciplines—physical activity, nutrition, psychology, and primary health care—and leading GPs from the Belgian association of GPs, who are potential end users of the program. The core theories, methods, practical applications, implementation options, and evaluation strategies were discussed among this planning group.
Based on needs assessment, physical activity and fruit and vegetable intake were selected as target behaviors. Insufficient physical activity and unhealthy diet are two important risk factors of chronic diseases (eg, diabetes and ischemic heart diseases) and cancers (eg, breast and colon cancer) [
Adults are recommended to consume at least five portions or 400 grams of fruit and vegetables a day, and data from the World Health Survey showed that 78% of the adult population consumed less than five portions of fruit and vegetables daily [
The performance objectives for the target PA are shown in
Performance objectives for physical activity.
Phases | Performance objectives | |
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Goal selection, setting, and representation | |
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Performance objective 1 | Adults recognize the importance of increasing physical activity levels |
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Performance objective 2 | Adults decide to change their physical activity levels and set physical activity goals |
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Active goal pursuit | |
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Performance objective 3 | Adults choose their own strategies to change their physical activity levels |
|
Performance objective 4 | Adults start pursuing their physical activity goals |
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Performance objective 5 | Adults monitor and evaluate their physical activity levels |
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Performance objective 6 | Adults maintain or adapt their physical activity goals to a higher level |
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Performance objective 7 | Adults adapt their goals and strategies when they are unable to reach their initial goals |
The health action process approach model of Schwarzer [
All performance objectives, related change objectives, and determinants for the target behavior PA are shown in
In
To translate the methods into practical applications, we used study protocols of effective interventions [
Methods and practical applications used in the intervention for the motivational phase.
Methods | Determinants | Practical applications |
General information | Risk awareness | General information is provided in the form of short texts and slogans. In these texts and slogans, physical activity guidelines and health benefits of sufficient physical activity levels are highlighted. |
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Outcome expectancies | Adults can read information about physical activity and select the information that they are interested in on a website. They can, for example, select to read information about positive outcomes due to sufficient physical activity levels or information about the benefits of increasing physical activity levels. |
Monitoring, |
Risk awareness | After filling in a questionnaire about physical activity level, personal feedback is provided in which adults’ levels of physical activity are provided, as well as how these compare to the recommended level. |
Tailored feedback and |
Preaction self-efficacy | The tailored feedback includes stories about peers who succeeded in increasing physical activity levels, also in difficult situations. For example, “Eric (40 years old) decided to be more physically active in his free time, by walking in the local park for 30 minutes, three times per week. When it was raining, Eric decided to go swimming instead of walking.” |
Prompting identification of barriers and problem solving, and tailored feedback | Preaction self-efficacy | A predefined list of possible difficulties (barriers and risk situations) to increase physical activity level is provided and adults can select these difficulties that are applicable to them. Based on their answers, tailored information and tips for solutions to overcome the indicated barriers and risk situations are provided; adults can select those solutions to apply which they are confident about. |
Methods and practical applications used in the intervention for the volitional phase.
