Predictors of adherence by adolescents to a cognitive behavior therapy website in school and community-based settings

Mixing Online and Face-to-Face Therapy: How to Benefit From Blended Care in Mental Health Care

Blended care, a combination of online and face-to-face therapy, is increasingly being applied in mental health care to obtain optimal benefit from the advantages these two treatment modalities have. Promising results have been reported, but a variety in descriptions and ways of operationalizing blended care exists. Currently, what type of "blend" works for whom, and why, is unclear. Furthermore, a rationale for setting up blended care is often lacking. In this viewpoint paper, we describe postulates for blended care and provide an instrument (Fit for Blended Care) that aims to assist therapists and patients whether and how to set up blended care treatment. A review of the literature, two focus groups (n=5 and n=5), interviews with therapists (n=14), and interviews with clients (n=2) were conducted to develop postulates of eHealth and blended care and an instrument to assist therapists and clients in setting up optimal blended care. Important postulates for blended care are the notion that both treatment modalities should complement each other and that set up of blended treatment should be based on shared decision making between patient and therapist. The "Fit for Blended Care" instrument is presented which addresses the following relevant themes: possible barriers to receiving blended treatment such as the risk of crisis, issues in communication (at a distance), as well as possible facilitators such as social support. More research into the reasons why and for whom blended care works is needed. To benefit from blended care, face-to-face and online care should be combined in such way that the potentials of both treatment modalities are used optimally, depending on patient abilities, needs, and preferences. To facilitate the process of setting up a personalized blended treatment, the Fit for Blended Care instrument can be used. By applying this approach in research and practice, more insight into the working mechanisms and optimal (personal) "blends" of online and face-to-face therapy becomes within reach.

Establishing and Governing e-Mental Health Care in Australia: A Systematic Review of Challenges and A Call For Policy-Focussed Research

BACKGROUND

Growing evidence attests to the efficacy of e-mental health services. There is less evidence on how to facilitate the safe, effective, and sustainable implementation of these services.

OBJECTIVE

We conducted a systematic review on e-mental health service use for depressive and anxiety disorders to inform policy development and identify policy-relevant gaps in the evidence base.

METHODS

Following the PRISMA protocol, we identified research (1) conducted in Australia, (2) on e-mental health services, (3) for depressive or anxiety disorders, and (4) on e-mental health usage, such as barriers and facilitators to use. Databases searched included Cochrane, PubMed, PsycINFO, CINAHL, Embase, ProQuest Social Science, and Google Scholar. Sources were assessed according to area and level of policy relevance.

RESULTS

The search yielded 1081 studies; 30 studies were included for analysis. Most reported on self-selected samples and samples of online help-seekers. Studies indicate that e-mental health services are predominantly used by females, and those who are more educated and socioeconomically advantaged. Ethnicity was infrequently reported on. Studies examining consumer preferences found a preference for face-to-face therapy over e-therapies, but not an aversion to e-therapy. Content relevant to governance was predominantly related to the organizational dimensions of e-mental health services, followed by implications for community education. Financing and payment for e-services and governance of the information communication technology were least commonly discussed.

CONCLUSIONS

Little research focuses explicitly on policy development and implementation planning; most research provides an e-services perspective. Research is needed to provide community and policy-maker perspectives. General population studies of prospective treatment seekers that include ethnicity and socioeconomic status and quantify relative preferences for all treatment modalities are necessary.

Development of a technology-based behavioral vaccine to prevent adolescent depression: A health system integration model

Efforts to prevent depression have become a key health system priority. Currently, there is a high prevalence of depression among adolescents, and treatment has become costly due to the recurrence patterns of the illness, impairment among patients, and the complex factors needed for a treatment to be effective. Primary care may be the optimal location to identify those at risk by offering an Internet-based preventive intervention to reduce costs and improve outcomes. Few practical interventions have been developed. The models for Internet intervention development that have been put forward focus primarily on the Internet component rather than how the program fits within a broader context. This paper describes the conceptualization for developing technology based preventive models for primary care by integrating the components within a behavioral vaccine framework. CATCH-IT (Competent Adulthood Transition with Cognitive-behavioral, Humanistic and Interpersonal Training) has been developed and successfully implemented within various health systems over a period of 14 years among adolescents and young adults aged 13-24.

Web Intervention for Adolescents Affected by Disaster: Population-Based Randomized Controlled Trial

OBJECTIVE

To assess the efficacy of Bounce Back Now (BBN), a modular, Web-based intervention for disaster-affected adolescents and their parents.

METHOD

A population-based randomized controlled trial used address-based sampling to enroll 2,000 adolescents and parents from communities affected by tornadoes in Joplin, MO, and several areas in Alabama. Data collection via baseline and follow-up semi-structured telephone interviews was completed between September 2011 and August 2013. All families were invited to access the BBN study Web portal irrespective of mental health status at baseline. Families who accessed the Web portal were assigned randomly to 1 of 3 groups: BBN, which featured modules for adolescents and parents targeting adolescents' mental health symptoms; BBN plus additional modules targeting parents' mental health symptoms; or assessment only. The primary outcomes were adolescent symptoms of posttraumatic stress disorder (PTSD) and depression.

RESULTS

Nearly 50% of families accessed the Web portal. Intent-to-treat analyses revealed time × condition interactions for PTSD symptoms (B = -0.24, SE = 0.08, p < .01) and depressive symptoms (B = -0.23, SE = 0.09, p < .01). Post hoc comparisons revealed fewer PTSD and depressive symptoms for adolescents in the experimental versus control conditions at 12-month follow-up (PTSD: B = -0.36, SE = 0.19, p = .06; depressive symptoms: B = -0.42, SE = 0.19, p = 0.03). A time × condition interaction also was found that favored the BBN versus BBN + parent self-help condition for PTSD symptoms (B = 0.30, SE = 0.12, p = .02) but not depressive symptoms (B = 0.12, SE = 0.12, p = .33).

CONCLUSION

Results supported the feasibility and initial efficacy of BBN as a scalable disaster mental health intervention for adolescents. Technology-based solutions have tremendous potential value if found to reduce the mental health burden of disasters.

CLINICAL TRIAL REGISTRATION INFORMATION

Web-based Intervention for Disaster-Affected Youth and Families; http://clinicaltrials.gov; NCT01606514.

Enhancing the Capacity of School Nurses to Reduce Excessive Anxiety in Children: Development of the CALM Intervention

PROBLEM

Excessive anxiety is among the most common psychiatric problems facing youth. Because anxious youth tend to have somatic complaints, many seek help from the school nurse. Thus, school nurses are in an ideal position to provide early intervention. This study addresses this problem and describes the plans to develop and test a new intervention (Child Anxiety Learning Modules; CALM), delivered by school nurses, to reduce child anxiety and improve academic functioning.

METHODS

An iterative development process including consultation with an expert panel, two open trials, and a pilot randomized controlled study comparing CALM to usual care is proposed. Feedback will be solicited from all participants during each phase and data on outcome measures will be provided by children, parents, teachers, and independent evaluators.

FINDINGS

Data will be collected on intervention satisfaction and feasibility. Primary outcomes that include child anxiety symptoms, classroom behavior, and school performance (e.g., attendance, grades, standardized test scores) will be collected at pre- and post-interventions and at a 3-month follow-up evaluation.

CONCLUSIONS

Pediatric anxiety is a common problem that school nurses frequently encounter. Consequently, they are well positioned to play a key role in enhancing access to behavioral health interventions to reduce anxiety and may therefore make a significant positive public health impact.

