Which intervention characteristics are related to more exposure to internet-delivered healthy lifestyle promotion interventions? A systematic review

Theoretical Perspectives of Adherence to Web-Based Interventions: a Scoping Review

PURPOSE

The purpose of this paper is to review the literature as this relates to theoretical perspectives of adherence to web-based interventions, drawing upon empirical evidence from the fields of psychology, business, information technology and health care.

METHODS

A scoping review of the literature utilising principles outlined by Arksey and O'Malley was undertaken.

RESULTS

Several relevant theoretical perspectives have emerged, eight of which are charted and discussed in this review. These are the Internet Intervention Model, Persuasive Systems Design, the 'PERMA' framework, the Support Accountability Model, the Model of User Engagement, the Technology Acceptance Model, the Unified Theory of Acceptance and Use of IT and the Conceptual Model of User Engagement.

CONCLUSIONS

The findings of the review indicate that an interdisciplinary approach, incorporating a range of technological, environmental and individual factors, may be needed in order to comprehensively explain user adherence to web-based interventions.

Digital technologies and adherence in respiratory diseases: the road ahead

Outcomes for patients with chronic respiratory diseases remain poor despite the development of novel therapies. In part, this reflects the fact that adherence to therapy is low and clinicians lack accurate methods to assess this issue. Digital technologies hold promise to overcome these barriers to care. For example, algorithmic analysis of large amounts of information collected on health status and treatment use, along with other disease relevant information such as environmental data, can be used to help guide personalised interventions that may have a positive health impact, such as establishing habitual and correct inhaler use. Novel approaches to data analysis also offer the possibility of statistical algorithms that are better able to predict exacerbations, thereby creating opportunities for preventive interventions that may adapt therapy as disease activity changes. To realise these possibilities, digital approaches to disease management should be supported by strong evidence, have a solid infrastructure, be designed collaboratively as clinically effective and cost-effective systems, and reflect the needs of patients and healthcare providers. Regulatory standards for digital interventions and strategies to handle the large amounts of data generated are also needed. This review highlights the opportunities provided by digital technologies for managing patients with respiratory diseases.

A Mobile Phone-Based Healthy Lifestyle Monitoring Tool for People With Mental Health Problems (MyHealthPA): Development and Pilot Testing

Background

People with mental health disorders live, on average, 20 years less than those without, often because of poor physical health including cardiovascular disease (CVD). Evidence-based interventions are required to reduce this lifespan gap.

Objective

This study aimed to develop, test, and evaluate a mobile phone–based lifestyle program (MyHealthPA) to help people with mental health problems improve key health risk behaviors and reduce their risk of CVD.

Methods

The development of MyHealthPA occurred in 3 stages: (1) scoping of the literature, (2) a survey (n=251) among people with and without the experience of mental health problems, and (3) program development informed by stages 1 and 2. A small pilot trial among young people with and without mental health disorders was also conducted. Participants completed a baseline assessment and were given access to the MyHealthPA program for a period of 8 weeks. They were then asked to complete an end-of-treatment assessment and a follow-up assessment 1 month later.

Results

In the study, 28 young people aged 19 to 25 years were recruited to the pilot trial. Of these, 12 (12/28, 43%) had been previously diagnosed with a mental illness. Overall, 12 participants (12/28, 43%) completed the end-of-treatment assessment and 6 (6/28, 21%) completed the follow-up assessment. Small improvements in fruit and vegetable consumption, level of physical activity, alcohol use, and mood were found between baseline and end of treatment and follow-up, particularly among people with experience of mental health issues. Most participants (history of mental illness: 4/7, 57%; no history of mental illness: 3/5, 60%) reported the program had above average usability; however, only 29% (2/7, no history of mental illness) to 40% (2/5, history of mental illness) of participants reported that they would like to use the program frequently and would recommend it to other young people. Participants also identified a number of ways in which the program could be improved.

Conclusions

This study describes the formative research and process of planning that formed the development of MyHealthPA and the evidence base underpinning the approach. The MyHealthPA program represents an innovative approach to CVD risk reduction among people with mental health problems. MyHealthPA appears to be an acceptable, easy-to-use, and potentially effective mHealth intervention to assist young people with mental illness to monitor risk factors for CVD. However, ways in which the program could be improved for future testing and dissemination were identified and discussed.