Methods | Determinants | Practical applications |
Selecting hindering factors/barriers and solutions |
Action planning |
Adults can first select hindering factors and barriers out of a predefined list. When applicable hindering factors and barriers are not available in the list, participants also have the possibility to write down another factor or barrier in an open-ended format. Next, participants can select solutions out of a predefined list or write down another solution. |
Goal setting | Action planning | A list with personal and relevant goals is formed based on previous answers; adults can select the goals to change that they are confident about. |
Stating SMARTagoals | Action planning | Adults are guided by questions to make a |
Public commitment | Social support | Adults can choose to send their action plan to others (eg, family and friends) to ask them to support them and invite them to also make an action plan. |
Prompt self-monitoring of behavior and prompt review of behavioral goals | Action planning |
Adults are asked to keep a record of their physical activity levels or fruit and vegetable intakes by one of the given suggestions (ie, personal paper agenda, mobile phone, Excel sheet, or online agenda). After the active goal pursuit was started, adults are also invited by email to report their behavior on the website. Periodic email reminders are sent to invite adults to fill out a questionnaire about the target behavior and their goals on the website. The results are compared with their previous behavior and goals, and iterative feedback is provided on the progress of behavior change. |
Set tasks on a gradient of difficulty | Maintenance self-efficacy | When adults have attained their goals, they are invited to change the goal by reformulating a more attainable or more difficult goal or by setting additional goals. |
Planning coping responses | Coping planning |
Adults are asked whether they experienced barriers while pursuing their goals. If so, they are invited to identify solutions to cope with the identified situations or barriers. Adults can again select solutions from a list that is generated based on the selected difficulties. |
Prompt review of behavioral goals and personal feedback | Recovery self-efficacy | When people do not achieve their goals, people get personal feedback that informs them that relapse is normal. They are also advised to try again, to choose other strategies, or to adapt their goals to more attainable goals. |
aSMART: specific, measurable, attainable, relevant, and time-bound.
MyPlan 1.0 was programmed in the freely available software LimeSurvey 2.0 [
In the first session, people fill out a questionnaire and receive tailored feedback about how their behavior compares to the health norms. Next, adults can select and read more information about the behavior (eg, in relation to diseases and health) and can make an action plan. To make an action plan, adults first have to indicate whether they expect difficulties in changing their health behaviors. If so, adults can select or formulate barriers and reflect upon possible solutions to overcome the barriers. Afterwards, adults can make an if/then plan and an action plan by reading tips and filling in questions about how, when, and where they will act on their behavior. Based on the answers, an action plan is generated by the computer’s algorithm (see
It is proposed that participants monitor their behavior when they start pursuing their goals, and are invited to send their action plan to friends or family. When session 1 is completed, the action plan is emailed to the participant. A week after adults make their action plan, they receive an email with a link to the website where they can evaluate whether their formulated goal was accomplished. The current behavior is compared with the previous behavior and health goals, and iterative tailored feedback is provided. Based on this feedback, participants can decide to further pursue their goal, or to adapt their goal to a more difficult or more attainable goal. Participants also have the opportunity to reflect on encountered difficulties and to search again for solutions. The last session has a similar structure as session 2, and is available 1 month after completing session 1. At the end of session 3, patients are also referred to the module
A further task in Step 4 is to test the feasibility, acceptability, and user-friendliness of the intervention [
Overview of the intervention program.
My Action plan: Example of an action plan for physical activity.
GPs who participated in the focus group interviews were positive about the use of a computer-tailored program that provides personal advice. GPs also appreciated that they did not need the expertise and time to compose personal advice for every patient, and may restrict their role to simply motivating and advising patients to use the intervention. However, doubts were raised on how to implement MyPlan 1.0 in general practice. By using tablets, MyPlan 1.0 patients can directly experience the use of the program and discuss their advice with their GP [
Decision tree for GPs: General practitioners can use the decision tree to decide on how to implement the intervention in general practice.
A clustered quasi-experimental trial with three conditions will be used to evaluate the intervention (see
In total, 30 adults will be selected in each of 15 general practices (n=450). First, a researcher will select 10 patients that will be allocated to the intervention group and 10 patients that will be allocated to the control group. Next, GPs will be asked to recruit another 10 patients to complete the intervention program. In this way, it can be evaluated whether GPs' involvement leads to more sustained use of the eHealth intervention, and higher levels of PA and FV intake. In both intervention groups, adults will be invited to complete session 1 either on a tablet in general practice or on their computer at home. Adults who do not use the tablet have to fill out a short questionnaire and leave their email address to be sent a reminder email to complete session 1 at home. After 1 week and 1 month of completing session 1, adults will receive an email to respectively start sessions 2 and 3. In the control group, adults will have to fill out a questionnaire at baseline in general practice or at home and at 1-month postintervention. To prompt adults to complete all questionnaires and sessions, reminder mails and SMS text messages will be sent. Inclusion criteria for participating in the study in both intervention and control groups are as follows: at least 18 years old, understand Dutch language, have an email address, and have access to the Internet. The outcome measures—increase in PA level, increase in FV intake, and self-regulation skills from baseline to postintervention—will be compared for the control and intervention conditions by conducting repeated measures multivariate analyses of variance (MANOVAs). Participant characteristics (ie, socioeconomic status [SES], age, sex, health status, and reaching health norms) will be compared at baseline. Characteristics that differ for the intervention and control groups will be added as covariates in further analyses. Furthermore, multilevel analyses will be conducted to take into account the clustering of participants into general practices.
