Health Education Research, Vol. 14, No. 2, 249-256,
April 1999
© 1999 Oxford University Press
Computer-tailored nutrition education: differences between two interventions
Department of Social Sciences, Netherlands Open University, PO Box 2960, 6401 DL Heerlen, The Netherlands,
1 Department of Health Education and Health Promotion, University of Limburg, PO Box 616, 6200 MD Maastricht,
2 The Netherlands and
3 Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI 96813, USA
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Abstract |
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The impact of two computer-tailored nutrition education interventions was assessed and compared in a randomized trial among 315 subjects with a pre-test–post-test comparison group design. Respondents in both the experimental and the comparison group received feedback tailored to their consumption of fat, fruit and vegetables. Respondents in the experimental group received additional psychosocial feedback tailored to their attitudes, perceived social support and self-efficacy expectations towards reducing their fat consumption and increasing their consumption of fruit and vegetables. A significant reduction in fat consumption and increase in the consumption of fruit and vegetables were found in both the experimental and the comparison group between pre-test and post-test. Respondents in the experimental group more often indicated that the feedback they received was interesting and easy to understand. Respondents in the comparison group more often reported having reduced their fat consumption because of the feedback they received. No significant differences in consumption of fat, fruit and vegetables were found at post-test between the experimental group and the comparison group. These results do not support the hypothesis that additional psychosocial information is an essential component of effective tailored feedback. The results indicate that tailored feedback might be effective in inducing dietary changes.
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Introduction |
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Diets high in fruit and vegetables and low in fat are associated with lower risk for chronic diseases, particularly cardiovascular disease and some cancers (Willett, 1994
). However, in the Netherlands, as well as in other European countries and the US, a high proportion of the populations eat more fat than is recommended (Hulshof et al., 1994; Subar et al., 1994). Furthermore, for most people fruit and vegetable intake does not meet the recommended daily intake levels (Block, 1991; Hulshof et al., 1994).
In the Netherlands, a number of different nutrition education approaches have been used in order to encourage people to adopt healthier diets. Important dietary problems in relation to primary prevention of the most common chronic diseases are present among a majority of the population. As a result, most nutrition education interventions have been designed to reach large population groups and often use mass media educational materials. Four consecutive nationwide mass media nutrition education campaigns were found to be unsuccessful in motivating the majority of Dutch people with high fat diets to reduce their fat consumption. Probably one of the main reasons for this lack of success was derived from the evaluation studies and from additional research. It has become clear that many Dutch people are not aware of their high fat intakes and that awareness of personal dietary risk behavior is an important determinant of motivation to change (Brug et al., 1994; Riedstra et al., 1994).
Therefore, nutrition education tools have been designed to make it easy for people to compare their dietary intake with dietary recommendations.
A recent development in personalized nutrition education is the use of `computer-tailored feedback' (Campbell et al., 1994; Brug et al., 1996). By means of computer-tailored feedback, subjects are provided with nutrition education information that is relevant to their personal (dietary) habits and/or personal beliefs toward healthy eating. There are clear indications that when health education is individualized by tailoring information to personal behavior, needs and/or beliefs of subjects, it is evaluated more positively and may be more effective than providing subjects with general health education (Campbell et al., 1994; Strecher et al., 1994; Brug et al., 1996).
The process of computer tailoring is similar to person-to-person patient counseling. Individual subjects are interviewed or surveyed (`screened') and the results are used to develop an individual treatment plan, behavior change plan or dietary advice. In computer tailoring the expertise of the nutrition educator is programmed into a computer which reads the (coded) survey responses and generates individualized feedback messages.
There is a great variety of variables that can be included in the screening tool as a basis for generating tailored feedback. In the studies on personalized dietary feedback that have been published to date, feedback has been provided on dietary intake levels, dietary patterns, psychosocial factors such as outcome expectancies and self-efficacy expectations and/or stages of change (Bowen et al., 1994; Campbell et al., 1994; Brug et al., 1996). It is still unclear what specific feedback elements are necessary in order to realize dietary changes.
