Murray Elizabeth
e-Health Unit Research Department of Primary Care and Population Health University College London London United Kingdom.
Med 2 0. 2012 Aug 14;1(2):e3. doi: 10.2196/med20.1741. eCollection 2012 Jul-Dec.
The potential advantages of using the Internet to deliver self-care and behavior-change programs are well recognized. An aging population combined with the increasing prevalence of long-term conditions and more effective medical interventions place financial strain on all health care systems. Web-based interventions have the potential to combine the tailored approach of face-to-face interventions with the scalability of public health interventions that have low marginal costs per additional user. From a patient perspective, Web-based interventions can be highly attractive because they are convenient, easily accessible, and can maintain anonymity/privacy. Recognition of this potential has led to research in developing and evaluating Web-based interventions for self-management of long-term conditions and behavior change. Numerous systematic reviews have confirmed the effectiveness of some Web-based interventions, but a number of unanswered questions still remain. This paper reviews the progress made in developing and evaluating Web-based interventions and considers three challenging areas: equity, effectiveness, and implementation. The impact of Web-based interventions on health inequalities remains unclear. Although some have argued that such interventions can increase access to underserved communities, there is evidence to suggest that reliance on Web-based interventions may exacerbate health inequalities by excluding those on the "wrong" side of the digital divide. Although most systematic reviews have found a positive effect on outcomes of interest, effect sizes tend to be small and not all interventions are successful. Further work is needed to determine why some interventions work and others do not. This includes considering the "active ingredients" or mechanism of action of these complex interventions and the context in which they are used. Are there certain demographic, psychological, or clinical factors that promote or inhibit success? Are some behaviors or some clinical problems more amenable to change by computer-based interventions? Equally problematic is the issue of implementation and integration of such programs into routine clinical practice. Many eHealth projects end when the research is concluded and fail to become part of mainstream clinical care. One way of addressing these challenges is to apply the Medical Research Council framework for developing, evaluating, and implementing complex interventions. This includes having a strong theoretical foundation, developing a proposed mechanism or pathway of action, ensuring that the evaluation adequately reflects this proposed pathway, and considering implementation from the beginning of the development process.
利用互联网提供自我护理和行为改变计划的潜在优势已得到广泛认可。人口老龄化，加上长期疾病的患病率不断上升以及更有效的医疗干预措施，给所有医疗保健系统带来了财政压力。基于网络的干预措施有可能将面对面干预的个性化方法与公共卫生干预措施的可扩展性相结合，后者对新增用户的边际成本较低。从患者的角度来看，基于网络的干预措施可能极具吸引力，因为它们方便、易于获取，并且可以保持匿名性/隐私性。认识到这种潜力促使人们开展研究，以开发和评估用于长期疾病自我管理和行为改变的基于网络的干预措施。许多系统评价证实了一些基于网络的干预措施的有效性，但仍有一些未解决的问题。本文回顾了在开发和评估基于网络的干预措施方面取得的进展，并考虑了三个具有挑战性的领域：公平性、有效性和实施。基于网络的干预措施对健康不平等的影响仍不明确。尽管有人认为此类干预措施可以增加服务不足社区的可及性，但有证据表明，依赖基于网络的干预措施可能会通过排除那些处于数字鸿沟“错误”一侧的人而加剧健康不平等。尽管大多数系统评价发现对感兴趣的结果有积极影响，但效应大小往往较小，而且并非所有干预措施都成功。需要进一步开展工作，以确定为何有些干预措施有效而有些无效。这包括考虑这些复杂干预措施的“活性成分”或作用机制以及使用它们的背景。是否存在某些人口统计学、心理学或临床因素会促进或抑制成功？某些行为或某些临床问题是否更适合通过基于计算机的干预措施来改变？同样成问题的是此类计划在常规临床实践中的实施和整合问题。许多电子健康项目在研究结束时就结束了，未能成为主流临床护理的一部分。应对这些挑战的一种方法是应用医学研究理事会制定、评估和实施复杂干预措施的框架。这包括拥有坚实的理论基础，制定提议的作用机制或途径，确保评估充分反映这一提议的途径，并从开发过程一开始就考虑实施问题。