Computerized Cognitive Behavior Therapy for Anxiety and Depression in Rural Areas: A Systematic Review

Background

People living in rural and remote communities have greater difficulty accessing mental health services and evidence-based therapies, such as cognitive behavior therapy (CBT), than their urban counterparts. Computerized CBT (CCBT) can be used to effectively treat depression and anxiety and may be particularly useful in rural settings where there are a lack of suitably trained practitioners.

Objective

To systematically review the global evidence regarding the clinical effectiveness and acceptability of CCBT interventions for anxiety and/or depression for people living in rural and remote locations.

Methods

We searched seven online databases: Medline, Embase Classic and Embase, PsycINFO, CINAHL, Web of Science, Scopus, and the Cochrane Library. We also hand searched reference lists, Internet search engines, and trial protocols. Two stages of selection were undertaken. In the first, the three authors screened citations. Studies were retained if they reported the efficacy, effectiveness or acceptability of CCBT for depression and/or anxiety disorders, were peer reviewed, and written in English. The qualitative data analysis software, NVivo 10, was then used to run automated text searches for the word “rural,” its synonyms, and stemmed words. All studies identified were read in full and were included in the study if they measured or meaningfully discussed the efficacy or acceptability of CCBT among rural participants.

Results

A total of 2594 studies were identified, of which 11 met the selection criteria and were included in the review. The studies that disaggregated efficacy data by location of participant reported that CCBT was equally effective for rural and urban participants. Rural location was found to both positively and negatively predict adherence across studies. CCBT may be more acceptable among rural than urban participants—studies to date showed that rural participants were less likely to want more face-to-face contact with a practitioner and found that computerized delivery addressed confidentiality concerns.

Conclusions

CCBT can be effective for addressing depression and anxiety and is acceptable among rural participants. Further work is required to confirm these results across a wider range of countries, and to determine the most feasible model of CCBT delivery, in partnership with people who live and work in rural and remote communities.

Access and completion of a Web-based treatment in a population-based sample of tornado-affected adolescents

Although Web-based treatments have significant potential to assess and treat difficult-to-reach populations, such as trauma-exposed adolescents, the extent that such treatments are accessed and used is unclear. The present study evaluated the proportion of adolescents who accessed and completed a Web-based treatment for postdisaster mental health symptoms. Correlates of access and completion were examined. A sample of 2,000 adolescents living in tornado-affected communities was assessed via structured telephone interview and invited to a Web-based treatment. The modular treatment addressed symptoms of posttraumatic stress disorder, depression, and alcohol and tobacco use. Participants were randomized to experimental or control conditions after accessing the site. Overall access for the intervention was 35.8%. Module completion for those who accessed ranged from 52.8% to 85.6%. Adolescents with parents who used the Internet to obtain health-related information were more likely to access the treatment. Adolescent males were less likely to access the treatment. Future work is needed to identify strategies to further increase the reach of Web-based treatments to provide clinical services in a postdisaster context.

Controlled trial of an Internet-based intervention for overweight teens (Next.Step): effectiveness analysis

Adolescent obesity is a major health problem. The need for effective adolescent weight management programs is of high clinical and public health relevance. This study evaluates the effectiveness of an e-therapeutic platform (Next.Step), aiming to promote weight management skills and the adoption of health-promoting lifestyles. This nonrandomized clinical trial with control group uses a sample of 94 adolescents who attended a paediatric obesity clinic. The experimental group was invited to access the platform Next.Step during 24 weeks, in addition to the standard treatment program. The control group followed the standard treatment protocol and joined a waiting list. Overall, the outcomes of the e-therapeutic program were not substantially better than those obtained with a traditional kind of intervention despite the intervention being associated with an improved health responsibility score (d = 0.51; p = 0.014). Several predictors of the Next.Step effectiveness were found.

CONCLUSION

Although the e-therapeutic program led to a significant increase in health responsibility, inconclusive results were found regarding the program effectiveness compared to the standard multidisciplinary intervention. The lack of significant differences between groups may be due to the reduced rates of program adherence and the high dropout rate.

WHAT IS KNOWN

• Adolescent obesity has reached epidemic proportions, and standard treatment programs have been unable to achieve the desired adherence so far. • Internet-based programs have already shown positive results in the adult obese population, but information is scarce regarding adolescents.

WHAT IS NEW

• This study assesses the effectiveness of a structured case management program including communication technologies on both the behavioural change and the health of obese adolescents. • The e-therapeutic program led to an increase in health responsibility.

Web-based interventions for youth internalizing problems: a systematic review

OBJECTIVE

To review published reports on Web-based treatment and prevention programs for depression, anxiety, and suicide prevention in children, adolescents, and emerging adults.

METHOD

A systematic search of the PsycINFO, PubMed, Medline, and Web of Science databases was conducted in December 2013. Programs were classified according to evidence-base level (Well-Established, Probably Efficacious, Possibly Efficacious, Experimental, and Of Questionable Efficacy).

RESULTS

Of the 14,001 citations initially identified, 25 articles met inclusion criteria for Web-based interventions. These described 9 programs, of which 8 were Internet based and 1 was a mobile application. No Web-based interventions for suicide prevention were identified. Of the randomized controlled trials (n = 14) and open trials (n = 3) identified, 10 reported significant postintervention reductions in symptoms of depression and/or anxiety or improvements in diagnostic ratings, with small to large effect sizes. Many of these studies also reported significant improvements at follow-up. The methodological quality of the studies varied. Many programs were limited by their small sample sizes and use of waitlist or no-treatment control groups.

CONCLUSION

There is limited evidence for the effectiveness of Web-based interventions for youth depression and anxiety. Additional research and program development are needed to fill the current gaps in the literature.

Analyzing engagement in a web-based intervention platform through visualizing log-data

Background

Engagement has emerged as a significant cross-cutting concern within the development of Web-based interventions. There have been calls to institute a more rigorous approach to the design of Web-based interventions, to increase both the quantity and quality of engagement. One approach would be to use log-data to better understand the process of engagement and patterns of use. However, an important challenge lies in organizing log-data for productive analysis.

Objective

Our aim was to conduct an initial exploration of the use of visualizations of log-data to enhance understanding of engagement with Web-based interventions.

Methods

We applied exploratory sequential data analysis to highlight sequential aspects of the log data, such as time or module number, to provide insights into engagement. After applying a number of processing steps, a range of visualizations were generated from the log-data. We then examined the usefulness of these visualizations for understanding the engagement of individual users and the engagement of cohorts of users. The visualizations created are illustrated with two datasets drawn from studies using the SilverCloud Platform: (1) a small, detailed dataset with interviews (n=19) and (2) a large dataset (n=326) with 44,838 logged events.

Results

We present four exploratory visualizations of user engagement with a Web-based intervention, including Navigation Graph, Stripe Graph, Start–Finish Graph, and Next Action Heat Map. The first represents individual usage and the last three, specific aspects of cohort usage. We provide examples of each with a discussion of salient features.

Conclusions

Log-data analysis through data visualization is an alternative way of exploring user engagement with Web-based interventions, which can yield different insights than more commonly used summative measures. We describe how understanding the process of engagement through visualizations can support the development and evaluation of Web-based interventions. Specifically, we show how visualizations can (1) allow inspection of content or feature usage in a temporal relationship to the overall program at different levels of granularity, (2) detect different patterns of use to consider personalization in the design process, (3) detect usability issues, (4) enable exploratory analysis to support the design of statistical queries to summarize the data, (5) provide new opportunities for real-time evaluation, and (6) examine assumptions about interactivity that underlie many summative measures in this field.

