This report demonstrates that a relatively complex, fully automated dietary behavior change program that integrates multiple interactive technologies can be developed and successfully implemented within the context of a real-world health delivery system. Possibly because of the prior experience of the collaborators in both dietary change and interactive technology projects, the development process went relatively smoothly. One key to having an attractive, easy-to-use and understandable end product was allowing adequate time to pilot the initial version of the program, to fully test the various data exchange interfaces and to make modifications based upon pilot feedback.
Both the automated and staff-assisted conditions were consistently implemented and rated as helpful by participants. The IVR aspects of the program were delivered somewhat less consistently and rated somewhat lower than the CD-ROM program components, possibly reflecting our team's greater experience with CD-ROM modalities. If later outcome data demonstrate that the automated program is effective in producing dietary changes, it appears that the WISE CHOICES intervention may be a scalable, relatively low-cost method of delivering behavior change services relative to in-person counseling. Obviously, future research is needed to document program effectiveness at both short-term and longer term follow-ups and the intervention costs.
These preliminary data suggest that it may be possible to fully automate health behavior change interventions. Our implementation and user satisfaction results suggest that CD-ROM elements worked very well, but that the IVR aspects of the program could be enhanced or possibly that some follow-up activities should be conducted by staff to enhance the connection of users to the clinical setting offering the program.
Other lessons learned include the advantage of delivering health education information and behavioral strategies via multiple redundant channels (e.g. text, video models and voice-over narration) to provide benefit for a wide range of users. The use of a central database to coordinate various intervention modalities also worked well and proved to be both robust and secure. In WISE CHOICES, we did not allow users to select different modalities, but rather decided upon the best technology for each intervention purpose (e.g. initial motivation, later follow-up, active problem-solving, goal monitoring). Future research may want to experiment with providing users their choice of modalities (e.g. Web versus IVR versus in-person) for components such as follow-up contact.
The satisfaction data suggest that the menu of strategies provided were seen as relevant to this target population. Although used infrequently, the write-in option may be important because having the option of further personalizing one's action plan—regardless of whether it is actually used—may contribute to perceptions of relevance and control. Unlike some interactive technology-based programs that completely tailor user strategies, we attempted to balance theoretical and experience-based suggestions with provision of choices for users. We feel that this element of user-tailoring adds value to the program.
The various technologies used in WISE CHOICES
all had strong ‘reach’ [19
], but the CD-ROM component did require participants to come to a clinic to complete the two action planning sessions. We chose to use CD-ROM rather than Internet because we did not want to limit participation to health plan members who had high-speed computer access, but future investigations may want to investigate mailed DVD or Internet-delivery options, especially as part of patient portals offered by an increasing number of health plans and organizations such as the Veterans Administration [20
In conclusion, we encourage future projects to explore multi-media programs that combine different technologies in creative and integrated ways, rather than relying on a single technology/modality to carry the entire weight of the intervention [22
]. Other future directions include testing different program variations to identify the optimal and most cost-effective use of human contact and the impact of interactive technology programs on the behavior of different patient subgroups (e.g. across levels of education, race/ethnicity computer experience and health literacy).