The Promise and Ambiguity of eHealth Research

Editorial
The Promise and Ambiguity of
eHealth Research
Lisa M. Lewis
C
hronic illness, although preventable and frequently
manageable, accounts for most of the deaths in the
United States (Centers for Disease Control and Prevention, 2013). Adopting healthy behaviors such as physical
activity, nutrition, smoking cessation, and medication adherence is imperative to reducing the burden of morbidity and
mortality associated with preventable illnesses. Early interventions targeted at improving these behaviors have proven
somewhat successful, and for some individuals, we saw modest improvements in the health of Americans. However, the
development and implementation of behavioral interventions
remained as a public health challenge. Since then, we have
learned that it is important to address the specific reasons
for which an individual may not be able to adopt and adhere
to health-promoting behaviors. We moved from the “onesize-fits-all” approach to the development of tailored interventions for promoting behavioral change.
Tailored interventions are more likely to enhance the
adoption of healthy behaviors because they are assessment
based, taking into account personal data and determinants
in order to determine the most effective strategies that meet
an individual’s needs (Kreuter, Farrell, Olevitch, & Brenna,
2000). The result is a message that is more likely to be viewed
as personally relevant, to be remembered, and to increase the
individual’s motivation to perform healthy behavior. And, indeed, evidence from a meta-analysis conducted by Noar,
Benac, and Harris (2007) suggested that tailored interventions
seem to be more effective in improving healthy behaviors
when compared to standard nontailored interventions.
A growing eHealth field has chartered a new course for
tailored interventions and a course that seems to have a limitless potential. eHealth is generally defined as the use of information and communication technologies for health promotion,
disease prevention, and disease management (Eng, 2001;
World Health Organization, 2006). The Internet, computerbased technologies, electronic health records, and videoconferencing are examples of commonly used eHealth methods
to deliver health behavioral interventions. A systematic review (Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood,
2006) highlighted several reasons for the delivery of behavioral interventions via eHealth. The reasons identified were
(a) reduction in delivery costs, (b) reduction in geographically
based barriers, and (c) convenience for users. Thus, eHealth
for intervention delivery seems promising for improving
Nursing Research
health and wellness, but a closer look at the literature reveals
that there are some ambiguous areas of eHealth research and
some unanswered questions that require further exploration.
The precise meaning of eHealth does not appear to be
clear. Even though the World Health Organization and others
have provided researchers with a standard definition of eHealth,
there is no clear consensus about the meaning of the term in
the literature. The meaning of eHealth varies by institution,
funding organizations, and the context in which the term is used,
lending itself to communication difficulties among the entities
that use the term. Fortunately for us, two universal themes common to eHealth definitions are identified in a systematic review
of 51 definitions (Oh, Rizo, Enkin, & Jadad, 2005). The universal
themes were health and technology. According to the authors,
health was mainly used in reference to health services and delivery whereas technology was used both as a tool to enable process
and as an embodiment of eHealth (e.g., health website, personal digital assistants, and interactive television). Themes less
mentioned in the review were commerce, activities, stakeholders, outcomes, place, and perspectives. Yet, questions remain concerning how the different concepts may influence
different stakeholders. Oh et al. (2005) posed the following
questions: What do individuals expect when they hear that
an intervention is an eHealth intervention? And, how does
eHealth change the nature of relationships and interactions
in the healthcare system?
Another area for researchers to consider concerns behavioral change sustainability. As is the case with traditional behavioral interventions, eHealth interventions do not seem to
sustain behavioral change once the intervention is completed.
For example, intervention effects were reported to peak from
4 to 12 months post baseline but begin to decline after
12 months based on a meta-analysis assessing the mean effect
for 88 eHealth interventions (Krebs, Prochaska, & Rossi, 2010).