Systematically Developing a Web-Based Tailored Intervention Promoting HPV-Vaccination Acceptability Among Mothers of Invited Girls Using Intervention Mapping

Background: Currently, the eHealth field calls for detailed descriptions of theory-based interventions in order to support improved design of such interventions. This article aims to provide a systematic description of the design rationale behind an interactive web-based tailored intervention promoting HPV-vaccination acceptability.

Methods: The 6-step Intervention Mapping (IM) protocol was used to describe the design rationale. After the needs assessment in Step 1, intervention objectives were formulated in Step 2. In Step 3, we translated theoretical methods into practical applications, which were integrated into a coherent intervention in Step 4. In Step 5, we anticipated future implementation and adoption, and finally, an evaluation plan was generated in Step 6.

Results: Walking through the various steps of IM resulted in a detailed description of the intervention. The needs assessment indicated HPV-vaccination uptake remaining lower than expected. Mothers play the most important role in decision-making about their daughter's immunization. However, they generally feel ambivalent after they made their decisions, and their decisions are based on rather unstable grounds. Therefore, intervention objectives were to improve HPV-vaccination uptake and informed decision-making, and to decrease decisional conflict among mothers of invited girls. Computer-tailoring was chosen as the main method; virtual assistants were chosen as a practical application to deliver interactive tailored feedback. To maximize compatibility with the needs of the target group, a user-centered design strategy by means of focus groups and online experiments was applied. In these, prototypes were tested and sequentially refined. Finally, efficacy, effectiveness, and acceptability of the intervention were tested in a randomized controlled trial. Results showed a significant positive effect of the intervention on informed decision-making, decisional conflict, and nearly all determinants of HPV-vaccination uptake (P < 0.001). Mothers evaluated the intervention as highly positive.

Discussion: Using IM led to an innovative effective intervention for promoting HPV-vaccination acceptability. The intervention maps will aid in interpreting the results of our evaluation studies. Moreover, it will ease the comparison of design rationales across interventions, and may provide leads for the development of other eHealth interventions. This paper adds to the plea for systematic reporting of design rationales constituting the process of developing interventions.

Reach of Messages in a Dental Twitter Network: Cohort Study Examining User Popularity, Communication Pattern, and Network Structure

Background

Increasing the reach of messages disseminated through Twitter promotes the success of Twitter-based health education campaigns.

Objective

This study aimed to identify factors associated with reach in a dental Twitter network (1) initially and (2) sustainably at individual and network levels.

Methods

We used instructors’ and students’ Twitter usernames from a Saudi dental school in 2016-2017 and applied Gephi (a social network analysis tool) and social media analytics to calculate user and network metrics. Content analysis was performed to identify users disseminating oral health information. The study outcomes were reach at baseline and sustainably over 1.5 years. The explanatory variables were indicators of popularity (number of followers, likes, tweets retweeted by others), communication pattern (number of tweets, retweets, replies, tweeting/ retweeting oral health information or not). Multiple logistic regression models were used to investigate associations.

Results

Among dental users, 31.8% had reach at baseline and 62.9% at the end of the study, reaching a total of 749,923 and dropping to 37,169 users at the end. At an individual level, reach was associated with the number of followers (baseline: odds ratio, OR=1.003, 95% CI=1.001-1.005 and sustainability: OR=1.002, 95% CI=1.0001-1.003), likes (baseline: OR=1.001, 95% CI=1.0001-1.002 and sustainability: OR=1.0031, 95% CI=1.0003-1.002), and replies (baseline: OR=1.02, 95% CI=1.005-1.04 and sustainability: OR=1.02, 95% CI=1.004-1.03). At the network level, users with the least followers, tweets, retweets, and replies had the greatest reach.

Conclusions

Reach was reduced by time. Factors increasing reach at the user level had different impact at the network level. More than one strategy is needed to maximize reach.

