The potential effectiveness of personalized nutrition communication through the Internet is promising in terms of addressing personal relevance, flexibility, interactive options and amount of people that can be reached. However, little research on the contribution to behaviour change has been done. The MyFood program at Wageningen University aims at providing insight into strategies to implement personalized nutrition communication through interactive tools. In this article we present the framework for research on social acceptance of personalized nutrition communication through interactive computer technology as part of the MyFood program.
In the last decades, effort put into improving dietary habits through health education has not been very effective: actual consumption does not match with basic recommendations for healthy nutrition. Despite some improvements, diets still contain too much saturated fat, sugar and salt and insufficient vegetables, fruits and fish. The growing burden of disease due to obesity, diabetes, cardiovascular and malignant diseases stresses the need for new and more effective health promotion strategies to change nutrition behaviour (RVZ, 2002; Ministry of Health, Welfare and Sports, 2003, 2004a, 2004b; Department of Health, 2004).
Recent research showed that consumers have an awareness of health topics like losing weight and lowering cholesterol (Van Dillen et al, 2004), but this awareness does not necessarily lead to behaviour change. High personal relevance and a stimulating social, political and physical environment are key areas for effective behaviour change interventions. The intervention itself should be based on prior research and on health behaviour change theory and has to include clear defined goals (Contento et al, 1995; Rootman, 2001; Contento et al, 2002; Hillsdon et al, 2004).
The rapid development of Interactive Computer Technology (ICT) opens doors to tailored assessment and advice at relative low costs (Leeuwis & Van den Ban, 2004). The potential effectiveness of interactive, personalized nutrition communication is promising as a way of addressing personal relevance, flexibility, interactive options and number of people that can be reached (Eng et al, 1999; SPICH, 1999; Stout et al, 2001; Eng, 2004). Currently, many Internet sites offer more or less individual tailored nutrition advice. Few web-based interventions include information of the ineffectiveness in terms of nutrition behaviour change (Bensley & Lewis, 2002; Evers et al, 2003). Their usefulness for growing burdens of disease due to obesity, diabetes cardiovascular and malignant diseases is not clear.
The need for innovative and more effective health promotion strategies to change nutrition behaviour was identified as high priority at Wageningen University, the Netherlands. In 2004 researchers from the nutrition, behavioural and communication department started working closely together to take a step forward by stimulating cooperation between science and society in order to improve consumer health.
In this article we will present the framework for the research on the social acceptance of personalized nutrition communication through ICT applications and results of a literature study on this topic. First we will define the research area of Health Promotion using Interactive Communication Tools. Second, we describe the framework, derived from literature, that we will use for our research on stakeholders and consumer perspectives on Personalized Nutrition Communication. In the final part of the article we present topics for discussion and suggestions for further research.
ICT in health promotion
The research area that focuses on applications designed to interact directly with consumers, with or without the presence of health-care professionals is named ‘Consumer Health Informatics’ (CHI). CHI analyses consumers’ needs for information, studies and implements methods of making information accessible to consumers and models and integrates consumers’ preferences into medical information systems. In this area of research different disciplines are integrated such as public health, health promotion and education and communication (Eysenbach, 2000). A more narrow description of the research area is defined by Robinson et al (1998): ICT in the field of health communication, Interactive Health Communication (IHC) is ‘the interaction of an individual—consumer, patient, caregiver or professiona—with or through an electronic device or communication technology to access or transmit health information, or to receive or provide guidance and support on a health-related issue’. The definition that captures the basics of health promotion was defined by the WHO Regional Office for Europe and published in the Ottawa Charter for Health Promotion in 1986: ‘health promotion is the process of enabling individuals and communities to increase control over, and to improve their health’ (Ottawa Charter, 1986).
Based on these definitions, Health Promotion using Interactive Health Communication tools as central in this research can be defined as ‘the use of interactive technology to provide access to or transmission of health information between consumers, health professionals, caregivers or between consumers and the computer-interface, in order to enable individuals to increase control over, and improve their health’.
Framework for social acceptance of personalized nutrition communication
The application of Interactive Health Communication technology can play an important role in providing interactive, individual tailored nutrition communication. IHC media can supplement face-to-face interaction with electronically mediated ones and lead to lower costs for nutrition interventions. In combination with the increasing demand of consumers to take responsibility for their own health, these are synergistic forces that promote nutrition communication in an information age health-care system. In this system, consumers can ideally use information technology to gain access to personally relevant information, interact with support groups and health professionals and gain more control over their own health. It can be argued that IHC technology should become an integral part of modern concepts of nutrition communication in public health and national health-care policies, thereby utilizing health-care resources more efficiently (Eysenbach, 2000; Eng, 2004).
