Digital health intervention at older ages
Authors: Martin Gulliford, Samah Alageel
Journal: The Lancet Digital Health (2019)

The potential of digital health intervention has increased rapidly through the widespread use of laptops, tablet computers, smart phones, and wearable devices. At the same time, our understanding how digital interventions can be theorised, and intervention components selected, to enhance intervention effectiveness has improved.1Michie S Yardley L West R Patrick K Greaves F Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop.J Med Internet Res. 2017; 19: e232Crossref PubMed Scopus (395) Google Scholar User-centred approaches to digital health intervention design can facilitate engagement with interventions for potential health benefit.2Yardley L Spring BJ Riper H et al.Understanding and promoting effective engagement with digital behavior change interventions.Am J Prev Med. 2016; 51: 833-842Summary Full Text Full Text PDF PubMed Scopus (445) Google Scholar Nevertheless, problems of low intervention use, high drop-out rates, and low efficacy continue to pose difficulties. Digital interventions might be of value in populations aged 65 years or older, in which long-term conditions are common and reduced mobility can lead to social isolation and loneliness, but digital exclusion remains an important concern. In the UK, 79% of all digitally excluded people are aged 65 years or older, and more than half of people older than age 75 years do not use the internet regularly.3Davidson S Digital inclusion evidence review 2018. London: Age UK.https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/age_uk_digital_inclusion_evidence_review_2018.pdfDate accessed: October 10, 2019Google Scholar Older people who do not use the internet have multiple markers of vulnerability, including lower income, living alone, mobility challenges, and difficulties with memory and concentration.3Davidson S Digital inclusion evidence review 2018. London: Age UK.https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/age_uk_digital_inclusion_evidence_review_2018.pdfDate accessed: October 10, 2019Google Scholar In The Lancet Digital Health, Edo Richard and colleagues4Richard E Moll van Charante EP Hoevenaar-Blom MP et al.Healthy ageing through internet counselling in the elderly (HATICE).Lancet Digital Health. 2019; (published online Nov 14)https://doi.org/10.1016/S2589-7500(19)30153-0Google Scholar report the results of the healthy ageing through internet counselling in the elderly (HATICE) trial, which investigated whether a coach-supported internet intervention to optimise self-management of risk factors could reduce the risk of cardiovascular disease in older people. The study included people aged 65 years or older who had access to the internet using a laptop, desktop computer, or tablet. The study had an anticipated participation rate of 10%.5Richard E Jongstra S Soininen H et al.Healthy ageing through internet counselling in the elderly: the HATICE randomised controlled trial for the prevention of cardiovascular disease and cognitive impairment.BMJ Open. 2016; 6e010806Crossref PubMed Scopus (63) Google Scholar The intervention included more than ten behaviour-change techniques, which is above the average number of seven behaviour-change techniques for digital interventions.6Yang CH Maher JP Conroy DE Implementation of behavior change techniques in mobile applications for physical activity.Am J Prev Med. 2015; 48: 452-455Summary Full Text Full Text PDF PubMed Scopus (111) Google Scholar These techniques included goal-setting behaviour, problem solving, social support, monitoring of behaviour by others, and self-monitoring of outcomes, which have proven effective in changing physical activity and healthy eating in older adults.7French DP Olander EK Chisholm A Mc Sharry J Which behaviour change techniques are most effective at increasing older adults' self-efficacy and physical activity behaviour? A systematic review.Ann Behav Med. 2014; 48: 225-234Crossref PubMed Scopus (277) Google Scholar The intervention design drew on Social Cognitive Theory, but the Stages of Change model is also discussed as a theoretical base for the coach-participant relationship. The restrictive eligibility criteria of the HATICE trial, and the intensity of the intervention, position Richard and colleagues' study as an explanatory trial. Nevertheless, the intervention had limited effectiveness over 18 months. Improvement in a composite Z score that combined systolic blood pressure, LDL cholesterol, and body-mass index (BMI) was reported (mean difference −0·05; 95% CI −0·08 to −0·01; p=0·008), but there was little evidence of effect for these measures individually (systolic blood pressure −1·12 mm Hg [–2·51 to 0·27]; LDL −0·05 mmol/L [–0·11 to 0·01]; BMI −0·15 kg/m2 [–0·28 to −0·01]), nor was there evidence of effect for smoking (−0·8, −2·0 to 0·4; p=0·21). The results are comparable to those observed in a non-randomised evaluation8Alageel S Gulliford MC Health checks and cardiovascular risk factor values over six years' follow-up: matched cohort study using electronic health records in England.PLoS Med. 2019; 16e1002863Crossref PubMed Scopus (21) Google Scholar of the National Health Service health check programme in England. These findings are also consistent with a systematic review9Alageel S Gulliford MC McDermott L Wright AJ Multiple health behaviour change interventions for primary prevention of cardiovascular disease in primary care: systematic review and meta-analysis.BMJ Open. 2017; 7e015375Crossref PubMed Scopus (36) Google Scholar of 31 trials done in primary care, which found that interventions that aimed to modify cardiovascular risk through individual-level intervention generally had very small effects. Many of the reviewed studies used less well designed interventions than the HATICE intervention. However, the high number of behaviour-change techniques used by the HATICE intervention might have increased its complexity without increasing its effectiveness. Interventions based on a combination of theories might increase the complexity of linking behavioural predictors and intervention components, making the process of applying theory to intervention planning ambiguous.10Michie S Prestwich A Are interventions theory-based? Development of a theory coding scheme.Health Psychology. 2010; 29: 1-8Crossref PubMed Scopus (472) Google Scholar Using fewer, but more effective, behaviour-change techniques linked to a single specific relevant theory might have increased intervention effectiveness. Richard and colleagues used sophisticated intervention design techniques and did a rigorous multinational evaluation, with the involvement of end users throughout intervention development. This digital intervention has the potential to provide ongoing engagement and professional support, which might lead to long-lasting behaviour change. However, the results of their study identify important questions for the design of future digital interventions. First, the low overall participation raises questions concerning the population-level effect of digital interventions. The effect of these interventions on inequalities is a major concern in the context of digital exclusion. Disparities are a concern not only in relation to basic levels of access, but digital inequalities also arise in relation to skills, participation, and efficacy among users. Second, this type of intervention might be most effective for traits that are under individual regulation. Cardiovascular risk factor values might result from the cumulative effect of multiple exposures over the life course and are also influenced by community-level and population-level determinants. Individual-level interventions require support from wider community-level actions, suggesting that digital interventions might often provide one strand in an overall intervention strategy. We declare no competing interests. Healthy ageing through internet counselling in the elderly (HATICE): a multinational, randomised controlled trialCoach-supported self-management of cardiovascular risk factors using an interactive internet intervention is feasible in an older population, and leads to a modest improvement of cardiovascular risk profile. When implemented on a large scale this could potentially reduce the burden of cardiovascular disease. Full-Text PDF Open Access