Outcome predictors of Internet-based brief sex therapy for sexual dysfunctions in heterosexual men

The authors investigated whether baseline and therapy process characteristics of 82 heterosexual men participating in an Internet-based sex therapy study predict posttreatment sexual functioning. Problem severity, baseline sexual desire and baseline sexual satisfaction, but also partner problems and quality of the therapeutic relationship are predictive for sexual functioning and sexual satisfaction after finishing Internet-based sex therapy. The obtained outcome predictors could benefit men with sexual dysfunctions by tailoring online therapy programs to their individual characteristics. In addition, therapists should realize that clients suffering from erectile dysfunction or premature ejaculation in online sex therapy attach great importance to the therapeutic relationship.

Does cognitive behavioural therapy have a role in improving problem solving and coping in adolescents with suicidal ideation?

Problem-solving and coping skills deficits have been shown in adolescents who experience suicide-related behaviours, including suicidal ideation. Little evidence exists about effective interventions for this population. We undertook a pilot study of an Internet-based CBT programme that included problem-solving skills training to investigate its impact on skills deficits. The study employed a pre-test/post-test design. Outcomes of interest were negative problem orientation, emotion- and task-focused coping, and adolescents’ perception of helpfulness of the intervention. Participants, recruited via the school wellbeing team, were assessed at baseline, at weekly intervention sessions and immediately post-intervention. Twenty-one adolescents completed the intervention. Over the course of the intervention, negative problem-solving orientation improved and students relied less on emotion-focused coping strategies. Because there was no control group, we cannot be certain that the changes seen between baseline and post-intervention can be attributed to the intervention. Adolescents rated the problem-solving and cognitive restructuring modules as particularly helpful. Interventions that include enhancement of problem-solving skills, as well as cognitive restructuring to address adolescents’ appraisal of problems and their ability to solve them appear promising for adolescents with suicidal ideation. Further investigation is warranted.

Uptake and adherence of a self-directed internet-based mental health intervention with tailored e-mail reminders in senior high schools in Norway

BACKGROUND

Internet-based cognitive behavioural therapy (ICBT) is a promising approach to the prevention and reduction of depressive symptoms among adolescents. This study aimed to evaluate the feasibility and efficacy of disseminating a self-directed internet-based mental health intervention (MoodGYM) in senior high schools. It also sought to investigate possible effects of tailored and weekly e-mail reminders on initial uptake and adherence to the intervention.

METHOD

A baseline survey was conducted in four senior high schools in two Norwegian municipalities (n = 1337). 52.8% (707/1337) of the students consented to further participation in the trial and were randomly allocated to one of three MoodGYM intervention groups (tailored weekly e-mail reminder (n = 175), standardized weekly e-mail reminder (n = 176 ) or no e-mail reminder (n = 175)) or a waitlist control group (n = 180). We tested for effects of the intervention on depression and self-esteem using multivariate analysis of variance, effects of tailored e-mail and self-reported current need of help on initial uptake of the intervention using logistic regression and the effect of weekly e-mails on adherence using ordinal regression.

RESULTS

There was substantial non-participation from the intervention, with only 8.5% (45/527) participants logging on to MoodGYM, and few proceeding beyond the first part of the programme. No significant effect on depression or self-esteem was found among the sample as a whole or among participants with elevated depression scores at baseline. Having a higher average grade in senior high school predicted initial uptake of the intervention, but tailored e-mail and self-reported current need of help did not. Weekly e-mail prompts did not predict adherence. The main reasons for non-use reported were lack of time/forgetting about it and doubt about the usefulness of the program.

CONCLUSION

Overall, disseminating a self-directed internet-based intervention to a school population proved difficult despite steps taken to reduce barriers in terms of tailoring feedback and dispatching weekly e-mail reminders. Providing mental health interventions within the school environment is likely to ensure better uptake among senior high school students, but there is a need to effectively communicate that such programmes can be helpful.

TRIAL REGISTRATION

The trial was registered retrospectively as ACTRN12612001106820.

Implementation of a school-based internet obesity prevention program for adolescents

OBJECTIVE

To evaluate the reach, adoption, and implementation of HEALTH[e]TEEN, a school-based Internet obesity prevention program, and examine differences in student participation and satisfaction by school, gender, age, and race/ethnicity.

DESIGN

Concurrent mixed method evaluation.

SETTING

Three public high schools in Connecticut.

PARTICIPANTS

Three hundred eighty-four adolescents, 8 teachers.

INTERVENTION(S)

HEALTH[e]TEEN vs HEALTH[e]TEEN plus coping skills training.

MAIN OUTCOME MEASURE(S)

Demographic and state-available data, measurements of student satisfaction and participation, interviews with school administrators and teachers.

ANALYSIS

Mixed and logistic models, content analysis.

RESULTS

The sample (n = 384) was diverse (35% white), with a mean age of 15.3 years and mean body mass index of 24.7 kg/m(2). Student participation (83% of lessons completed) and satisfaction (mean 3.6 out of 5) was high. Schools implementing the program in class had higher satisfaction and participation compared with schools that implemented the program as homework (P ≤ .001 and < .001, respectively). Girls had higher satisfaction and participation compared with boys (P = .02 and .03, respectively). Younger students had higher participation compared with older students, but no difference in satisfaction was noted (P = .03).

CONCLUSIONS AND IMPLICATIONS

Two school-based Internet programs to decrease obesity reached diverse adolescents, and were adopted and implemented with high student satisfaction and participation. Implementation of the intervention was influenced by setting (classroom vs homework), teacher characteristics, student age, and gender.

Rethinking the dose-response relationship between usage and outcome in an online intervention for depression: randomized controlled trial

Background

There is now substantial evidence that Web-based interventions can be effective at changing behavior and successfully treating psychological disorders. However, interest in the impact of usage on intervention outcomes has only been developed recently. To date, persistence with or completion of the intervention has been the most commonly reported metric of use, but this does not adequately describe user behavior online. Analysis of alternative measures of usage and their relationship to outcome may help to understand how much of the intervention users may need to obtain a clinically significant benefit from the program.

Objective

The objective of this study was to determine which usage metrics, if any, are associated with outcome in an online depression treatment trial.

Methods

Cardiovascular Risk E-couch Depression Outcome (CREDO) is a randomized controlled trial evaluating an unguided Web-based program (E-couch) based on cognitive behavioral therapy and interpersonal therapy for people with depression and cardiovascular disease. In all, 280 participants in the active arm of the trial commenced the program, delivered in 12 modules containing pages of text and activities. Usage data (eg, number of log-ins, modules completed, time spent online, and activities completed) were captured automatically by the program interface. We estimated the association of these and composite metrics with the outcome of a clinically significant improvement in depression score on the Patient Health Questionnaire (PHQ-9) of ≥5 points.

Results

In all, 214/280 (76.4%) participants provided outcome data at the end of the 12-week period and were included in the analysis. Of these, 94 (43.9%) participants obtained clinically significant improvement. Participants logged into the program an average of 18.7 times (SD 8.3) with most (62.1%, 133/214) completing all 12 modules. Average time spent online per log-in was 17.3 minutes (SD 10.5). Participants completed an average of 9 of 18 activities available within the program. In a multivariate regression model, only the number of activities completed per log-in was associated with a clinically significant outcome (OR 2.82, 95% CI 1.05-7.59). The final model predicted 7.4% of variance in outcome. Curve estimates indicated that significant logarithmic (P=.009) and linear (P=.002) relationships existed between activities completed per log-in and clinically significant change.

