A Systematic Review of School-Based Ehealth Interventions Targeting Multiple Risk Behaviors for Chronic Disease

Introduction: Six key behavioral risk factors (alcohol use, smoking, poor diet, physical inactivity, sedentary behavior and poor sleep; “the Big 6”) have been identified as strong determinants of chronic disease. School-based interventions that target multiple risk behaviors have the potential to improve health outcomes and eHealth interventions offer advantages in terms of engagement, reach and scalability. This study aimed to determine the existence and efficacy of eHealth school-based preventive interventions targeting multiple risk behaviors among secondary school students.

Methods: This systematic review was prospectively registered with the International Prospective Register of Systematic Reviews and was written in accordance with PRISMA Statement. Four electronic databases were systematically searched from 2000-2017. Eligible studies were randomized controlled trials of preventive interventions that targeted two or more of the “Big 6” risk factors, and were delivered to adolescents at school via eHealth methods (Internet, computers or mobile technology). Two reviewers independently screened studies, extracted data and assessed risk of bias. Study outcomes were summarized qualitatively, and meta-analyses are underway where it is appropriate to combine studies.

Results: A total of 22 studies evaluating 16 programs were eligible. 20 studies evaluated web-based programs and 2 were delivered via CD-ROM. 18 studies were underpinned by behavioral theory, including the Transtheoretical Model (n=10) and Theory of Planned Behavior (n=7). All of the Big 6 risk behaviors were targeted in at least one study, with the exception of sleep. Physical activity (n=10) and diet (n=10) were the most commonly targeted behaviors (mean of 2.5 risk factors targeted per program). Nine studies demonstrated significant intervention effects in modifying at least one risk behavior; with 8 of these studies modifying 2 or more behaviors. Physical activity and diet were the two risk factors most likely to improve. Effective programs all included some form of tailored, normative or stage-matched feedback, but varied in intensity (ranging from 3 to 8 sessions).

Conclusions: Findings from this review indicate that eHealth school-based multiple health behavior interventions can modify lifestyle behaviors and are effective in reducing multiple risk behaviors, especially in relation to diet and activity. However, efficacy was limited for interventions that targeted substance use outcomes, few studies addressed sedentary behavior and no program aimed to improve sleep habits. Future research should aim to develop eHealth interventions that can effectively modify numerous important risk factors.