A high dose or quantity of participation was not associated with a decreased risk of gaining above the recommended weight gain range. Among women with a high amount of participation, defined as returning 4 or more postcards, a high quality participation (setting 2 or more appropriate goals) was significantly related to decreased risk of excessive gestational weight gain.
Generally, participation measured as attendance (i.e. dose received), is associated with greater success in face-to-face weight management interventions [8–10]. The relationship between dose received and successful outcomes for community-based interventions is not as strong. The Pound of Prevention pilot study in Minnesota similarly used postcards to monitor participation with the weight maintenance intervention and found the number of postcards returned was only marginally associated with weight loss . A correspondence-based postpartum weight loss intervention found that the number of returned homework assignments, a basic measure of participation, was not associated with success in the intervention . The number of self-monitoring records, however, was significantly correlated to weight loss. Self-monitoring has recently been identified as an effective technique to improve physical activity and healthy eating, and interventions that included self-monitoring and another component of control theory, goal setting, were even more effective . Similarly, full-participation in goal setting activities in a work-site intervention to improve physical activity was not related to changes in physical activity, but there was a dose response relationship between the difficulty of goals and change in physical activity [16, 17]. Thus, the quality of participation seems to be important for success in non-face-to-face interventions and should be included in process evaluations along with dose received.
Goal setting is a complex process that includes: 1) recognizing the need for change via some type of assessment, 2) establishing a goal, 3) committing to the goal, 4) monitoring goal-related activities, and 5) self-rewarding for goal attainment . Ideally, goals should be difficult yet attainable, specific and measureable, and set for a specific period of time . Although goal setting is generally found to be an effective dietary and physical activity behavior change strategy, few nutrition and physical activity interventions actually implement the full goal setting process. Consequently, few have explicitly examined the quality of goals set by participants as part of process evaluation . Our instructions on the postcards were to write down, “one specific change,” related to the topic of the newsletter. There were elements of assessment and self-monitoring in some of the newsletters and postcards. Thus goal setting for this intervention was mostly confined to step 2, establishing a goal, so only the qualitative aspects of this component were examined.
Contemporary non-face-to-face interventions are increasingly web-based and participation (e.g. viewing materials) can be easily monitored by tracking website visits. A web-based program with online goal-setting to improve self-management of epilepsy found that although participation was high (many goals set), 68% of goals were too general or only somewhat specific . Despite having offered guidelines for writing goals, the authors concluded that participants needed more assistance with goal-setting in order to facilitate behavior change. Goal-setting interventions with no face-to-face interaction need to provide support for setting quality goals either through detailed instructions or through a guided-goal setting tool [18, 20, 21]. Finally, qualitative research could help to identify both important program processes from the participants’ perspectives and alternative ways of assessing both the quantity and quality of participation with community-based interventions .