Conclusions

Only one objective measure of usage was independently associated with better outcome of a Web-based intervention of known effectiveness. The 4 usage metrics retained in the final step of the regression accounted for little outcome variance. Medium level users appeared to have little additional benefit compared to low users indicating that assumptions of a linear relationship between use and outcome may be too simplistic and further models and variables need to be explored to adequately understand the relationship.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000085077; http://www.anzctr.org.au/ACTRN12610000085077.aspx (Archived by WebCite at http://www.webcitation.org/6K9FQtKBn).

A service-based evaluation of a therapist-supported online cognitive behavioral therapy program for depression

BACKGROUND

Evidence suggests that Internet-delivered cognitive behavioral therapy (CBT) may be as effective as face-to-face delivery for depression, but attrition and engagement rates remain a challenge.

OBJECTIVE

This service-based study aimed to evaluate an online, therapist-supported, CBT-based program for depression. The program was specifically designed to address engagement issues, most notably by integrating online therapist support and communication within the platform.

METHODS

Participants were 80 adults who were registered university students. Participants used the modular online program over 8 weeks, supported by a therapist. Engagement information was gathered automatically by the online system, and analyzed for all participants. Severity of participants' self-reported symptoms of depression were assessed preintervention and postintervention using the Beck Depression Inventory-II (BDI-II). Postintervention measures were completed by 53 participants.

RESULTS

A high level of engagement was observed compared to a previous study within the same service, along with extensive use of a range of program features. A statistically significant (P<.001) decrease in self-reported depressive symptomatology from preintervention (mean BDI-II 25.47) to postintervention (mean BDI-II 15.53) with a large effect size (d=1.17) was also observed.

CONCLUSIONS

The results indicate the potential of unintrusive and easily provided online support to enhance engagement with online interventions. The system described in the paper also illustrates how such online support can be tightly integrated with interactive online programs by using a range of design strategies intended to improve the user experience.

Adherence to the MoodGYM program: outcomes and predictors for an adolescent school-based population

BACKGROUND

Program adherence has been associated with improved intervention outcomes for mental and physical conditions. The aim of the current study is to investigate adolescent adherence to an Internet-based depression prevention program in schools to identify the effect of adherence on outcomes and to ascertain the predictors of program adherence.

METHODS

Data for the current study (N=1477) was drawn from the YouthMood Project, which was conducted to test the effectiveness of the MoodGYM program in reducing and preventing symptoms of anxiety and depression in an adolescent school-based population. The current study compares intervention effects across three sub-groups: high adherers, low adherers and the wait-list control condition.

RESULTS

When compared to the control condition, participants in the high adherence intervention group reported stronger intervention effects at post-intervention and 6-month follow-up than participants in the low adherence group for anxiety (d=0.34-0.39 vs. 0.11-0.22), and male (d=0.43-0.59 vs. 0.26-0.35) and female depression (d=0.13-0.20 vs. 0.02-0.04). No significant intervention effects were identified between the high and low adherence groups. Being in Year 9, living in a rural location and having higher pre-intervention levels of depressive symptoms or self-esteem were predictive of greater adherence to the MoodGYM program.

LIMITATIONS

The program trialled is Internet-based and therefore the predictors of adherence identified may not generalise to face-to-face interventions.

CONCLUSIONS

The current study provides preliminary support for the positive relationship between program adherence and outcomes in a school environment. The identification of significant predictors of adherence will assist in identifying the type of user who will engage most with an online depression prevention program.

An internet obesity prevention program for adolescents

PURPOSE

To compare the effectiveness of two school-based internet obesity prevention programs for diverse adolescents on body mass index (BMI), health behaviors, and self-efficacy, and to explore moderators of program efficacy. It was hypothesized that the addition of coping skills training to a health education and behavioral support program would further enhance health outcomes.

METHODS

A randomized clinical trial with cluster randomization by class and repeated measures with follow-up at 3 and 6 months was conducted (n = 384). BMI was assessed by use of standard procedures. Sedentary behavior, physical activity, nutrition behavior, self-efficacy, and satisfaction were assessed with self-report measures. Data analysis consisted of mixed model analyses with autoregressive covariance structure for repeated data by use of intent-to-treat procedures.

RESULTS

The mean age of students was 15.31 years (±0.69), with a mean BMI of 24.69 (±5.58). The majority were girls (62%) and of diverse race/ethnicity (65% non-white). There were no significant differences between groups on any outcomes and no change in BMI over time. There were significant improvements in health behaviors (sedentary behavior, moderate and vigorous physical activity, healthy eating, fruit and vegetable intake, sugar beverages, and junk food intake) and self-efficacy. Gender and lesson completion moderated select health outcomes. There was excellent participation and high satisfaction with the programs.

CONCLUSIONS

School-based internet obesity prevention programs are appealing to adolescents and improve health behaviors. The differential effect of coping skills training may require longer follow-up.

Prevalence and characteristics of smokers interested in internet-based smoking cessation interventions: cross-sectional findings from a national household survey

Background

An accurate and up-to-date estimate of the potential reach of Internet-based smoking cessation interventions (ISCIs) would improve calculations of impact while an understanding of the characteristics of potential users would facilitate the design of interventions.

Objective

This study reports the prevalence and the sociodemographic, smoking, and Internet-use characteristics of smokers interested in using ISCIs in a nationally representative sample.

Methods

Data were collected using cross-sectional household surveys of representative samples of adults in England. Interest in trying an Internet site or “app” that was proven to help with stopping smoking was assessed in 1128 adult smokers in addition to sociodemographic characteristics, dependence, motivation to quit, previous attempts to quit smoking, Internet and handheld computer access, and recent types of information searched online.

Results

Of a representative sample of current smokers, 46.6% (95% CI 43.5%-49.6%) were interested in using an Internet-based smoking cessation intervention. In contrast, only 0.3% (95% CI 0%-0.7%) of smokers reported having used such an intervention to support their most recent quit attempt within the past year. After adjusting for all other background characteristics, interested smokers were younger (OR=0.98, 95% CI 0.97-0.99), reported stronger urges (OR=1.29, 95% CI 1.10-1.51), were more motivated to quit within 3 months (OR=2.16, 95% CI 1.54-3.02), and were more likely to have made a quit attempt in the past year (OR=1.76, 95% CI 1.30-2.37), access the Internet at least weekly (OR=2.17, 95% CI 1.40-3.36), have handheld computer access (OR=1.65, 95% CI 1.22-2.24), and have used the Internet to search for online smoking cessation information or support in past 3 months (OR=2.82, 95% CI 1.20-6.62). There was no association with social grade.

Conclusions

Almost half of all smokers in England are interested in using online smoking cessation interventions, yet fewer than 1% have used them to support a quit attempt in the past year. Interest is not associated with social grade but is associated with being younger, more highly motivated, more cigarette dependent, having attempted to quit recently, having regular Internet and handheld computer access, and having recently searched for online smoking cessation information and support.

Type 1 diabetes eHealth psychoeducation: youth recruitment, participation, and satisfaction

Background

The Internet and other eHealth technologies offer a platform for improving the dissemination and accessibility of psychoeducational programs for youth with chronic illness. However, little is known about the recruitment process and yield of diverse samples in Internet research with youth who have a chronic illness.

Objective

The purpose of this study was to compare the demographic and clinical characteristics of youth with Type 1 diabetes on recruitment, participation, and satisfaction with 2 eHealth psychoeducational programs.

