Effectiveness of the Components of a Digital Multiple Health Behavior Change Intervention Among Individuals Seeking Help Online (Coach): Factorial Randomized Trial

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Abstract
Background: Extant digital multiple health behavior change interventions have shown promise in various populations; however, evidence for a broader approach among the general population is lacking. Moreover, existing interventions often contain several components but are typically assessed as a whole, meaning it remains unclear to what extent individual components contribute to intervention effects and how they may interact to influence health outcomes. Objective: This study estimates the effects of 6 components of a digital health behavior change intervention on alcohol, diet, physical activity, and smoking outcomes among individuals searching for help online. Methods: A double-blind randomized factorial trial design with 6 two-level factors was used. Adults from the general public in Sweden who were seeking help to change their behaviors were recruited through web searches and social media. Participants were eligible if they were 18 years or older and had at least one health behavior classified as unhealthy. Effects of 6 components were estimated: screening/feedback, goal-setting/planning, motivation, skills/know-how, mindfulness, and self-authored SMS text messages. Primary outcomes were weekly alcohol consumption and frequency of heavy episodic drinking, average daily fruit and vegetable consumption, weekly moderate-to-vigorous physical activity, and 4-week point-prevalence smoking. Results: A total of 5419 individuals were randomized. Overall, the screening/feedback component was the most effective for changing health behaviors, along with goal-setting/planning and motivation to change. In particular, there was evidence that screening/feedback increased average daily portions of fruit and vegetables at 2 months (mean difference 0.17, compatibility interval [CoI] 0.09-0.25, probability of effect [POE] >99.9%) and at 4 months (mean difference 0.13, CoI 0.04-0.21, POE 99.9%) and reduced the frequency of heavy episodic drinking at 4 months (incidence rate ratio 0.91, CoI 0.81-1.03, POE 94.2%). Components also interacted to further improve health outcomes, most notably the combination of screening/feedback with motivation to change, which further increased fruit and vegetable consumption (2 months: mean difference 0.20, CoI 0.09-0.30, POE >99.9%; 4 months: mean difference 0.17, CoI 0.05-0.29, POE 99.8%). Conclusions: The results from this study contribute to the development of more effective interventions by providing novel insights into the effects of individual and pairwise components of complex digital health behavior change interventions. Trial Registration: ISRCTN Registry ISRCTN16420548; http://www.isrctn.com/ISRCTN16420548 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2022-061024

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