Questionnaire responses
Questionnaire statements and the proportions of participants (total and per country) naming each item as a reason for participation in the HATICE RCT are shown in Figure 3. In the whole study population, the most common reasons for participation were: 1) the willingness to contribute to research (selected by 85% of all respondents);
2) the possibility to gain health benefits through lifestyle improvements (84%); and 3) the possibility to receive additional medical monitoring (79%). These reasons were followed by the willingness to improve dietary and exercise habits (71% and 60%, respectively) and personal health concerns (54%). Overall, 53% of the respondents stated that they decided to participate in the HATICE RCT because it was both a fun and effective way to improve their health. All other pre-specified reasons were selected by fewer than 50% of the respondents.
In France and the Netherlands, altruism was the most frequently mentioned reason for participation (96% and 94%, respectively), while in Finland it was the third most common reason (77%). The most frequently named reason in Finland was to obtain health benefits through lifestyle improvement (91%), which was selected more often as a reason in Finland and in France (82%) than in the Netherlands (62%). Dutch respondents were also less likely to emphasize diet- or exercise-related aspects. A similar proportion of respondents in all three countries indicated medical monitoring and personal health concerns as reasons for participation.
With regard to Internet-related reasons, no between-country differences were observed in the proportion of respondents indicating that the HATICE RCT was a fun or effective way to improve their health. However, French respondents were particularly prone to emphasize the flexibility and user-friendliness of the Internet (58% in France, 44% in Finland, 28% in the Netherlands), and Finnish respondents showed more interest than others in an eHealth study like HATICE because they wanted to appear modern (38% in Finland, 27% in France, 19% in the Netherlands).
5.3.1
Figure 3. The percentage of respondents (total and per country) indicating each statement as a reason for participation in the HATICE RCT.
The proportions of participants (total and per country) naming each item as their main reason for participation in the HATICE RCT are shown in Figure 4. In the whole population, the most frequently mentioned main reasons were the contribution to research (32%), health benefits through lifestyle improvement (24%), and additional medical monitoring (19%). Being worried about health was selected by 8% of the respondents. Altruistic reasons appeared to be more important in France (51%) and the Netherlands (37%) than in Finland (23%). Medical monitoring was emphasized as a main reason particularly in Finland (24% vs. 13% in the Netherlands and 11% in France). Personal health concerns were selected as the main reason by 10% of the Finnish and 11% of the Dutch respondents, whereas they were hardly mentioned in France (1%). While the attitude towards the Internet was overall positive and it was considered a fun and effective tool to improve health, only approximately 4% of all respondents mentioned any Internet-related reason as their main reason for participation. In total, 12 individuals specified ‘other reason’ as their main reason for participation. In addition to reasons which fall under the categories of altruism, lifestyle improvement, and medical monitoring, the following aspects were also mentioned: curiosity, interest in health and memory-related topics, being advised to participate by a GP, and the non-pharmacological nature of the intervention (i.e., health advice instead of drug treatment).
Figure 4. The percentage of respondents (total and per country) indicating each statement as the main reason for participation in the HATICE RCT.
A total of just 32 individuals completed the non-participation questionnaire (10 in Finland, 19 in France, 3 in the Netherlands). Common reasons for non-participation written in the free-text field included the following: lack of time, having other commitments, having already a healthy lifestyle, participation in another study, receiving already sufficient medical care, and self-exclusion (i.e., the person considered that the trial eligibility criteria listed in the invitation letter were not met).
Interviews
In line with the questionnaire responses, a willingness to contribute to research, the desire to change lifestyle to gain health benefits, and an interest in additional medical monitoring emerged in the interviews as the most common reasons for participation in HATICE. Through the content analysis, a desire to maintain independence, wellbeing, and the ability to function in old age was identified as the main theme: it appeared to be a key incentive underlying the decision to participate (Figure 5).
With respect to altruistic reasons, the interviewees frequently expressed concerns over aging and health deterioration, and it shaped their perceptions of medical research. Such individuals were motivated to contribute to research specifically focused on older adults’ health and wellbeing. Although the interviewees talked selflessly about helping others or society, and considered participation as a duty and privilege, increased awareness of aging-related health issues and the importance of research was in some cases linked to personal concerns and experiences with severely ill family members or institutionalized relatives. Altruistic reasons were
expressed particularly in France, whereas they seemed mostly subordinate to other more important reasons in Finland and in the Netherlands.
Lifestyle improvement through the HATICE RCT was discussed in detail mostly in Finland and in the Netherlands. The interviewees tended to recognize where they had room for improvement and often gave concrete examples of risk factors or unhealthy behaviors they wanted to focus on. Participation was commonly envisioned as having a personal trainer who would provide support and tailored advice for sustained lifestyle changes and boost motivation. Rather than being free of disease or infirmity, the main motivation towards lifestyle change was to keep in shape in order to lead an active, socially fulfilling, and mobile life now and later in old age. A wish to avoid disability and institutionalization was frequently expressed.
With respect to medical monitoring, some interviewees expressed a need for reassurance, and some considered it an add-on to their current care (e.g., more frequent monitoring of blood lipids or glucose). Some, on the other hand, perceived it as a simple, low-threshold way to share their concerns with health care professionals and to learn about their health status and risk. Early detection of health issues and better monitoring of existing diseases were considered important in order to lead an independent and disability-free life. Medical monitoring and health concerns were emphasized particularly in Finland, where the interviewees frequently mentioned difficulties in accessing health care. Other issues were also raised, such as the lack of continuity in care and lack of contact with an own assigned GP. Medical monitoring was mentioned to a lesser extent in the Netherlands, and in France these aspects were not spontaneously mentioned as reasons for participation.
Figure 5. The most common reasons for participation in HATICE based on the interviews.
The light blue triangles represent the most important reasons expressed by the participants;
examples of quotes are shown for each reason. The dark blue triangle represents the main theme and underlying motivation for participation.