Methods

Youth with Type 1 diabetes from 4 sites in the United States were invited to participate (N=510) with 320 eligible youth consenting (mean age=12.3, SD 1.1; 55.3% female; 65.2% white; and mean A1C=8.3, SD 1.5). Data for this secondary analysis included demographic information (age, race/ethnicity, and income), depressive symptoms, and recruitment rates, including those who refused at point of contact (22.0%), passive refusers who consented but did not participate (15.3%), and those who enrolled (62.7%). Participation (80% lessons completed) and a satisfaction survey (ie, how helpful, enjoyable) were also analyzed. Chi-square or analysis of variance (ANOVA) analyses were used.

Results

There were significant differences in recruitment rates by income and race/ethnicity such that black, Hispanic, or mixed race/ethnicity and low-income youth were more likely to refuse passively compared to white and higher-income youth who were more likely to enroll (P<.001). Participation in program sessions was high, with 78.1% of youth completing at least 4 of 5 sessions. There were no significant differences in participation by program, age, gender, or race/ethnicity. Low-income youth were less likely to participate (P=.002). Satisfaction in both programs was also high (3.9 of 5). There were significant gender, race/ethnicity, and income differences, in that girls (P=.001), black, Hispanic, or mixed race/ethnicity youth (P=.02), and low-income youth (P=.02) reported higher satisfaction. There were no differences in satisfaction by program or age.

Conclusions

Results indicate that black, Hispanic, or mixed race/ethnicity youth and low-income youth with Type 1 diabetes are less likely to enroll in Internet-based research than white and higher-income youth; thus, creative recruitment approaches are needed. Low-income youth were less likely to participate, possibly due to access. However, once enrolled, youth of diverse race/ethnicity and low-income youth with Type 1 diabetes were as highly satisfied with the eHealth programs as white youth and those with higher income. Results suggest that eHealth programs have the potential to reach diverse youth and be appealing to them.

Effectiveness of a web-based cognitive-behavioral tool to improve mental well-being in the general population: randomized controlled trial

Background

Interventions to promote mental well-being can bring benefits to the individual and to society. The Internet can facilitate the large-scale and low-cost delivery of individually targeted health promoting interventions.

Objective

To evaluate the effectiveness of a self-directed Internet-delivered cognitive-behavioral skills training tool in improving mental well-being in a population sample.

Methods

This was a randomized trial with a waiting-list control. Using advertisements on a national health portal and through its mailing list, we recruited 3070 participants aged 18 or over, resident in England, and willing to give their email address and access a fully automated Web-based intervention. The intervention (MoodGYM) consisted of 5 interactive modules that teach cognitive-behavioral principles. Participants in the intervention arm received weekly email reminders to access the intervention. The control group received access to the intervention after the trial was completed and received no specific intervention or email reminders. Outcomes were assessed by using self-completion questionnaires. The primary outcome was mental well-being measured with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes were Center for Epidemiologic Studies Depression scale (CES-D) depression scores, Generalized Anxiety Disorder 7-item scale (GAD-7) anxiety scores, EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) quality of life scores, physical activity, and health service use. All outcomes were measured at baseline, and at 6- and 12-week follow-ups.

Results

A total of 1529 (49.80%) participants completed final follow-up at 12 weeks. Retention was 73.11% (1123/1536) in the control arm and 26.47% (406/1534) in the intervention arm. No relationship between baseline measures and withdrawal could be established. The analysis of WEMWBS mental well-being scores using a linear mixed model for repeated measures showed no difference between intervention and control group at baseline (difference –0.124 points, 95% CI –0.814 to 0.566), and significant improvements for the intervention group at 6 weeks (2.542 points, 95% CI 1.693-3.390) and at 12 weeks (2.876 points, 95% CI 1.933-3.819). The model showed a highly significant (P<.001) intervention by time interaction effect. There were also significant improvements in self-rated scores of depression and anxiety. Given the high level of attrition, a sensitivity analysis with imputed missing values was undertaken that also showed a significant positive effect of the intervention.

Conclusions

Participants allocated to the intervention arm had an average increase of approximately 3 points on the WEMWBS scale compared to no increase for participants in the control group. Three points on this scale is approximately one-third of a standard deviation. In a low-cost automated intervention designed to shift the population distribution of mental well-being, a small difference per individual could yield a major benefit in population terms. In common with other Web-based interventions, there were high rates of attrition. Further work is needed to improve acceptability, to evaluate against placebo effect, and to disaggregate the effect on mental well-being from the effect on depression and anxiety.

Trial Registration

International Standard Randomised Controlled Trial Number Register ISRCTN 48134476; http://www.controlled-trials.com/ISRCTN48134476 (Archived by WebCite® at http://www.webcitation.org/6DFgW2p3Q)

To adhere or not, and what we can do to help

Two factors predict treatment outcome, how effective the treatment is and whether the patient takes or follows the treatment plan. As clinicians or scientists, we strive to develop newer and more effective treatments, both pharmacological and non-pharmacological to improve treatment outcome in our patient population. Adherence is the single most modifiable factor associated with treatment outcome, yet how often is the issue of adherence addressed in clinical consultations? The best treatment is rendered useless if not adhered to. Initial adherence rates are low and get worse with time, but methodological difficulties in studies make it difficult to determine both the clinical implication of suboptimal adherence and successful strategies. Further research should apply more rigour to the area of definition and measurement, be sufficiently powered and long term, and measure possible confounders, to allow for an understanding on the link and impact between adherence and clinical outcome. This article reviews some of the main issues with regard to adherence and cost implications of suboptimal adherence and suggests future directions.

Persuasive system design does matter: a systematic review of adherence to web-based interventions

Background

Although web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed. Technology as a means to communicate the content in web-based interventions has been neglected in research. Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content. In this paper we examine technology from a holistic perspective. We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence.

Objective

This study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention.

Methods

We conducted a systematic review of studies into web-based health interventions. Per intervention, intervention characteristics, persuasive technology elements and adherence were coded. We performed a multiple regression analysis to investigate whether these variables could predict adherence.

Results

We included 101 articles on 83 interventions. The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention. Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 2.9 out of a possible 7.0). Dialogue support and social support are less commonly employed (mean 1.5 and 1.2 out of a possible 7.0, respectively). When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = .004), setup (p < .001), updates (p < .001), frequency of interaction with a counselor (p < .001), the system (p = .003) and peers (p = .017), duration (F = 6.068, p = .004), adherence (F = 4.833, p = .010) and the number of primary task support elements (F = 5.631, p = .005). Our final regression model explained 55% of the variance in adherence. In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence.

Conclusions

Using intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained. Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence. Rather, the differences in technology and interaction predict adherence. The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere.

Survey non-response in an internet-mediated, longitudinal autism research study

OBJECTIVE

To evaluate non-response rates to follow-up online surveys using a prospective cohort of parents raising at least one child with an autism spectrum disorder. A secondary objective was to investigate predictors of non-response over time.

MATERIALS AND METHODS

Data were collected from a US-based online research database, the Interactive Autism Network (IAN). A total of 19,497 youths, aged 1.9-19 years (mean 9 years, SD 3.94), were included in the present study. Response to three follow-up surveys, solicited from parents after baseline enrollment, served as the outcome measures. Multivariate binary logistic regression models were then used to examine predictors of non-response.

RESULTS

31,216 survey instances were examined, of which 8772 or 28.1% were partly or completely responded to. Results from the multivariate model found non-response of baseline surveys (OR 28.0), years since enrollment in the online protocol (OR 2.06), and numerous sociodemographic characteristics were associated with non-response to follow-up surveys (all p<0.05).