Increased access through interventions based on IHC technology that provide personalized nutrition communication will influence individuals and society. It will actualize important social–ethical issues like shifting responsibilities for health, easy and equal access of health and privacy. Individualization of food and eating habits can influence the responsibility of a person for providing food to their family and social network. Also many practical issues related to the actual product of nutrition communication based on ICT are at stake. The increasing complexity of nutrition communication will complicate tasks of health professionals and demand more of their costly time without addressing the lack of reimbursement (SPICH, 1999; Meijboom et al, 2003; Korthals, 2004).
The first step in this research is to explore the perspectives of stakeholders and consumers (Figure 1) on chances and barriers to successful introduction of Personalized Nutrition Communication. During the research, specific attention will be paid to the perspectives of health-care practitioners for integrating interactive applications in primary health-care practice. The framework we will use for our research is based on a literature study in a diverse range of research fields.
Diffusions of innovations
In the first edition of the book ‘Diffusions of Innovations’ in 1962, Everett Rogers identified characteristics of innovations that affect the rate at which they are adopted. Today, his ‘perceived attributes of innovations’ still offer an excellent basis for this research. Perceived attributes are individual, subjective evaluations, derived from individuals’ personal experiences and perceptions and conveyed by interpersonal networks, drive the innovation process and thus determine an innovation's rate of adoption. According to Rogers (1995), almost 50–87 per cent of the variance in the rate of adoption is explained by five attributes.
Relative advantage: the degree to which an innovation is perceived as being better than the idea it supersedes.
Compatibility: the degree to which an innovation is perceived as consistent with existing values, past experiences, and needs of potential adopters.
Complexity: the degree to which an innovation is perceived as relatively difficult to understand and use.
Trialability: the degree to which an innovation may be experimented with on a limited basis.
Observability: the degree to which results of an innovation are visible to others.
Other variables affecting the adoption rate of an innovation are:
Type of innovation decision (individual-optional innovation decisions are generally adopted more rapidly than a collective innovation decision, for instance by an organization).
Nature of the communication channels diffusing the innovation (mass media, interpersonal).
The nature of the social system in which the innovation is diffusing (norms, degree of network interconnections).
Extent of change agents’ promotion efforts (adoption of opinion leaders).
Based on Rogers’ attributes three key-areas are defined: product orientation, social–ethical issues and preconditions for collaboration (Figure 2).
Relative advantage: effect
Already in the review in 1995, Contento stressed the need for research on the effectiveness of new media like Internet (Contento et al, 1995). At this moment, still little is known about the specific contribution of interactive health communication media (IHC) to the effectiveness of health promotion interventions. The Science Panel on Interactive Communication and Health (SPICH, 1999) offers an ‘Evaluation Reporting Template’ containing six key criteria that can be applied to most IHC programs. The criteria measure accuracy and appropriateness of content, usability, maintainability, bias and efficacy and effectiveness. The first criteria can be measured relatively easily looking closely into the program. Efficacy (a programs impact under controlled conditions) and effectiveness (impact under real-life circumstances) are measures of the extent to which a program actually has its intended impact. Do programs aiming at nutrition behaviour change actually move people into changing behaviour?
A review of on-line health assessment programs, based on these criteria, concluded that most sites lack information with regard to evaluation results and effectiveness. Only 7 per cent of the sites provided such information (Bensley & Lewis, 2002). The lack of evidence of the effect of interactive applications in nutrition communication can influence stakeholders perception on the advantage of this innovation.
Relative advantages: technology and tailoring
In Interactive Health Communication many underlying basic technologies can offer different advantages. Medical devices and information systems will benefit from the rapid increase of processing power and data storage capacities. Networking bandwidth and data compression facilitates the share of large information files between health-care providers (eg. image files from radiology tests). The fast development of encryption technology that permits secure transmission of data will facilitate the need for confidentiality of personal information in health-care practices. Wireless technology like handheld palm-top devices allow clinicians access to computerized patient records at any time and place. The number of information appliances will accelerate not only in computers but also in telephones, televisions and other devices. The availability of software-programs that filter information and find and retrieve information over a network that helps end users, the so-called intelligent agents, will grow. An interesting area is the development of sensors for measuring health parameters that connect with computers. Blood pressure monitors can become an integral part of computer devices and allow monitoring of previously more costly parameters (Grosel et al, 2003).