In a study on the effects of personalized dietary feedback without additional psychosocial information, Bowen et al. (Bowen et al., 1994) reported that subjects with the highest fat consumptions who received feedback about their fat consumption were least likely to intend to reduce their fat intake. In two other studies that have been reported on the effectiveness of (computer-) tailored nutrition education, a combination of dietary feedback and psychosocial information was given. Both studies showed that these tailored interventions were effective in inducing dietary changes (Campbell et al., 1994; Brug et al., 1996). Based on the literature to date, one could hypothesize that supplementing personalized dietary feedback with psychosocial information is necessary in order for the feedback to be effective in motivating subjects to change their diets.
In the present study, the effects of two computer-tailored nutrition education interventions were compared in a randomized trial. The first intervention (comparison group) provided subjects with personal letters with tailored dietary feedback about fat, fruit and vegetables only. In the second intervention (experimental group), tailored letters with dietary feedback was supplemented by feedback about personal outcome expectancies, perceived social influences and self-efficacy expectations. This second intervention has been tested before in a randomized trial in which its impact was compared to general nutrition information (Brug et al., 1996). The results of this study showed that the comprehensive tailored nutrition information letters were more effective in inducing a reduction in fat consumption than personal letters with general nutrition information.
It was hypothesized that both tailored letters would have a significant impact on the reduction of fat intake and increases in fruit and vegetable consumption. Furthermore, it was hypothesized that, compared with the subjects in the comparison group, subjects in the experimental group would:
- Judge the tailored feedback letters more positively.
- Increase their intentions to reduce their fat intake and their intentions to increase fruit and vegetable intake more.
- Decrease their consumption of fat and increase their consumption of fruit and vegetables more.
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Methods |
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Three inter-related elements are necessary for providing subjects with computer-tailored nutrition education:
- A screening instrument with which it is possible to assess the variables on which the tailored feedback will be based.
- A message source file with feedback messages tailored to all possible screening results.
- A computer program that selects specific feedback messages for each individual subject from the source file based on the subject's screening results.
The screening questionnaire
A self-administered written questionnaire, which consisted of a total of 102 items, was used as a screening tool. The questionnaire took about 20 min to complete. The first part of the questionnaire consisted of a food-frequency questionnaire with which it is possible to assess consumption of fat, fruit and vegetables in a valid and reliable way. Specific information about the validity of the food-frequency questionnaire has been published elsewhere (van Assema et al., 1993;, Brug et al., 1995b). From the food-frequency questionnaire a fat score can be computed that ranges between 12 and 60. This score can be used in order to rank subjects according to absolute fat intake and to detect changes in fat consumption over time (van Assema et al., 1993). For fruit and vegetable consumption the number of servings per day could be computed (,Brug et al., 1995b).
In the second part of the questionnaire the subjects were asked about possible outcome expectancies (taste, amount of effort, price and several health consequences) of reducing fat intake and increasing fruit and vegetable consumption that together were supposed to reflect the respondents attitudes. Furthermore, items were included about the perceived social influence of important others [spouse, (other) household members, colleagues] and self-efficacy expectations. The latter were assessed by asking subjects how confident they were about being able to reduce their fat intake and increase their fruit and vegetable consumption in general and in different difficult situations (eating out, eating snacks, at parties). Finally, questions were included about how subjects rated their level of consumption of fat, fruit and vegetables, and questions about the subjects' intentions to reduce their fat intake and increase their fruit and vegetable consumption. All questions on these psychosocial factors could be answered on seven-point scales. Attitudes, social influences, self-efficacy expectations and self-rated intake have been repeatedly identified as important psychosocial determinants of dietary behavior (Stafleu et al., 1991; Raats et al., 1993; Sheeka et al., 1993; Brug et al., 1994, 1995b). The psychosocial questionnaire was based on focus group interviews (van Assema et al., 1993; Brug et al., 1995a). The psychosocial questions have been used before, and proved to be significant correlates of intention and dietary intake (Brug et al., 1994, 1995b).