DISCUSSION

Consistent with the current literature, response rates to online surveys were somewhat low. While many demographic characteristics were associated with non-response, time since registration and participation at baseline played the greatest role in predicting follow-up survey non-response.

CONCLUSION

An important hazard to the generalizability of findings from research is non-response bias; however, little is known about this problem in longitudinal internet-mediated research (IMR). This study sheds new light on important predictors of longitudinal response rates that should be considered before launching a prospective IMR study.

Vitality predicts level of guideline-concordant care in routine treatment of mood, anxiety and somatoform disorders

OBJECTIVE

To examine the clinical and psychosocial correlates of adherence to treatment guidelines among outpatients with common mental disorders in a routine clinical setting.

METHODS

In this retrospective cohort study, we analysed 192 patients who were treated for a mood, anxiety or somatoform disorder with pharmacotherapy, psychotherapy or a combination of both treatment modalities. Guideline adherence was assessed with a disorder independent set of quality indicators during up to 3 years of follow-up. At baseline, a standardized diagnostic interview, the Brief Symptom Inventory (BSI), the Short Form 36 (SF-36) and demographic variables were assessed. Using multivariable regression analysis we identified independent predictors associated with guideline adherence.

RESULTS

Patients were aged 36.8 years (SD 11.6) on average. The majority of patients were treated with psychotherapy (47.4%), followed by pharmacotherapy (37.5%) and a combination of pharmacotherapy and psychotherapy (15.1%). Three adherence groups were defined: low (29.7%), intermediate (43.2%) and high (27.1%). Univariate predictors of low adherence were low scores on the subscales vitality and social functioning of the SF-36. In the multivariable model, low adherence was independently predicted by a score lower than 50 on the subscale vitality of the SF-36 (odds ratio per 10 units increase in vitality = 1.34, 95% confidence interval: 1.06-1.71). No significant differences were found within socio-demographic variables, co-morbidity and the scores on the BSI subscales between the adherence groups.

CONCLUSIONS

We found that patients with low scores on the vitality subscale of the SF-36 were at the highest risk to receive low guideline-concordant care. Understanding factors that affect treatment adherence may help to prevent non-adherence and increase the quality of care as well as cost-effectiveness.

Psychological and educational interventions for preventing depression in children and adolescents

BACKGROUND

Depression is common in young people, has a marked negative impact and is associated with self-harm and suicide. Preventing its onset would be an important advance in public health.  

OBJECTIVES

To determine whether psychological or educational interventions, or both, are effective in preventing the onset of depressive disorder in children and adolescents.

SEARCH METHODS

The Cochrane Depression, Anxiety and Neurosis Review Group's trials registers (CCDANCTR) were searched at the editorial base in July 2010. Update searches of MEDLINE, EMBASE, PsycINFO and ERIC were conducted by the authors in September 2009. Conference abstracts, reference lists of included studies and reviews were searched and experts in the field contacted.

SELECTION CRITERIA

Randomised controlled trials of psychological or educational prevention programmes, or both, compared with placebo, any comparison intervention, or no intervention for young people aged 5 to 19 years-old, who did not currently meet diagnostic criteria for depression or who were below the clinical range on standardised, validated, and reliable rating scales of depression, or both, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion and rated their quality. Sample sizes were adjusted to take account of cluster designs and multiple comparisons. We contacted study authors for additional information where needed. 

MAIN RESULTS

Fifty-three studies including 14,406 participants were included in the analysis. There were only six studies with clear allocation concealment, participants and assessors were mostly not blind to the intervention or blinding was unclear so that the overall risk of bias was moderately high. Sixteen studies including 3240 participants reported outcomes on depressive diagnosis. The risk of having a depressive disorder post-intervention was reduced immediately compared with no intervention (15 studies; 3115 participants risk difference (RD) -0.09; 95% confidence interval (CI) -0.14 to -0.05; P<0.0003), at three to nine months (14 studies; 1842 participants; RD -0.11; 95% CI -0.16 to -0.06) and at 12 months (10 studies; 1750 participants; RD -0.06; 95% CI -0.11 to -0.01). There was no evidence for continued efficacy at 24 months (eight studies; 2084 participant; RD -0.01; 95% CI -0.04 to 0.03) but limited evidence of efficacy at 36 months (two studies; 464 participants; RD -0.10; 95% CI -0.19 to -0.02). There was significant heterogeneity in all these findings. There was no evidence of efficacy in the few studies that compared intervention with placebo or attention controls.

AUTHORS' CONCLUSIONS

There is some evidence from this review that targeted and universal depression prevention programmes may prevent the onset of depressive disorders compared with no intervention. However, allocation concealment is unclear in most studies, and there is heterogeneity in the findings. The persistence of findings suggests that this is real and not a placebo effect. 

Health literacy and willingness to use online health information by teens with asthma and diabetes

OBJECTIVE

This study measured health literacy in a population of teens in treatment for asthma or diabetes and tested the association between health literacy and willingness to use online health resources.

MATERIALS AND METHODS

About 180 patients aged 13-18 years treated for asthma or diabetes in specialty care clinics completed assessments of demographic characteristics, health literacy, and Internet access and use. Teens were provided a resource page listing selected publically available health-related Web sites and asked about perceived ease of use, perceived usefulness, and intent to use the listed Web sites. The relationship between demographic characteristics, health literacy, and online health information use was tested using chi-squared or Fisher's exact test. Predictors of intent to use resource page Web sites were assessed using bivariate and multivariate ordinal logistic regression.

RESULTS

About 92% of participants had adequate health literacy. Over 50% of participants had previously searched online for health information. Older age was the only significant predictor of health information search. Most teens (79%) reported intent to use at least one Web site from the resource page at least occasionally within the next 3 months. Higher health literacy (odds ratio [OR]=6.24, p<0.01) and stronger perceived usefulness (OR=1.74, p=0.01) were associated with greater intent for regular use, after controlling for demographic and Internet access variables.

CONCLUSIONS

Teens with lower health literacy searched online for health information as often as peers with higher literacy, but were less likely to express the intent to use recommended sites. Belief in the usefulness of a Web site is the strongest attitudinal predictor of intended future use.

Usefulness of internet in adolescent mental health outpatient care

Internet has become increasingly common in adolescents' daily lives and also in health care. However, there is still need to explore how nurses perceive its use as a part of adolescents' treatment. This explorative qualitative study aim was to explore how nurses perceive the usefulness of Internet in adolescents' outpatient care in mental health. The data were collected among nurses (n=12) working in two psychiatric adolescent outpatient clinics in university central hospitals in Finland. The data were collected in focus group interviews and analysed using inductive content analysis. The analysis showed that Internet use could promote the care process of adolescents with depression by supporting their self-reflection and self-management, enhancing nurses' understanding of adolescents' daily lives and facilitating nurse-adolescent interaction. Disadvantages identified among nurses were fear of role changes in the nurse-adolescent interaction, changes in the intervention, when Internet might be a third party in the face-to-face interaction and negative effects of Internet on adolescents. Facilitators in the use of Internet were nurses' positive attitude to Internet, knowledge and experiences of Internet usage. Nurses' negative attitude to Internet and lack of training and instructions were seen as barriers in promoting the successful utilization of Internet among adolescents with depression in outpatient care.

