Development of Nutri-eSCREEN®

Nutri-eSCREEN® is an internet version of SCREENII (Seniors in the Community Risk Evaluation for Eating and Nutrition, Version II), a valid and reliable nutrition screening tool for adults aged 50+ [15, 16]. In addition to the original SCREENII questions, the Nutri-eSCREEN internet site also offers the opportunity for self-management by providing individualized guidance and feedback to users based on how they answered these questions. SCREENII was specifically developed to be self-administered and to include upstream behaviours such as consumption of fruits and vegetables and fluid intake, while also identifying common risk factors known to influence food intake in this segment of the population (e.g. swallowing problems, grocery shopping or cooking difficulty, eating alone). SCREEN II has 16 questions that receive a score, with a total score range of 0-64. Each question has response options with scores of 0 to 4. Lower scores indicate increased nutrition problems or risk. Different cut-points for nutrition risk have been suggested for SCREEN II [16]: low risk (score <54), high risk (<50) and very high risk (<45). Implementation research with SCREEN identified that older adults were interested in seeing if their eating habits were comparable to guidelines such as Canada’s Food Guide and wanted educational material to help them improve their eating habits and diet [17]. This knowledge and the use of behaviour change theory (specifically the Health Belief Model, COM-B) [18, 19] resulted in the development of Nutri-eSCREEN® designed as a self-management platform for nutrition risk in those over the age of 50 years. Specific aspects of the Health Belief Model incorporated into Nutri-eSCREEN are: a) perceived susceptibility to poor nutrition; participants are given information on ‘how they are doing well’ and ‘where they need to improve’ and b) perceived benefits; educational material outlines the benefits of improved eating habits. The COM-B model identifies that behaviour is influenced by capability (e.g. knowledge, skills), opportunity (e.g. resources, interpersonal support), and motivation (e.g. behaviour seen as a good thing, emotional reactions to behaviour). The tailored messages provided to respondents are designed to increase knowledge, help participants to identify opportunities that support behaviour change, and see the improvement in their eating habits as positive and feasible. Linkages in the site to recipes and other materials help users to develop skills.

A rigorous development process was undertaken over an 18-month period. The first step in this process was to conduct focus groups with diverse older adults (rural, francophone, urban, low income) to determine interest and expectations for an internet platform. Focus groups were digitally recorded and underwent qualitative content analysis [20] to identify key areas for consideration in building the platform. Barriers to the use of such a site and considerations for format and function was also ascertained from older adults participating in these four focus groups (n = 29 participants: Grp 1 n = 6, 1 M; Grp 2 n = 5, 3 M; Grp 3 n = 11, 1 M; Grp 4 n = 7, 0 M). Informants indicated that a self-management site like Nutri-eSCREEN® would be useful to many older adults. In addition to communications, such as email, health information and recipes were voiced as primary reasons why these older adults searched and used the internet. Examples of key functional considerations were font, keeping pages uncluttered, and being aware that many older adults may not have a printer, even if they do have a personal computer. Other considerations were: credibility of material, maintaining privacy and providing information in short, focused messages. Prior research suggests that professional bodies, universities, and governments are considered as credible bodies for health information [21]. As such, Nutri-eSCREEN® was built in collaboration with Dietitians of Canada and EatRight Ontario.

Subsequent to these focus groups, an advisory group was established to guide the development of Nutri-eSCREEN®. This group consisted of public health nutritionists and experts in health communications (n = 5) and three older adults who had extensive experience in internet communications. Next, ten key informants (n = 4 Male) who had developed internet platforms or had experience educating the public using the internet were also interviewed with a semi-structured questionnaire to gain their insights and learn from their experiences. Content analysis of digitally recorded individual interviews identified that principles of design echoed the comments of the older adults who had participated in focus groups. Examples of further considerations for developing Nutri-eSCREEN® gleaned from interviews were: in-person follow-up post screening if the older adult so desired; tracking of functionality and use of the site by seniors (e.g. how long it takes to complete the questions); promoting accessibility through visual cues, font, page style etc.; use of personalized, motivating messages; and making it easy for users to make diet changes by linking results to recipes and other relevant online content. These findings are consistent with prior work on development of high quality health information internet sites [14, 22].

With the assistance of the older adult advisors, a prototype platform was developed. Three draft versions of the prototype were developed. The final draft was tested for usability with 46 older adults who had a range of computer (use per week: n = 16 never; n = 4, < 1 hr/wk;n = 6, 1-3 hrs/wk; n = 12, 4-15 hrs/wk; n = 8, 15 + hrs/wk; ) and internet experience (searches per week: n = 7, never; n = 7, <1/wk; n = 13, 2-9/wk; n = 2, 10-20/wk) including a group of low income seniors (n = 7) with limited to no experience. As they moved through each page of the site, they described what they were thinking about when they interacted with the webpage [23]. Usability analysis was conducted in an iterative manner; ideas and suggestions from prior participants were asked of subsequent ones to determine if these modifications would be an improvement. These suggestions were recorded in hard-copy by the two assessors. Results post each interview were reviewed among the team to identify those suggested changes worth pursuing with subsequent participants. The primary focus of usability analysis was to identify challenges in functionality of the site; for example the size of the radial buttons and challenges posed by using a mouse to click on these buttons. Older adults were also asked specific questions to determine their perceptions of the look and feel of key aspects of the site. These seniors also completed the paper version of SCREENII approximately two-weeks prior to assess the inter-modal reliability of the internet platform.

The internet platform was found to be highly reliable (ICC = 0.89 for average measures 95 % CI 0.80, 0.94; F test significant at p < 0.0001) with the paper form of SCREENII and the results of this usability testing were used to improve and finalize the platform. For example, font was made larger and bolding removed in some areas to promote readability and the SCREENII score was removed, as this was not readily interpretable or meaningful to the older adult users. Prior work with older adults, identified that ‘risk’ terminology was not well understood and could be inflammatory [24]. Thus with the removal of the score, concepts of ‘where you are doing well’ and ‘where you can improve’ were used to build the tailored messaging. Tailored messages were developed by the health professional advisory team and a clear language consultant wrote and revised these messages. Messages were focused on building capability, identifying opportunity for supporting the behaviour, and motivating the participants to change key behaviours identified by the questions as needing improvement. Older adult advisors were involved in all aspects of redesign until completion. Nutri-eSCREEN® was launched as a useable platform in January 2012. Data from users is stored in aggregated spreadsheets on a secure server managed by Dietitians of Canada. In addition to the SCREENII questions, users provide their profile (age, gender, location, how heard about the site). As the site is linked to EatRight Ontario, users from Ontario have access to a dial-a-dietitian service for follow-up. Ethics clearance for the descriptive analysis of Nutri-eSCREEN® presented here was provided by a University of Waterloo ethics board.

Descriptive analysis

A three-year period from June 1, 2012- May 31, 2015 was chosen to complete a descriptive analysis of the Nutri-eSCREEN® and its participants. The purpose of this analysis was to characterize users (e.g. age, gender), including their self-reported nutrition behaviours based on the results from the SCREENII questions embedded within the Nutri-eSCREEN® platform. Frequencies and mean (+/-SD) are provided. Associations between SCREENII items and demographic characteristics of users were also completed using Chi square and Student’s t-test to examine associations and make group comparisons. Associations beyond gender and age group comparisons were also examined where theoretical relationships were believed to exist, such as difficulty chewing being associated with reported lower meat and alternatives intake. As anyone can use the internet site, any users who identified that they were less than 50 years of age were excluded from this analysis. Due to the large number of users and to avoid the identification of spurious associations, statistical significance for associations and group comparisons was only noted when the p value was <0.0001.