Title:
Adaptive e-learning to improve dietary behaviour: a systematic review and cost-effectiveness analysis.

Abstract:
UK public health policy strongly advocates dietary change for the improvement of population health and emphasises the importance of individual empowerment to improve health. A new and evolving area in the promotion of dietary behavioural change is 'e-learning', the use of interactive electronic media to facilitate teaching and learning on a range of issues including health. The high level of accessibility, combined with emerging advances in computer processing power, data transmission and data storage, makes interactive e-learning a potentially powerful and cost-effective medium for improving dietary behaviour.
This review aims to assess the effectiveness and cost-effectiveness of adaptive e-learning interventions for dietary behaviour change, and also to explore potential psychological mechanisms of action and components of effective interventions.
Electronic bibliographic databases (Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Dissertation Abstracts, EMBASE, Education Resources Information Center, Global Health, Health Economic Evaluations Database, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science) were searched for the period January 1990 to November 2009. Reference lists of included studies and previous reviews were also screened; authors were contacted and trial registers were searched.
Studies were included if they were randomised controlled trials, involving participants aged ≥ 13 years, which evaluated the effectiveness of interactive software programs for improving dietary behaviour. Primary outcomes were measures of dietary behaviours, including estimated intakes or changes in intake of energy, nutrients, dietary fibre, foods or food groups. Secondary outcome measures were clinical outcomes such as anthropometry or blood biochemistry. Psychological mediators of dietary behaviour change were also investigated. Two review authors independently screened results and extracted data from included studies, with any discrepancies settled by a third author. Where studies reported the same outcome, the results were pooled using a random-effects model, with weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated. Cost-effectiveness was assessed in two ways: through a systematic literature review and by building a de novo decision model to assess the cost-effectiveness of a 'generic' e-learning device compared with dietary advice delivered by a health-care professional.
A total of 36,379 titles were initially identified by the electronic searches, of which 43 studies were eligible for inclusion in the review. All e-learning interventions were delivered in high-income countries. The most commonly used behavioural change techniques reported to have been used were goal setting; feedback on performance; information on consequences of behaviour in general; barrier identification/problem solving; prompting self-monitoring of behaviour; and instruction on how to perform the behaviour. There was substantial heterogeneity in the estimates of effect. E-learning interventions were associated with a WMD of +0.24 (95% CI 0.04 to 0.44) servings of fruit and vegetables per day; -0.78 g (95% CI -2.5 g to 0.95 g) total fat consumed per day; -0.24 g (95% CI -1.44 g to 0.96 g) saturated fat intake per day; -1.4% (95% CI -2.5% to -0.3%) of total energy consumed from fat per day; +1.45 g (95% CI -0.02 g to 2.92 g) dietary fibre per day; +4 kcal (95% CI -85 kcal to 93 kcal) daily energy intake; -0.1 kg/m2 (95% CI -0.7 kg/m2 to 0.4 kg/m2) change in body mass index. The base-case results from the E-Learning Economic Evaluation Model suggested that the incremental cost-effectiveness ratio was approximately £102,112 per quality-adjusted life-year (QALY). Expected value of perfect information (EVPI) analysis showed that although the individual-level EVPI was arguably negligible, the population-level value was between £37M and £170M at a willingness to pay of £20,000-30,000 per additional QALY.
The limitations of this review include potential reporting bias, incomplete retrieval of completed research studies and data extraction errors.
The current clinical and economic evidence base suggests that e-learning devices designed to promote dietary behaviour change will not produce clinically significant changes in dietary behaviour and are at least as expensive as other individual behaviour change interventions.
Despite the relatively high EVPI results from the cost-effectiveness modelling, further clinical trials of individual e-learning interventions should not be undertaken until theoretically informed work that addresses the question of which characteristics of the target population, target behaviour, content and delivery of the intervention are likely to lead to positive results, is completed.
The National Institute for Health Research Health Technology Assessment programme.