The message source file
The message source file consisted of 223 different feedback messages. The messages could be divided into two categories: dietary feedback and psychosocial feedback.
Different dietary feedback messages were written for various categories of dietary behavior for fat, fruit and vegetables. For example, for fat, the source file included messages for subjects eating more fat than is recommended, for subjects eating more fat than is recommended as well as more than their peer group average fat consumption and for subjects who were eating according to the recommendations for fat. Further messages were included that addressed six different possibly important dietary fat sources (milk and milk products, meat and meat products, spreads, cheese, hot snacks, and sweet snacks) in which low-fat alternatives for high-fat choices were suggested. Fat scores of 22 for women and 25 for men were used as operationalizations of the upper levels of the Dutch recommended intake of 35% energy from fat. Fruit and vegetables messages were included for subjects eating less than the recommended amount of fruit and vegetables and subjects eating according to recommendations. One serving of vegetables per day and two pieces of fruit per day were used to operationalize the Dutch recommendations (200 g of vegetables and two pieces of fruit per day). Messages also included suggestions on how to eat more fruit and vegetables during meals and for snacks. Subjects were advised to change their dietary behaviors that were not in accordance with recommendations and to sustain their dietary behaviors that were according to recommendations.
In order to provide subjects with psychosocial feedback, messages were included in the source file that addressed possible negative outcome beliefs and messages meant to sustain positive outcome expectancies of fat reduction. For subjects who did not expect social support for fat reduction a message was included with suggestions on how to cope with a negative social environment. For subjects with low self-efficacy expectations in certain situations (when eating out, at parties, etc.), messages were included with suggestions on how to cope with these situations. Similar feedback alternatives were included in the messages source file for psychosocial feedback related to fruit and vegetable consumption.
The tailoring computer program
A computer program was written in Turbo Pascal which linked individual screening results to specific feedback messages from the source file. For this purpose each different message was given a unique code. The program consisted mainly of a number of so-called `IF–THEN statements'. These statements were the decision rules for the selection of specific feedback messages from the source file for individual subjects based on their answers on the screening questions. Further, the program controlled the creation and printing of personal feedback letters from the selected messages.
In both interventions subjects received personal tailored feedback letters, mailed to their home addresses. The letters for both interventions were printed on identical paper that was specially designed for the tailored nutrition education letters. In both interventions the name of the subject was printed in the letter's introduction and in the final paragraph of the tailored letter. In both types of tailored letters similar illustrative cartoons were used and similar recipes for low-fat meals were included.
The control intervention provided subjects only with dietary feedback about their fat, fruit and vegetable consumption as compared to recommended dietary intake levels and suggestions on how to make healthier choices based on the person's dietary habits. In the experimental intervention the dietary feedback was supplemented with psychosocial information tailored to the subjects' individual attitudes, perceived social support and self-efficacy expectations.
Study design and procedures
The study was conducted among a predominantly female population of employees of a regional organization for home care. The screening questionnaires were distributed to 696 employees by 36 middle managers. Subjects were randomly assigned to the experimental or control intervention. The screening questionnaire was returned by 347 respondents (50% response), of which 170 were assigned to the experimental group and 177 to the control group. Respondents who completed the screening questionnaire received their tailored nutrition information letter at their home address approximately 2 weeks after returning the screening questionnaire. Between 3 and 4 four weeks later a second questionnaire was mailed to the home addresses of the respondents. This questionnaire was similar to the screening questionnaire but a number of questions that were used solely for tailoring purposes and not as impact measures were left out. Additional questions were included about the respondents' reactions to the tailored letters they received.
The post-test questionnaire was completed and returned by 315 subjects (152 in the experimental group and 163 in the comparison group). All analyses were conducted among these 315 subjects who completed both questionnaires (91% of the subjects who completed the baseline screening, 45% of the original sample).
