abstract: 'Background: UK public health policy strongly advocates dietary change

  for the improvement of population health and emphasises the importance

  of individual empowerment to improve health. A new and evolving area in

  the promotion of dietary behavioural change is `e-learning'', the use of

  interactive electronic media to facilitate teaching and learning on a

  range of issues including health. The high level of accessibility,

  combined with emerging advances in computer processing power, data

  transmission and data storage, makes interactive e-learning a

  potentially powerful and cost-effective medium for improving dietary

  behaviour.

  Objective: This review aims to assess the effectiveness and

  cost-effectiveness of adaptive e-learning interventions for dietary

  behaviour change, and also to explore potential psychological mechanisms

  of action and components of effective interventions.

  Data sources: Electronic bibliographic databases (Cumulative Index to

  Nursing and Allied Health Literature, The Cochrane Library, Dissertation

  Abstracts, EMBASE, Education Resources Information Center, Global

  Health, Health Economic Evaluations Database, Health Management

  Information Consortium, MEDLINE, PsycINFO and Web of Science) were

  searched for the period January 1990 to November 2009. Reference lists

  of included studies and previous reviews were also screened; authors

  were contacted and trial registers were searched.

  Review methods: Studies were included if they were randomised controlled

  trials, involving participants aged >= 13 years, which evaluated the

  effectiveness of interactive software programs for improving dietary

  behaviour. Primary outcomes were measures of dietary behaviours,

  including estimated intakes or changes in intake of energy, nutrients,

  dietary fibre, foods or food groups. Secondary outcome measures were

  clinical outcomes such as anthropometry or blood biochemistry.

  Psychological mediators of dietary behaviour change were also

  investigated. Two review authors independently screened results and

  extracted data from included studies, with any discrepancies settled by

  a third author. Where studies reported the same outcome, the results

  were pooled using a random-effects model, with weighted mean differences

  (WMDs), and 95\% confidence intervals (CIs) were calculated.

  Cost-effectiveness was assessed in two ways: through a systematic

  literature review and by building a de novo decision model to assess the

  cost-effectiveness of a `generic'' e-learning device compared with

  dietary advice delivered by a health-care professional.

  Results: A total of 36,379 titles were initially identified by the

  electronic searches, of which 43 studies were eligible for inclusion in

  the review. All e-learning interventions were delivered in high-income

  countries. The most commonly used behavioural change techniques reported

  to have been used were goal setting; feedback on performance;

  information on consequences of behaviour in general; barrier

  identification/problem solving; prompting self-monitoring of behaviour;

  and instruction on how to perform the behaviour. There was substantial

  heterogeneity in the estimates of effect. E-learning interventions were

  associated with a WMD of +0.24 (95\% CI 0.04 to 0.44) servings of fruit

  and vegetables per day; -0.78g (95\% CI -2.5g to 0.95g) total fat

  consumed per day; -0.24g (95\% CI -1.44g to 0.96g) saturated fat intake

  per day; -1.4\% (95\% CI -2.5\% to -0.3\%) of total energy consumed from

  fat per day; +1.45g (95\% CI -0.02g to 2.92g) dietary fibre per day; +4

  kcal (95\% CI -85 kcal to 93 kcal) daily energy intake; -0.1 kg/m(2)

  (95\% CI -0.7 kg/m(2) to 0.4 kg/m(2)) change in body mass index. The

  base-case results from the E-Learning Economic Evaluation Model

  suggested that the incremental cost-effectiveness ratio was

  approximately 102,112 per quality-adjusted life-year (QALY). Expected

  value of perfect information (EVPI) analysis showed that although the

  individual-level EVPI was arguably negligible, the population-level

  value was between 37M pound and 170M pound at a willingness to pay of

  20,000-30,000 pound per additional QALY.

  Limitations: The limitations of this review include potential reporting

  bias, incomplete retrieval of completed research studies and data

  extraction errors.

  Conclusion: The current clinical and economic evidence base suggests

  that e-learning devices designed to promote dietary behaviour change

  will not produce clinically significant changes in dietary behaviour and

  are at least as expensive as other individual behaviour change

  interventions.

  Future work recommendations: Despite the relatively high EVPI results

  from the cost-effectiveness modelling, further clinical trials of

  individual e-learning interventions should not be undertaken until

  theoretically informed work that addresses the question of which

  characteristics of the target population, target behaviour, content and

  delivery of the intervention are likely to lead to positive results, is

  completed.'
affiliation: 'Edwards, P (Corresponding Author), London Sch Hyg \& Trop Med, Fac Epidemiol
  \& Populat Hlth, London WC1, England.

  Harris, J.; Felix, L.; Ferguson, E.; Free, C.; Edwards, P., London Sch Hyg \& Trop
  Med, Fac Epidemiol \& Populat Hlth, London WC1, England.

  Miners, A.; Lock, K., London Sch Hyg \& Trop Med, Fac Publ Hlth \& Policy, London
  WC1, England.

  Murray, E., UCL, Res Dept Primary Care \& Populat Hlth, London, England.

  Michie, S., UCL, Res Dept Clin Educ \& Hlth Psychol, London, England.

  Landon, J., Natl Heart Forum, London, England.'
author: Harris, J. and Felix, L. and Miners, A. and Murray, E. and Michie, S. and
  Ferguson, E. and Free, C. and Lock, K. and Landon, J. and Edwards, P.
author_list:
- family: Harris
  given: J.
- family: Felix
  given: L.
- family: Miners
  given: A.
- family: Murray
  given: E.
- family: Michie
  given: S.
- family: Ferguson
  given: E.
- family: Free
  given: C.
- family: Lock
  given: K.
- family: Landon
  given: J.
- family: Edwards
  given: P.
da: '2023-09-28'
doi: 10.3310/hta15370
eissn: 2046-4924
files: []
issn: 1366-5278
journal: HEALTH TECHNOLOGY ASSESSMENT
keywords-plus: 'TAILORED NUTRITION INTERVENTION; FAT INTAKE INTERVENTION; REDUCING

  RISK-FACTORS; PHYSICAL-ACTIVITY; RANDOMIZED-TRIAL; WEIGHT-LOSS;

  VEGETABLE CONSUMPTION; CARDIOVASCULAR RISK; SMOKING-CESSATION;

  SELF-EFFICACY'
language: English
month: OCT
number: '37'
number-of-cited-references: '122'
orcid-numbers: 'Michie, Susan/0000-0003-0063-6378

  Edwards, Phil/0000-0003-4431-8822

  Murray, Elizabeth/0000-0002-8932-3695

  Harris, Jody/0000-0002-3369-1253

  Felix, Lambert/0000-0001-6517-9089

  Free, Caroline/0000-0003-1711-0006'
pages: 1+
papis_id: ebc10dbd9ee3d9e0fb30bb6cdb58f96e
ref: Harris2011adaptiveelearning
researcherid-numbers: 'Michie, Susan/A-1745-2010

  '
times-cited: '56'
title: 'Adaptive e-learning to improve dietary behaviour: a systematic review and
  cost-effectiveness analysis'
type: Article
unique-id: WOS:000300462800001
usage-count-last-180-days: '0'
usage-count-since-2013: '77'
volume: '15'
web-of-science-categories: Health Care Sciences \& Services
year: '2011'