title: Effects on Engagement and Health Literacy Outcomes of Web-Based Materials Promoting Physical Activity in People With Diabetes: An International Randomized Trial.
abstract: Developing accessible Web-based materials to support diabetes self-management in people with lower levels of health literacy is a continuing challenge.
  
  
  
  The objective of this international study was to develop a Web-based intervention promoting physical activity among people with type 2 diabetes to determine whether audiovisual presentation and interactivity (quizzes, planners, tailoring) could help to overcome the digital divide by making digital interventions accessible and effective for people with all levels of health literacy. This study also aimed to determine whether these materials can improve health literacy outcomes for people with lower levels of health literacy and also be effective for people with higher levels of health literacy.
  
  
  
  To assess the impact of interactivity and audiovisual features on usage, engagement, and health literacy outcomes, we designed two versions of a Web-based intervention (one interactive and one plain-text version of the same content) to promote physical activity in people with type 2 diabetes. We randomly assigned participants from the United Kingdom, Austria, Germany, Ireland, and Taiwan to either an interactive or plain-text version of the intervention in English, German, or Mandarin. Intervention usage was objectively recorded by the intervention software. Self-report measures were taken at baseline and follow-up (immediately after participants viewed the intervention) and included measures of health literacy, engagement (website satisfaction and willingness to recommend the intervention to others), and health literacy outcomes (diabetes knowledge, enablement, attitude, perceived behavioral control, and intention to undertake physical activity).
  
  
  
  In total, 1041 people took part in this study. Of the 1005 who completed health literacy information, 268 (26.67%) had intermediate or low levels of health literacy. The interactive intervention overall did not produce better outcomes than did the plain-text version. Participants in the plain-text intervention group looked at significantly more sections of the intervention (mean difference -0.47, 95% CI -0.64 to -0.30, P<.001), but this did not lead to better outcomes. Health literacy outcomes, including attitudes and intentions to engage in physical activity, significantly improved following the intervention for participants in both intervention groups. These improvements were similar across higher and lower health literacy levels and in all countries. Participants in the interactive intervention group had acquired more diabetes knowledge (mean difference 0.80, 95% CI 0.65-0.94, P<.001). Participants from both groups reported high levels of website satisfaction and would recommend the website to others.
  
  
  
  Following established practice for simple, clear design and presentation and using a person-based approach to intervention development, with in-depth iterative feedback from users, may be more important than interactivity and audiovisual presentations when developing accessible digital health interventions to improve health literacy outcomes.
  
  
  
  International Standard Randomized Controlled Trial Number (ISRCTN): 43587048; http://www.isrctn.com/ISRCTN43587048. (Archived by WebCite at http://www.webcitation.org/6nGhaP9bv).
authors.affiliation: Department of Psychology, University of Southampton, Southampton, United Kingdom.
authors.forename: Ingrid
authors.identifier: 0000-0001-9341-6133
authors.initials: I
authors.lastname: Muller
authors.affiliation: Department of Psychology, University of Southampton, Southampton, United Kingdom.|University of Southampton, Department of Health Sciences, Southampton, United Kingdom.
authors.forename: Alison
authors.identifier: 0000-0003-2962-029X
authors.initials: A
authors.lastname: Rowsell
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom.
authors.forename: Beth
authors.identifier: 0000-0001-5432-7437
authors.initials: B
authors.lastname: Stuart
authors.affiliation: Department of Psychology, University of Southampton, Southampton, United Kingdom.
authors.forename: Victoria
authors.identifier: 0000-0002-2157-2855
authors.initials: V
authors.lastname: Hayter
authors.affiliation: Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom.
authors.forename: Paul
authors.identifier: 0000-0003-3664-1873
authors.initials: P
authors.lastname: Little
authors.affiliation: Gesundheit Österreich GmbH (Austrian Public Health Institute), Vienna, Austria.
authors.forename: Kristin
authors.identifier: 0000-0001-7322-6754
authors.initials: K
authors.lastname: Ganahl
authors.affiliation: Centre for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany.
authors.forename: Gabriele
authors.identifier: 0000-0002-1591-0539
authors.initials: G
authors.lastname: Müller
authors.affiliation: UCD College of Business, University College Dublin, Dublin, Ireland.
authors.forename: Gerardine
authors.identifier: 0000-0001-8516-4431
authors.initials: G
authors.lastname: Doyle
authors.affiliation: Taipei Medical University and National Taipei Hospital, Taipei, Taiwan.
authors.forename: Peter
authors.identifier: 0000-0002-2675-9483
authors.initials: P
authors.lastname: Chang
authors.affiliation: Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, CA, United States.
authors.forename: Courtney R
authors.identifier: 0000-0002-1111-8595
authors.initials: CR
authors.lastname: Lyles
authors.affiliation: School of Public Health, University of Sydney, Sydney, Australia.
authors.forename: Don
authors.identifier: 0000-0001-6497-2827
authors.initials: D
authors.lastname: Nutbeam
authors.affiliation: Department of Psychology, University of Southampton, Southampton, United Kingdom.
authors.forename: Lucy
authors.identifier: 0000-0002-3853-883X
authors.initials: L
authors.lastname: Yardley
mesh_terms: D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D015444:Exercise; D005260:Female; D057220:Health Literacy / Q000379:methods*; D006801:Humans; D020407:Internet; D008297:Male; D008875:Middle Aged; D012648:Self Care
keywords: diabetes; digital intervention; health literacy; physical activity; quantitative trial