Statistical analysis
Differences between the experimental group and the comparison group at baseline in gender distribution, education, age, intentions, consumption of fat, fruit and vegetables, and self-rated intake were tested with 
2 tests or analysis of variance.
Analyses of variance were used to test for differences in consumption of fat, fruit and vegetables, and differences in intentions between baseline and post-test. Since respondents who had high fat intake or low intake of fruit or vegetables at baseline were most strongly advised to change, the changes among these respondents were of special interest. Therefore, the differences between baseline and post-test were analyzed separately for these subjects.
Differences in the subjects' reactions to the tailored letters between the experimental group and the comparison group were also tested with 2 tests or with analyses of variance.
Finally, in order to test for differences in intervention effects between the experimental group and the comparison group, analyses of co-variance were conducted, testing for significant differences at post-test in fat consumption-per-day scores, servings of vegetables and fruit per day, intentions to reduce fat consumption, and intentions to increase fruit and vegetable consumption, while adjusting for baseline levels and other possible confounding variables. Differences with P < 0.05 were considered to be significant. We hypothesized that the comprehensive tailored intervention would be more effective. However, since both the experimental group and the comparison group received quite extensive tailored feedback, we did not want to rule out the possibility of testing for effect differences in the opposite direction. Therefore, all analyses were two-tailed.
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Results |
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The participants were predominantly female (89%) and the majority of the respondents had lower professional education or less. The subjects were between 19 and 59 years old with a mean age of 40 years. No significant differences were found between subjects who completed the whole study and those who dropped out between pre-test and post-test in socio-demographic features, body mass index, dietary behavior or intentions. No significant difference in response rate was found between the experimental and comparison group.
Differences at baseline
At baseline, subjects in the experimental group had a significantly lower mean age, ate significantly more servings of vegetables per day, and estimated their personal intake of vegetables and fruit significantly more positive than subjects in the comparison group (Table I). The difference in self-rated fat intake was of borderline significance. Respondents were randomly assigned to either the experimental group or the control group. Therefore, equal groups were to be expected. Since no differences were found between responders and non-responders, nor in response rate between both groups, the differences at baseline must be attributed to chance.
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Differences between pre-test and post-test
A significant reduction in mean fat score from 27.0 to 26.1 (F = 17.1, P < 0.01) between pre-test and post-test was found for the whole study population. Among respondents with high fat intake at baseline (n = 233) the reduction in fat points was 6% from 29.0 to 27.2 (F = 52.1, P < 0.01). The mean vegetable consumption did not change significantly between pre-test and post-test, but among respondents with low vegetable intake (n = 106) at baseline a significant 13% increase from 0.8 to 0.9 (F = 23.8, P < 0.01) servings per day was found. The mean fruit consumption increased from 1.6 to 2.0 (F = 28.6, P < 0.01) servings per day and among respondents with low fruit intake at baseline (n = 207) a 70% increase from 0.8 to 1.4 (F = 78.3, P < 0.01) in the mean number of servings per day was found.
Differences in impact between the tailored letters
No difference in post-test fat scores was found between the experimental group and the comparison group after adjustments were made for baseline differences in fat scores, self-rated fat intake and age (Table I
). The difference in post-test-adjusted mean vegetable intake between the experimental group and the comparison group was of borderline significance, the comparison group had the higher mean intake. The adjusted mean fruit intake at post-test was not significantly different between the experimental group and the comparison group. Furthermore, no differences in post-test intentions were found between the two groups.
Participants' reactions to the tailored letters
Large majorities of the participants in both the experimental and the comparison group reported that they read and saved the letter, and talked about the letter with others (Table II). Respondents in both groups rated the information in their tailored letters as interesting, personally relevant and credible. Respondents in the experimental group thought that the letter, and especially the information about vegetables and fruit, was significantly more interesting (F = 4.3, P < 0.05) and somewhat less difficult to understand (F = 3.8, P = 0.05), than did respondents in the comparison group. Substantial proportions of subjects in both groups stated that they changed their opinion about their diets and/or changed their dietary intake as a result of the letters they received (Table II). Respondents in the comparison group significantly more often stated that they changed their fat consumption as a result of their tailored letters.