Design of the clustered quasi-experimental trial: A clustered quasi-experimental trial with three conditions will be used to evaluate the intervention. Group 1 is an intervention group recruited by a researcher, Group 2 is a control group recruited by a researcher, and Group 3 is an intervention group recruited by a GP.
Using IM increases the likelihood of developing an effective eHealth intervention and the transparency of intervention components, which makes replication possible for future researchers [
Various eHealth interventions are based on motivational theories like the theory of planned behavior [
Self-regulation has recently been considered as a preferred method to overcome the intention-behavior gap and thus to promote health behavior [
A further strength of our study is the comprehensive involvement of GPs in Step 5—implementation in general practice—of the IM protocol. To ensure the feasibility of the implementation in general practice, we involved GPs from the start of the development of the intervention. During focus group interviews, important barriers for the implementation of the intervention in general practice were reported. For example, the time burden for GPs when participating in preventive actions was of major importance. Therefore, an intervention in which the personal advice was provided by a computer program was well appreciated. MyPlan 1.0 can prompt GPs to motivate their patients to adopt a healthy lifestyle, but GPs are not expected to provide extensive preventive counseling. However, some GPs will make more of an effort than others to motivate patients. Therefore, in the evaluation study all participating GPs will be asked to motivate patients to use the intervention program to set personal and attainable health goals, rather than to prescribe health recommendations and general information. Also of importance is the creation of different choices about how and when GPs may implement the intervention. Therefore, a decision tree and a list of practical solutions to implement the intervention via tablets and flyers in general practice was generated.
In Step 6—evaluation—it will be investigated whether the direct involvement of GPs in the program matters. More specifically, we will evaluate whether GPs’ involvement leads to more sustained use of the intervention and higher levels of PA and FV intake. Also, multilevel analyses will be conducted to control for the clustering of participants into different general practices. Furthermore, it will also be important to evaluate the quality of participants’ action plans because previous research has shown that action plans of participants can be of poor quality [
Following the IM protocol is a complex and time-consuming enterprise [
Performance objectives, their related change objectives, and their determinants for the target behaviors physical activity and fruit and vegetable intake.
School for Public Health and Primary Care
fruit and vegetable
Research Foundation-Flanders
general practitioner
intervention mapping
multivariate analysis of variance
physical activity
socioeconomic status
specific, measurable, attainable, relevant, and time-bound
short message service
The study was commissioned, financed, and steered by the Ministry of the Flemish Community, Department of Welfare, Public Health and Family. We would like to thank Armand De Clercq for his support in developing and programming the eHealth intervention. Furthermore, we also want to thank Linda Springvloet and Michel Walthouwer for giving insight into their program and to explain the different parts of their program. Maïté Verloigne is supported by the Research Foundation-Flanders (FWO) (postdoctoral research fellowship: FWO13/PDO/191).
JP developed the intervention and drafted the manuscript. IDB, GC, and MV supervised the development of the study, helped to draft the manuscript, and revised the manuscript for important intellectual content. AO participated in the development of the content of the intervention and also revised the manuscript for important intellectual content.
None declared.