The increased capacity to store, present, sort and analyse data, offers opportunities to retrieve optimal strategies for personalized communication through tailoring. Several cognitive and behavioural models include personal relevance as an essential part of effective interventions. The Elaboration Likelihood Model (ELM) (Petty & Cacioppo, 1986) states that individuals are more motivated to elaborate and actively process information that is perceived as personal relevant, which in turn is more likely to induce attitude change. Research by Kreuter and Stretcher (1996) showed that personalized advice on health stimulates active processing of information significantly more compared to general advice. Factors that contribute to personal relevance are beliefs concerning health, motives for and perceived relevance of change, barriers to behaviour change, self-efficacy to perform the desired behaviour, preferences, current practices and habits, and preferences of information sources. The Stages of Change model assumes that information should be tailored to an individual's specific stage of behaviour change. This tailoring contributes to personal relevance of the intervention (Prochaska et al, 1992). The perceived personal relevance can be increased by tailoring the information to an individual's interests. Research has shown that personalized advice is more effective compared to general advice in reducing fat-consumption (Campbell et al, 1994; Brug et al, 1996), increasing vegetable and fruit consumption (Brug et al, 1998; Campbell et al, 1999), increasing physical activity (Kreuter & Stretcher, 1996; Marcus et al, 1998; Bull et al, 1999) and smoking cessation (Prochaska et al, 1993; Stretcher et al, 1994; Curry et al, 1995). Oenema (2004) concluded that respondents that received web-based tailored interventions had a significantly greater intention to change fat and fruit intake than respondents that received generic nutrition information. They rated the intervention as more personally relevant, more individualized and newer (Oenema, 2004). The higher effectiveness of personalized advice is attributed to the higher personal relevance.
Relative advantages: contribution to empowerment
Improved access to health information on demand, broader choices, and options for promotion of interaction among users and between professionals and consumers all facilitate empowerment. Empowerment is closely related to health outcomes in that powerlessness has been shown to be a broad-based risk factor for diseases. Several studies have shown that people who feel ‘in control’ over a situation concerning their health, have better outcomes compared to those that feel ‘powerlessness’ (Israel & Sherman, 1990; Anderson et al, 1995). Interactive self-assessment tools, for instance concerning diet, can help individuals to focus on central issues and take action to improve their health. Increasing access to health information and alternative treatment can facilitate shared decision making, which is important for health related empowerment of people (SPICH, 1999). Empowerment through IHC technologies can also be facilitated by online support groups that can make people feel connected to others with similar health conditions (Gustafson et al, 1999a).
One of the barriers for the slow pace at which the Public Health Care system includes IHC into practice is due to social–ethical barriers (Grosel et al, 2003). Insecurity on the impact of IHC applications on structure, process and outcomes of health and health care postpones regulatory decisions. Meaningfulness of personalized nutrition communication is a major issue, specifically about the promises that are made, and commercial goals can interfere with health goals. Inaccurate or inappropriate use of IHC applications can result in people losing trust in health-care providers and make people search for inappropriate care.
Rogers defines compatibility as the degree to which an innovation is perceived as consistent with existing values, past experiences, and needs of potential adopters. The variable ‘nature of social systems’ refers to the existing norms and the degree of network interconnections. The increasing access to personalized nutrition communication through Internet causes important changes for individuals, health professionals, businesses and society at large and is sure to raise ethical issues about existing values and norms (Korthals, 2004; Schulenberg & Yutrzenka, 2004). It will offer new and unforeseen possibilities and problems, questions about consequences for individuals and society and on what will be discovered and created. These issues are likely to affect perceptions of the benefits and risks and will therefore largely contribute to the success or failure of this innovation. From the literature we derived important areas of ethical concerns on responsibilities for health and health care, privacy issues, the information gap and influence on collective and individual habits, values and norms related to food choice.
