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Effective use of mediated programming in physical activity interventions

This is an excerpt from Developing Effective Physical Activity Programs by Lynda Ransdell,Mary Dinger,Jennifer Huberty & Kim Miller.

Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.

Factors Related to Successful Mediated Physical Activity Interventions

Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.

General Factors Related to Success in All Mediated Interventions

The following six factors are related to success with any type of mediated intervention, regardless of medium:

• Increasing dose-response
• Designing memorable campaign slogans and information
• Using market segmentation and message personalization strategies
• Targeting multiple media outlets
• Ensuring theoretical fidelity
• Paying attention to quality control

• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).

• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.

• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).

• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).

• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).

• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.

• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.

Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:

• The mass media should target multiple media outlets in a systematic and sustained fashion.
• Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
• Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
• The message coming from the mass media should be singular and simple-so it will be memorable.
• Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.

Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):

• Follow up with participants quickly after distributing print material.
• Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
• Make sure the information is concise, accurate, and specifically directed to the targeted population.
• Pilot test materials with members of the targeted population.
• Write materials to a level appropriate for the targeted population.

Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:

• Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
• Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
• Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).

Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.

Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.

• Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
• Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):

• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them

According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they

• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.

• Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.

• Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.

Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):

• Be aware that those in the iPod generation are typically young and technologically savvy.
• When possible, provide the means for interaction with others.
• Pilot test podcasts with members of the target population.
• Make sure podcasts are simple and easy to download with a computer.

Sample Successful Program

Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.

The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.

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