Helping individuals maintain their behavioral change is warranted post eHealth intervention and leaves us to ponder
one major question regarding sustained behavioral change:
Are the actual eHealth interventions sustained once the programs are completed?
eHealth design features need further exploration. For example, variations seen in the outcomes for eHealth interventions are partly the result of the type of design features used
in the interventions. A systematic review of 52 published reports highlighted 4 of 11 interactive eHealth features that
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The Promise and Ambiguity of eHealth Research
may mediate the effects of the intervention design on outcomes (Morrison, Yardley, Powell, & Michie, 2012). The four
features are social context and support, contacts with the
intervention, tailoring, and self-management. Social context
and support facilitate individuals’ perceptions of their human
or human-like interaction. Contacts with intervention were either expert-initiated or user-initiated and provide the means in
which the individual interacts with the intervention. Tailoring
provides relevant information matched to the individual or
groups. Self-management is the use of personal information
for reflective monitoring. Because some of these design features are not specific to eHealth interventions, Morrison et al.
(2012) urged researchers to consider some of the following
unanswered questions for a fuller understanding of how and
why these features work. What are the mechanisms that make
each of these four features effective? Why is it that user-initiated
contacts (e.g., ask the experts) seem to have little influence on
intervention outcomes? Are self-management strategies more
effective when they are structured or unstructured?
The eHealth research field is becoming well established,
and with its burgeoning body of literature comes areas that call
for clarification. The ambiguous components of eHealth—its
definition, intervention sustainability, and characteristics of its
effective design features—are challenges for future research.
The field is well poised for and could benefit from published
reports that document important information such as intervention details, descriptions of the development and implementation of interventions, and stakeholder expectations of
eHealth interventions. Indeed, these unanswered questions
pose an exciting opportunity for nursing scientists and make
eHealth research ambiguous and promising at the same time.
Lisa M. Lewis is Editorial Board Member, Nursing Research.
The author has no conflicts of interest to disclose.
www.nursingresearchonline.com
Corresponding author: Lisa M. Lewis, PhD, RN, FAAN, Department of
Family and Community, School of Nursing, University of Pennsylvania, 418
Curie Blvd., Philadelphia, PA 19104-4217 (e-mail: lisaml@nursing.upenn.edu).
DOI: 10.1097/NNR.0000000000000097
REFERENCES
Centers for Disease Control and Prevention. (2013). Death and mortality.
Retrieved from http://www.cdc.gov/nchs/fastats/deaths.htm
Eng, T. R. (2001). The eHealth landscape: A terrain map of emerging
information and communication technologies in health and
health care. Princeton, NJ: Robert Wood Johnson Foundation.
Griffiths, F., Lindenmeyer, A., Powell, J., Lowe, P., & Thorogood, M.
(2006). Why are health care interventions delivered over the internet? A systematic review of the published literature. Journal of
Medical Internet Research, 8, e10. doi: 10.2196/jmir.8.2.e10
Krebs, P., Prochaska, J. O., & Rossi, J. S. (2010). A meta-analysis of
computer-tailored interventions for health behavior change.
Preventive Medicine, 51, 214–221. doi: 10.1016/j.ypmed.2010
.06.004
Kreuter, M. W., Farrell, D., Olevitch, L., & Brenna, L. (2000). Tailoring health messages: Customizing communication with computer technology. Mahwah, NJ: Erlbaum.
Morrison, L. G., Yardley, L., Powell, J., & Michie, S. (2012). What
design features are used in effective e-Health interventions? A
review using techniques from critical interpretive synthesis. Telemedicine Journal and e-Health, 18, 137–144. doi: 10.1089/tmj
.2011.0062
Noar, S. M., Benac, C. N., & Harris, M. S. (2007). Does tailoring matter?
Meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin, 133, 673–693.
Oh, H., Rizo, C., Enkin, M., & Jadad, A. (2005). What is eHealth? A systematic review of published definitions. Journal of Medical Internet Research, 7(1), e1.
World Health Organization. (2006). Building foundations for eHealth:
Progress of member states: Report of the Global Observatory for
eHealth. Retrieved from http://www.who.int/goe/publications/
bf_FINAL.pdf
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.