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Discussion |
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Significant changes in dietary intake of fat, vegetables and fruit were reported by the participants in this study after receiving a tailored nutrition information letter. These changes were found especially among subjects who were more strongly advised to change based on their unfavorable consumption patterns at baseline. The mean fat score dropped approximately 6%, vegetable consumption increased 13% and the mean fruit consumption among these subjects increased 70%. The Dutch Nutrition Council has initiated nationwide campaigns in order to reach a 10% reduction in mean fat intake in the Netherlands. Therefore, a 6% reduction, as was found in the present study with a single intervention activity, seems to be a clinically relevant change. Fruit and vegetable consumption is substantially lower than recommended in the Netherlands and has been declining in recent years. The increase in vegetable intake and, especially, fruit intake that was found in the present study was substantial. For fruit intake, the mean intake at post-test met the Dutch recommendation to include two pieces of fruit in the daily diet.
In an earlier study in which the impact of the comprehensive tailored letters was compared to general dietary advice, similar changes in fat, fruit and vegetable consumption were found in the tailored feedback condition (Brug et al., 1996), while in a study conducted in the US, Campbell et al. (Campbell et al., 1994) found a 23% decrease in total fat but little change in fruit and vegetable consumption among subjects who received tailored nutrition information.
Respondents in the present study were quite positive about the feedback they received. A majority of the study population said that they changed their opinion about their diets and changed their diets as a result of the feedback they received. These proportions were greater than in a study where a comparable feedback tool was used among predominantly male and relatively highly educated employees at an oil company in the Netherlands, where proportions between 8 and 39% of self-reported changes were found (Brug et al., 1996). Differences in gender distribution and educational level might account for the differences between these two studies. Additional analyses of our data showed that respondents in the lowest educational category had read their letters more often and found their tailored letters significantly more interesting and relevant than respondents with higher education. Our study did not include enough men to study gender differences.
There were only small differences in impact between the two versions of the tailored nutrition information letters that were tested in this study. The respondents were more satisfied with the more comprehensive letters, but the short version had a somewhat greater impact on vegetable consumption. Also, respondents who received the shorter letters more often reported having changed their diets because of the letters. It could be that because the comprehensive letters contained more information, they were longer, and while the respondents thought they were more interesting, the abundance of information diluted the most important messages in the letters that encouraged them to make changes. Perhaps the specific messages were more prominent in the shorter letters because there was less additional information to `obscure' the essential information. The results of the study do not support our hypotheses that additional tailored psychosocial information is necessary in order to have the desired impact on changes in diet.
It can be concluded that the additional tailored psychosocial information that was given to respondents in the experimental group in this study did not lead to a significantly higher impact on recommended dietary changes. Nevertheless, respondents who received the tailored letters with additional psychosocial feedback were more satisfied with the information they received. The results confirm the conclusions from earlier research that computer-tailored nutrition education is a promising means to motivate subjects to change their diets towards recommended intake levels (Campbell et al., 1994; Brug et al., 1996) and the results indicate that extensive dietary feedback without psychosocial information is sufficient to accomplish these results.
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Acknowledgments |
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The authors wish to thank Jack Berben for his work in the development of the tailoring program and the employees of the organization for home care in Zuid-Limburg for participating in the study. The study was financially supported by the Dutch Cancer Society. The contribution of P. v. A. was financially supported by the Dutch Heart Foundation.
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References |
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Block, G. (1991) Dietary guidelines and the results of food consumption surveys. American Journal of Clinical Nutrition, 53, 356s–357s.
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Received on September 22, 1997; accepted on February 11, 1998
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