Internet-based depression prevention over the life course: a call for behavioral vaccines

Technology-based approaches for the prevention of depression offer considerable benefits including easy access, patient autonomy, and "nonconsumable" services that are autonomous from traditional (face-to-face) interventions. The authors have previously worked to develop Internet interventions based on the frameworks for conventional, face-to-face effective community-based interventions, and propose to integrate these models into a "behavioral vaccine model" aptly applicable to technology-based delivery. This article reviews the literature on Internet-based depression prevention programs using this behavioral vaccine development model, reviewing literature relevant to each component of the model in turn.

The use of e-health applications for anxiety and depression in young people: challenges and solutions

AIM

E-health applications are effective. However, challenges to their uptake amongst youth need to be investigated. This paper aims to explore the barriers to the use of these programs by young people and the methods by which these barriers might be overcome.

METHODS

Qualitative review of research literature.

RESULTS

Barriers to the use of these programs included the difficulty in engaging young people in their use, perceptions that the programs have low adherence, and clinician concerns about their value, effectiveness and safety. Evidence to date suggests that more research is needed to understand the reasons more young people do not engage with them. However, adherence rates are reasonable when properly benchmarked and the applications can be appropriately implemented in clinical and educational settings.

CONCLUSIONS

Optimal methods for implementing these applications will require further targeted research.

Theme issue on e-mental health: a growing field in internet research

This theme issue on e-mental health presents 16 articles from leading researchers working on systems and theories related to supporting and improving mental health conditions and mental health care using information and communication technologies. In this editorial, we present the background of this theme issue, and highlight the content of this issue.

Online group course for parents with mental illness: development and pilot study

Background

Children of parents with mental illness (COPMI) are at greater risk of developing mental disorders themselves. Since impaired parenting skills appear to be a crucial factor, we developed a facilitated 8-session preventative group course called KopOpOuders (Chin Up, Parents) delivered via the Internet to Dutch parents with psychiatric problems. The goal was to promote children’s well-being by strengthening children’s protective factors via their parents. To reach parents at an early stage of their parenting difficulties, the course is easily accessible online. The course is delivered in a secure chat room, and participation is anonymous.

Objective

This paper reports on (1) the design and method of this online group course and (2) the results of a pilot study that assessed parenting skills, parental sense of competence, child well-being, and course satisfaction.

Method

The pilot study had a pre/post design. Parenting skills were assessed using Laxness and Overreactivity subscales of the Parenting Scale (PS). Sense of parenting competence was measured with the Ouderlijke Opvattingen over Opvoeding (OOO) questionnaire, a Dutch scale assessing parental perceptions of parenting using the Feelings of Incompetence and Feelings of Competence subscales. Child well-being was assessed with the total problem score, Emotional Problems, and Hyperactivity subscales of the Strengths and Difficulties Questionnaire (SDQ). Paired samples t tests were performed, and Cohen’s d was used to determine effect sizes. Intention-to-treat analyses and analyses of completers only were both performed. Course satisfaction was evaluated using custom-designed questionnaires.

Results

The sample comprised 48 parents with mental illness. The response rate was 100% (48/48) at pretest and 58% (28/48) at posttest. Significant improvements were found on PS Laxness and Overreactivity subscales (P < .01) and on the OOO Feelings of Incompetence and Competence subscales (P < .01) in analysis of completers only as well as by intention-to-treat analysis. Effects were moderate on the PS (d = .52 and d = .48) and were large and moderate on the OOO (d = 0.61 and d = 0.46). At pretest, 75% and 64% of PS scores were in the clinical range, which declined to 43% and 39% at posttest. No significant changes were found for child well-being. Scores for approximately two thirds of children were not in the clinical range at both pretest and posttest. The mean course satisfaction score was 7.8 on a 10-point scale. Of all participants, 20% (10/48) followed all the sessions.

Conclusion

This online group course on parenting skills is innovative in the field of e-support and among interventions for mentally ill parents. The pilot results are promising, showing moderate to large effects for parenting skills and parental sense of competence. Test scores at baseline indicating parenting problems were largely in the clinical range, and baseline scores indicating problems among the children were in the nonclinical range, suggesting that parents were reached at an early stage. Course satisfaction was high. Future research should focus on cost effectiveness and course adherence.

The ins and outs of an online bipolar education program: a study of program attrition

BACKGROUND

The science of eHealth interventions is rapidly evolving. However, despite positive outcomes, evaluations of eHealth applications have thus far failed to explain the high attrition rates that are associated with some eHealth programs. Patient adherence remains an issue, and the science of attrition is still in its infancy. To our knowledge, there has been no in-depth qualitative study aimed at identifying the reasons for nonadherence to-and attrition from- online interventions.

OBJECTIVE

This paper explores the predictors of attrition and participant-reported reasons for nonadherence to an online psycho-education program for people newly diagnosed with a bipolar disorder.

METHODS

As part of an ongoing randomized controlled trial (RCT) evaluating an online psycho-education program for people newly diagnosed with a bipolar disorder, we undertook an in-depth qualitative study to identify participants' reasons for nonadherence to, and attrition from, the online intervention as well as a quantitative study investigating predictors of attrition. Within the RCT, 370 participants were randomly allocated to 1 of 2 active interventions or an attention control condition. Descriptive analyses and chi-square tests were used to explore the completion rates of 358 participants, and standard regression analysis was used to identify predictors of attrition. The data from interviews with a subsample of 39 participants who did not complete the online program were analyzed using "thematic analysis" to identify patterns in reported reasons for attrition.

RESULTS

Overall, 26.5% of the sample did not complete their assigned intervention. Standard multiple regression analysis revealed that young age (P= .004), male gender (P= .001), and clinical recruitment setting (P= .001) were significant predictors of attrition (F(7,330)= 8.08, P< .001). Thematic analysis of interview data from the noncompleter subsample revealed that difficulties associated with the acute phases of bipolar disorder, not wanting to think about one's illness, and program factors such as the information being too general and not personally tailored were the major reasons for nonadherence.

CONCLUSIONS

The dropout rate was equivalent to other Internet interventions and to face-to-face therapy. Findings from our qualitative study provide participant-reported reasons for discontinuing the online intervention, which, in conjunction with the quantitative investigations about predictors, add to understanding about Internet interventions. However, further research is needed to determine whether there are systematic differences between those who complete and those who do not complete eHealth interventions. Ultimately, this may lead to the identification of population subgroups that most benefit from eHealth interventions and to informing the development of strategies to improve adherence.

TRIAL REGISTRATION

ACTRN12608000411347; http://www.anzctr.org.au/ACTRN12608000411347.aspx (Archived by WebCite at http://www.webcitation.org/5uX4uYwVN).

Stages of use: consideration, initiation, utilization, and outcomes of an internet-mediated intervention

BACKGROUND

Attrition, or nonuse of the intervention, is a significant problem in e-health. However, the reasons for this phenomenon are poorly understood. Building on Eysenbach's "Law of Attrition", this study aimed to explore the usage behavior of users of e-health services. We used two theoretical models, Andersen's Behavioral Model of Health Service Utilization and Venkatesh's Unified Theory of Acceptance and Use of Technology, to explore the factors associated with uptake and use of an internet-mediated intervention for caregivers taking care of a family member with dementia.

METHODS

A multiphase, longitudinal design was used to follow a convenience sample of 46 family caregivers who received an e-health intervention. Applying the two theories, usage behavior was conceptualized to form four stages: consideration, initiation, utilization (attrition or continuation), and outcome. The variables and measurement scales were selected based on these theories to measure the sociodemographic context, technology aptitudes, and clinical needs of the caregivers.

