Online Health Intervention Programs – Dealing With Attrition

June 2, 2011

In recent years, developers have released thousands of Web-based and mobile intervention programs that purport to help people quit smoking, improve their nutrition and activity levels, and institute other salutary changes in health-related behavior.

In recent years, developers have released thousands of Web-based and mobile intervention programs that purport to help people quit smoking, improve their nutrition and activity levels, and institute other salutary changes in health-related behavior.

These programs have drawn attention because of their potential to improve health for millions, at low cost. In addition, the platforms on which some are built permit developers to add new tools like games, social networks and analytical capacity that can, many believe, enhance their impact.

Clinical trials have shown that many of these programs do work.

For example, a randomized trial by Australian scientists showed that public registrants to a cognitive behavior therapy website had reductions in symptoms of anxiety and depression. Another randomized trial by Swiss scientists revealed that an Internet-based smoking cessation program helped people quit their habit.

Nevertheless, with a few notable exceptions, venture capital firms have been reluctant to invest in startups proposing to commercialize programs like these. It’s likely they’ll stay on the sidelines until the startups can prove their programs can attract a large, active user base, and that users can achieve and maintain the targeted health benefit outside the controlled environment of a clinical trial. Oh, and it wouldn’t hurt if startups also had a plan to monetize their applications, as well.

The challenge can be boiled down to the problem of attrition. People stop accessing these programs because they lose motivation, can’t find the time, or become frustrated by clunky interfaces and data entry requirements. Sometimes, they simply move on to another application.

Recently, a study by Miriam Wanner and colleagues from the Institute of Social and Preventive Medicine validated investor concerns about the attrition problem. But to some, it offered hope that newer platform features like games and onlne communities may be able to address it satisfactorily.

The scientists set-out to understand the determinants of utilization of Active-online, a free physical activity website in Switzerland. They found that by far, the most important determinant of sustained use was the circumstance in which people began using the site in the first place. Specifically, the attrition rate was 67% among registered open access users and only 26% among those who participated in a randomized trial of the site. Similarly, open access users spent less time on specially tailored modules (7.5 vs. 9.2 minutes) than trial participants. 

Wanner’s group also found that the attrition rate was lower among males and older individuals. Interestingly, emails designed to encourage continued engagement seemed to work among trial participants, but not among those who signed up of their own free will.

What Can We Make of This?
First, a caveat. The results of this study are not generalizable. Patient selection criteria and trial design features could easily have driven high and/or unusually sustained utilization among the trial participants in Wanner’s study. Perhaps the scientists selected particularly motivated subjects. Perhaps the continued support or improved access to providers drove increased utilization of the site among trial participants. Indeed, the above-mentioned Australian study found that open access users benefitted from an online behavioral therapy program to the same extent as participants in a clinical trial of the application.

That said, attrition is a massive problem, as Wanner’s group found. Investors are right to be skeptical about attempts to commercialize these programs. A clinical trial showing that an intervention is efficacious does not necessarily mean that the intervention will be effective in the real world, when people use it as they please and often, without the kind of support that can be afforded participants in a trial.

We know a lot, but not enough about the attrition problem when online and mobile health interventions are used in open access settings. In Wanner’s study, males and older individuals were more likely to stick with the program. In an earlier study, the main predictors of continued utilization were older age, never having smoked, meeting the guidelines for at least moderate physical activity and vegetable consumption, and being obese. Other studies suggest that more highly educated trial participants are more likely to demonstrate sustained utilization of online health programs. It’s possible that sociocultural variables can predict sustained use as well.

The results of Wanner’s studies and other like it however, suggest that the biggest determinant of sustained program utilization is the extent to which these programs can support their users. Emotional, cognitive, social  and logistic support from trial personnel likely drove the observed differences in Wanner’s study.

Outside the realm of a clinical trial, support needs to come from elsewhere…peers or providers, for example. The newer online programs feature online communities and gaming apps that can create a supportive environment for users. Some programs are offered within the context of a ‘medical model’; that is, they are ‘prescribed’ by providers who then follow-up to assure safe, continued utilization.

Wherever it comes from, effective support is going to be essential to the commercial success of these programs. In subsequent posts, we’ll cover online communities and gamification as support tools for web-based and mobile health intervention programs.