Responsibilities for health and health care
The source of advice contributes to the efficacy of interventions. General practitioners and dieticians are perceived as the most trustworthy sources of information on nutrition (DeAlmeida et al, 1997; Hiddink et al, 1997; Mant, 1997; RVZ, 2003; Thompson et al, 2003; Harrington et al, 2004; Van Dillen et al, 2004). In 1989 the report of the United States Preventive Services Task Force concluded that health behaviour counselling is more likely to save lives and improve health compared to what doctors normally do for preventive care (physical examinations and screening tests) (AHCPR, 1997). The enthusiasm over the importance of health promotion was tempered by later studies. These conclude that counselling leads to behaviour change in only 1–5 per cent of the patients (Stange et al, 2002). Still, clear focus on the need for preventive health promotion exists in many countries. The most recent publication on healthy living of the Dutch Ministry of Health, Welfare and Sport (2004b) estimates that at least 20 per cent of all disabling illnesses is attributable to unhealthy lifestyles. Between 5 and 9 per cent of total expenses for health care in the Netherlands are the result of unhealthy lifestyles, obesity and high blood pressure. Prevention has therefore high priority in health care. All relevant parties, including health-care services, insurers, municipalities, companies, manufacturers, schools and the public at large, need to take responsibility. People need to be reached in the doctor's consultation room, at home, at work, at school and where they spend leisure time. Regarding public health, incentives will be provided to identify lifestyle related health risks in a timely manner and to address these issues with patients (Ministry of Health, Welfare and Sports, 2004a).
In reality, many general practitioners are sceptical whether counselling on healthy lifestyles is worth their time. Busy clinicians lack the time, skills and resource for such advice and do not (yet) receive financial reimbursement for this type of activities. Research in the United States on a large number of patient observations showed that time spent on health promotion was less than 0.7 min averaged across all visits and less than 1.35 min during visits in which it occurs (Stange et al, 2002).
Individual physicians and dietitians sometimes offer Internet-sites and email-appointments but their number is still very limited. Health professionals may perceive IHC technology as a threat to professional autonomy and authority. Their status as the most important source of health information may decrease. They have to accept the increasing role and responsibility of patients in decisions on health. Health professionals will have to find a balance between their role as an authority and as a facilitator or partner in care (Gustafson et al, 1999b; SPICH, 1999; Van Woerkum, 2003).
IHC applications for tailoring health information to individuals will raise issues on the risk of abuse of personal information. Sensitive personal data, beyond the traditional medical record, will be collected so issues on privacy and informed consent will be raised (SPICH, 1999; RVZ, 2003; Korthals, 2004; Schulenberg & Yutrzenka, 2004).
IHC technology can reach large audiences at relative low costs. This can facilitate equal access to information on health. But there is also a potential risk for widening the information gap between the information-rich and information-poor. Mass media is known for widening the information gap because of a larger effect on well-informed, well-educated people in the mass media audience (Tichenor et al, 1970; Rogers, 1986). Already in 1974 several possible impacts of new communication technologies were addressed by Katzman (1974). An increased amount of information would be communicated to all individuals in an audience, but the information-rich were likely to benefit more. Information-rich people have more knowledge and more options to put this knowledge into practice. Therefore, information-rich have a larger demand for gaining knowledge. Also, an information overload will require technology that provides relevant information. Information-rich people will be more likely to have access to this technology. Both impacts will contribute to widening of the information gap. In health care, the same was observed. In earlier decades, during the industrial age, the inverse care law described the idea that availability of good medical care tends to vary inversely with the need for medical care in the population served (Hart, 1971; Eysenbach, 2000). In the information age, people with low education and low health literacy might suffer from a ‘inverse information law’ meaning that access to appropriate information is particularly difficult for those who need it most (SPICH, 1999; Eysenbach, 2000; RVZ, 2003). Active focus of public health policy on the need for broad and equal access to Interactive Health Technology is needed to prevent the widening of the information gap.
Collective and individual habits, values and norms related to food choice
The focus in IHC is on individual choices and decisions. However, food choice is largely embedded in the collective values and norms of society. During family meals, shared diners with friends, celebration of religious or cultural festivities, individual choices put pressure on the expression of care, friendship and belonging. Individuals face these issues daily and take them into account in their risk-benefit evaluation of individual nutrition advice.
In their choice of certain foods people express their values and norms and their identity. Personalized nutrition communication may affect an individual's perspective on food, health and disease and therefore their identity. It also might influence the possibilities of sharing collective values of food in cultural and social interactions (Korthals, 2004).
Easy changes in food choice like eating more fruits and vegetables might have large health benefits. Considering that not many people comply with general nutrition guidelines, the question of legitimacy of more complex, personalized communication can be raised.
Preconditions for collaboration
Large reviews on health interventions define a stimulating social, political and physical environment as key areas for effective interventions (Contento et al, 1995, 2002; Hillsdon et al, 2004). A participatory, multistrategy approach, involving stakeholders and public will contribute to this stimulating environment. The focus in a participatory approach is on helping people to identify their own concerns and can therefore contribute to personal relevance (Koelen & Van den Ban, 2004). Some of the most effective interventions on the prevention of smoking have occurred through multiple community interventions that were developed and implemented through a network involving scientists, practitioners and a wide range of public, private and nonprofit organizations (Best et al, 2003).
