Evaluation of national interventions to promote physical activity in Switzerland with a focus on internet-based approaches

Background: The importance of physical activity for health is well documented in the literature: Reduced overall mortality, reduced risks of cardiovascular disease, colon cancer, and type 2 diabetes are just a few of the known positive effects. However, in Switzerland only 41.1% of adults adhere to the health-enhancing physical activity recommendations. Therefore, effective interventions are needed to increase physical activity levels. Two national interventions in Switzerland targeting adults are Allez Hop, a more traditional approach offering local physical activity courses once a week during a three-month period, and Active-online (www.active-online.ch), a Web-based individually tailored programme. Evaluation should play an important role in the development and implementation of health promotion programmes, however, there is no great tradition of evaluating physical activity interventions in Switzerland. Moreover, not much is known about the effectiveness of computer-tailored interventions when they are delivered in a real-life setting over the Internet. The overall goal of this PhD thesis was to evaluate Active-online in a formative and summative way, and to contrast these scientifically thorough approaches with more pragmatic evaluation approaches used to evaluate Allez Hop. Methods: A review of the literature was carried out regarding the effectiveness of computer-tailored interventions. For the summative evaluation, a randomised controlled trial (RCT) with 1531 volunteers was conducted over the Internet to assess the effectiveness of Active-online compared to a nontailored information website in a real-life setting. Information on physical activity levels was collected at baseline, and 6 weeks, 6 months and 13 months after baseline by self-report (using an online questionnaire) and objectively (using accelerometers in a subsample, N=133). In terms of formative evaluation, data on user characteristics and patterns of intervention use (adherence, attrition, and predictors of repeated intervention use) were analysed from 2003 to 2009 and compared between open access users and RCT participants. The different evaluation approaches used to evaluate Allez Hop during its implementation period (1997 to 2008) were summarised. The most recent step was the introduction of routine Allez Hop course evaluations using a semiautomated Web-based approach, providing a feedback report to course instructors. The feasibility of the Web-based tool was first tested in a pilot study and then in an open setting. The question of a population impact of Allez Hop was approached analysing data from a one sample pretest posttest evaluation survey carried out in course participants in 2005 and data from repeated cross-sectional representative population-based surveys. Results: The literature regarding the effectiveness of Web-based tailored physical activity interventions was scarce. The few existing studies were mostly carried out in a controlled setting. Evidence on the efficacy in these controlled studies was equivocal. According to our RCT, Active-online was not more effective in increasing self-reported physical activity levels compared to the nontailored website, and the self-reported increases observed in all groups were not supported by accelerometer data. Analysis of user data revealed that the individual use of Active-online was low in RCT participants but also in open access users. Regarding Allez Hop, several evaluations were conducted on different levels (course participants, instructors, partners, stakeholders, population) between 1997 and 2008. More than 18 000 courses were realised attracting around 200 000 participants over a decade. Around 90% of course participants were women with a mean age of just under 50 years. The programme has succeeded in reaching a high proportion of insufficiently active individuals (around 70% in 2005) and has reached a high degree of acceptance and appreciation both in participants and in the general population. The Web-based routine course evaluation tool proved to be feasible. Evidence on the effectiveness of Allez Hop based on repeated data assessments in course participants in 2005 was limited due to methodological problems. However, changes in physical activity at the population level between 1997 and 2007, especially in the main user group of Allez Hop (middle-aged women), and large increases in the proportion of individuals regularly walking (one of the main course disciplines), indicated a potential "Allez Hop effect". Conclusions: Active-online and Allez Hop are among the best-evaluated national physical activity promotion programmes in Switzerland. Even though the programmes and the evaluation approaches differ, both evaluations have contributed valuable information for the development and optimisation of the programmes. Our RCT was one of the first studies which assessed the effectiveness of an intervention like Active-online in a real-life setting using a minimal contact strategy, open access online delivery of the intervention, and online assessment of baseline and follow-up data. The findings from these evaluation studies highlight the potential and the limitations of Web-based physical activity interventions. Approaches used in the evaluation of Allez Hop, which started as an implementation and not as a research project, may be described as pragmatic. The evaluation of population-based public health programmes is associated with specific methodological challenges, and thorough designs like RCTs are mostly not feasible. Therefore, researchers are encouraged to use other approaches for the evaluation of such programmes, and it is recommended that evaluation should be an integral part of future physical activity promotion projects in Switzerland both during development and implementation.