RESULTS

In the Consideration Stage, caregivers who felt that the information communication technology (ICT)-mediated service was easy to use were more likely to consider participating in the study (p = 0.04). In the Initiation Stage, caregivers who showed greater technology acceptance were more likely to initiate service earlier (p = 0.02). In the Utilization Stage, the frequent users were those who had a more positive attitude toward technology (p = 0.04) and a lower perceived caregiver competence (p = 0.04) compared with nonusers. In the Outcome Stage, frequent users experienced a decline in perceived burden compared with an escalation of perceived burden by nonusers (p = 0.02).

CONCLUSIONS

We illustrate a methodological framework describing how to develop and expand a theory on attrition. The proposed framework highlighted the importance of conceptualizing e-health "use" and "adoption" as dynamic, continuous, longitudinal processes occurring in different stages, influenced by different factors to predict advancement to the next stage. Although usage behavior was influenced mainly by technological factors in the initial stages, both clinical and technological factors were equally important in the later stages. Frequency of use was associated with positive clinical outcomes. A plausible explanation was that intervention benefits motivated the caregivers to continue the service and regular use led to more positive clinical outcome.

Engagement and retention: measuring breadth and depth of participant use of an online intervention

BACKGROUND

The Internet provides us with tools (user metrics or paradata) to evaluate how users interact with online interventions. Analysis of these paradata can lead to design improvements.

OBJECTIVE

The objective was to explore the qualities of online participant engagement in an online intervention. We analyzed the paradata in a randomized controlled trial of alternative versions of an online intervention designed to promote consumption of fruit and vegetables.

METHODS

Volunteers were randomized to 1 of 3 study arms involving several online sessions. We created 2 indirect measures of breadth and depth to measure different dimensions and dynamics of program engagement based on factor analysis of paradata measures of Web pages visited and time spent online with the intervention materials. Multiple regression was used to assess influence of engagement on retention and change in dietary intake.

RESULTS

Baseline surveys were completed by 2513 enrolled participants. Of these, 86.3% (n = 2168) completed the follow-up surveys at 3 months, 79.6% (n = 2027) at 6 months, and 79.4% (n = 1995) at 12 months. The 2 tailored intervention arms exhibited significantly more engagement than the untailored arm (P < .01). Breadth and depth measures of engagement were significantly associated with completion of follow-up surveys (odds ratios [OR] = 4.11 and 2.12, respectively, both P values < .001). The breadth measure of engagement was also significantly positively associated with a key study outcome, the mean increase in fruit and vegetable consumption (P < .001).

CONCLUSIONS

By exploring participants' exposures to online interventions, paradata are valuable in explaining the effects of tailoring in increasing participant engagement in the intervention. Controlling for intervention arm, greater engagement is also associated with retention of participants and positive change in a key outcome of the intervention, dietary change. This paper demonstrates the utility of paradata capture and analysis for evaluating online health interventions.

TRIAL REGISTRATION

NCT00169312; http://clinicaltrials.gov/ct2/show/NCT00169312 (Archived by WebCite at http://www.webcitation.org/5u8sSr0Ty).

Evaluation of an online cognitive behavioural therapy program by patients with traumatic brain injury and depression

PRIMARY OBJECTIVE

The most frequently reported psychiatric symptom after traumatic brain injury (TBI) is depression. This study examined whether internet-delivered cognitive behaviour therapy (CBT) could be appropriate and effective for patients with mild or moderate TBI and depression.

METHODS AND PROCEDURES

Patients were recruited for an at-home, 6-week internet-based CBT program (MoodGYM). Participants were assessed during this period by weekly telephone calls and at 12 months post-enrolment. Intervention completion rates, predictors of adherence, user feedback and changes in scores on validated depression scales were assessed.

MAIN OUTCOMES AND RESULTS

Twenty-one patients were recruited: 64% and 43% completed the 6-week intervention and the 12-month follow-up, respectively. Adherence rates were not predicted by demographic or injury characteristics in this small sample. Patients identified reading, memory and comprehension requirements as limitations of the program. Scores on the depression scales were significantly decreased upon completion of the intervention and at the 12-month follow-up.

CONCLUSIONS

The MoodGYM program may be effective for treating symptoms of depression in patients with TBI. While adherence rates were not predicted by age, education level or injury severity, demands upon memory and concentration which may already be compromised in these patients need to be considered.

Achieving adolescent adherence to treatment of major depression

When treatments are ordered for adolescent major depression, or for other adolescent medical illnesses, adherence and clinical outcomes are likely to be unsatisfactory, unless 4 basic principles of the medical treatment of adolescent illness are implemented. These comprise providing effective patient and parent/caregiver education, establishing effective patient and caregiver therapeutic alliances, providing effective treatment, and managing other factors associated with treatment adherence as indicated. The goals of treatment are to achieve the earliest possible response and remission. Failure to treat adolescent major depression successfully has potentially serious consequences, including worsened adherence, long-term morbidity, and suicide attempt. Accordingly, prescribed treatment must be aggressively managed. Doses of an antidepressant medication should be increased as rapidly as can be tolerated, preferably every 1-2 weeks, until full remission is achieved or such dosing is limited by the emergence of unacceptable adverse effects. A full range of medication treatment options must be employed if necessary. Treatment adherence, occurrence of problematic adverse effects, clinical progress, and safety must be systematically monitored. Adolescents with major depression must be assessed for risk of harm to self or others. When this risk appears significant, likelihood of successful outcomes will be enhanced by use of treatment plans that comprehensively address factors associated with treatment nonadherence. Abbreviated and comprehensive plans for the treatment of potentially fatal adolescent illnesses are outlined in this review.

Attrition from self-directed interventions: investigating the relationship between psychological predictors, intervention content and dropout from a body dissatisfaction intervention

The aims of this study were to (a) identify the predictors of attrition from a fully self-directed intervention, and (b) to test whether an intervention to increase gratitude is an effective way to reduce body dissatisfaction. Participants (N=479, from the United Kingdom) aged 18-76 years took part in a self-help study via the Internet and were randomized to receive one of two interventions, gratitude diaries (n=130), or thought monitoring and restructuring (n=118) or a waitlist control (n=231) for a two week body dissatisfaction intervention. The gratitude intervention (n=40) was as effective as monitoring and restructuring (n=22) in reducing body dissatisfaction, and both interventions were significantly more effective than the control condition (n=120). Participants in the gratitude group were more than twice as likely to complete the intervention compared to those in the monitoring and restructuring group. Intervention content, baseline expectancy and internal locus of control significantly predicted attrition. This study shows that a gratitude intervention can be as effective as a technique commonly used in cognitive therapy and is superior in retaining participants. Prediction of attrition is possible from both intervention content and psychological variables.

Adolescent Internet Depression Prevention: Preferences for Intervention and Predictors of Intentions and Adherence

Adolescents in primary care with sub-threshold depression (not reaching criteria for disorder) symptoms may be candidates for early intervention to prevent onset of major depressive disorder. However, we know little about their attitudes toward such interventions or what may predict motivation or adherence for preventive interventions. We also describe preferences for different types of interventions and conduct exploratory analyses to identify predictors of motivation to prevent depression and subsequent adherence to an Internet-based intervention. Adolescents with sub-threshold depressed mood favored novel behavioral treatment approaches, such as Internet-based models for depression prevention. Adolescent beliefs about the intervention and perceived social norms predicted intention to participate in depression prevention. The most important significant predictors of adherence were beliefs about the intervention. Careful attention to the specific beliefs and attitudes of users toward intervention should be incorporated into intervention design as well as evolving public health strategies to prevent depressive disorders.