Investing in the formation of collaboration networks that promote, support and sustain ongoing dialogue and sharing of experiences can contribute to a supportive environment in which the healthy choice is the easy choice. Interactive applications can be used, as an additional tool next to personal contact, for maintaining frequent contact between the network participants. Assuming that an IHC-based intervention is successful, large databases will be produced containing valuable information on information-needs and personal characteristics of the users. Policy makers, health professionals, insurance companies and other relevant stakeholders can use these results for more consumer-oriented health policies. This facilitates a multistrategy approach. Privacy-issues related to the use of personal information always need to be taken into account. The interactive character of IHC media also facilitates on-going participation of users, stakeholders and developers. New technologies can turn stakeholders and users into co-developers and active participants in the process (SPICH, 1999).
To create a supportive environment, collaboration of relevant stakeholders is essential. The growing burden of disease due to obesity, diabetes, cardiovascular and malignant diseases has a large impact on all members of society on the individual and collective level. The urgency to develop effective interventions to change nutrition behaviour is high. Government, health care, insurers, nutrition-education organizations, industry and consumer organizations all have expressed their concern about the increasing problem of obesity. In their statements, they all stress the need for social responsibility and collective action in order to make the healthy choice the easy choice. The Dutch Ministry of Health, Welfare and Sports, the British Department of Health and the WHO stated in their most recent strategies the need for a preventive approach to health in which all stakeholders feel responsible for the goal of reducing lifestyle related diseases (RIVM, 2002; Department of Health, 2004; Ministry of Health, Welfare and Sports, 2003, 2004a, 2004b; WHO, 1997). Although the precondition of a common goal with high urgency seems to exist, the formation of a collaborative alliance will be difficult.
In this article, many trends and chances that facilitate successful introduction of IHC in nutrition communication were addressed. However, the fast growing number of nutrition related websites that lack scientific base and that are partly biased by commercial messages, can be a large barrier.
Insights into chances and barriers are not enough to pave the way to nutrition behaviour change through web-based communication. Large effort needs to be put into further development of personalized assessments, insights into food behaviour and criteria for effective web-based interventions. The contribution of empowerment to behaviour change is still not defined very clearly. This complicates the definition of the capabilities of IHC technology to facilitate empowerment through interactive tools. Insecurity on effectiveness of interactive interventions hinders the investment in the development of evidence-based Internet-based programs.
Finally, we want to bring to the discussion that there is still uncertainty on the effect of the consumption of specific foods on health. In recent research, it was found that increased fruit and vegetable consumption did not lead to a statistically significant reduction in the development of major chronic diseases (Hung et al, 2004). The effects on health of specific foods to individuals are even further away from being ‘scientifically proven’. This lack of conclusive evidence can influence the perspectives on the usefulness of personalized nutrition communication. However, interventions need to be based on the constantly changing state of the art of science. Early research on the options of putting future insights of science into nutrition interventions is needed. Future research in the MyFood program will focus on the social acceptance of Personalized Nutrition Communication based on insights in the interaction between genes and nutrients. Also, effort will be put into the formation of a collaborating platform for discussion on successful introduction of Personalized Nutrition Communication.
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Discussion after Bouwman
Van Weel: You mentioned evidence as a common denominator of how you are bringing this together and how you are going to measure their input. Would it not be interesting to see whether all these partners mean the same by evidence? Beforehand they will all agree that it should be evidence based, but then talk to industry, and maybe they have a completely different concept of what evidence is. This might be a big problem for exercises like this. And the other point, you specifically named public health. But I think you will recruit potential users not so much from the public health but from individual health, and they might be different players.
Bouwman: We are also trying to find those stakeholders for their motivational part in it. You are right.
Van Weel: This is definitely a development we should take on board, but an increasing part of the population at risk at this moment is a population that will never use the internet. Maybe you should not want to use internet, because that might be the main barrier; maybe you should use brochures.
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Cite this article
Bouwman, L., Hiddink, G., Koelen, M. et al. Personalized nutrition communication through ICT application: how to overcome the gap between potential effectiveness and reality. Eur J Clin Nutr 59, S108–S116 (2005). https://doi.org/10.1038/sj.ejcn.1602182
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