Efficacy of online lifestyle interventions targeting lifestyle behaviour change in depressed populations: A systematic review

BACKGROUND

It is well established that depression and non-communicable diseases are highly co-morbid and bi-directional in nature. 'Lifestyle medicine' has recently gained traction in the field of psychiatry, aimed at improvement of both physical and mental health. Online interventions can be an effective and inexpensive alternative or supplement to therapy that is delivered using more traditional modes, overcoming barriers that may prohibit people from accessing treatment by promoting flexibility and accessibility.

METHODS

This systematic review evaluates the existing evidence for the efficacy or effectiveness of lifestyle interventions for (1) individuals with depressive symptoms, (2) clinically depressed populations or discussing the outcomes of depression within a subset of a larger cohort that are delivered online or via smart phone. Included studies were randomised controlled trials, with active comparator conditions, in adult populations and with reported lifestyle and depression-related outcomes. The analysis examined attrition, engagement, adherence and behaviour change techniques employed to achieve the target behaviours.

RESULTS

Seven studies were included in the review and targeted behaviour change in five domains: alcohol reduction, improved sleep quality/insomnia reduction, increased physical activity, reduced/cessation of substance abuse and smoking cessation. Four of the studies achieved significant improvements in the targeted behaviour; of these three also reported significant improvements in depressive symptoms. No studies reported significant improvements in depressive symptoms without a change in the target lifestyle behaviour.

CONCLUSION

The results of this review highlight the potential of online lifestyle interventions as adjunctive treatments for depression, and the possibility of achieving significant improvements in depressive symptoms when targeting lifestyle behaviour change.

A Web-Based Acceptance-Facilitating Intervention for Identifying Patients' Acceptance, Uptake, and Adherence of Internet- and Mobile-Based Pain Interventions: Randomized Controlled Trial

Background

Internet- and mobile-based interventions are effective for the treatment of chronic pain. However, little is known about patients’ willingness to engage with these types of interventions and how the uptake of such interventions can be improved.

Objective

The aim of this study was to identify people’s acceptance, uptake, and adherence (primary outcomes) with regard to an internet- and mobile-based intervention for chronic pain and the influence of an information video as an acceptance-facilitating intervention (AFI).

Methods

In this randomized controlled trial with a parallel design, we invited 489 individuals with chronic pain to participate in a Web-based survey assessing the acceptance of internet- and mobile-based interventions with the offer to receive an unguided internet- and mobile-based intervention for chronic pain after completion. Two versions of the Web-based survey (with and without AFI) were randomly sent to two groups: one with AFI (n=245) and one without AFI (n=244). Participants who completed the Web-based survey with or without AFI entered the intervention group or the control group, respectively. In the survey, the individuals’ acceptance of pain interventions, measured with a 4-item scale (sum score ranging from 4 to 20), predictors of acceptance, sociodemographic and pain-related variables, and physical and emotional functioning were assessed. Uptake rates (log in to the intervention) and adherence (number of completed modules) to the intervention was assessed 4 months after intervention access. To examine which factors influence acceptance, uptake rate, and adherence in the internet- and mobile-based interventions, we conducted additional exploratory subgroup analyses.

Results

In total, 57 (intervention group) and 58 (control group) participants in each group completed the survey and were included in the analyses. The groups did not differ with regard to acceptance, uptake rate, or adherence (P=.64, P=.56, P=.75, respectively). Most participants reported moderate (68/115, 59.1%) to high (36/115, 31.3%) acceptance, with 9.6% (11/115) showing low acceptance (intervention group: mean 13.91, SD 3.47; control group: mean 13.61, SD 3.50). Further, 67% (38/57, intervention group) and 62% (36/58, control group) had logged into the intervention. In both groups, an average of 1.04 (SD 1.51) and 1.14 (SD 1.90) modules were completed, respectively.

Conclusions

The informational video was not effective with regard to acceptance, uptake rate, or adherence. Despite the high acceptance, the uptake rate was only moderate and adherence was remarkably low. This study shows that acceptance can be much higher in a sample participating in an internet- and mobile-based intervention efficacy trial than in the target population in routine health care settings. Thus, future research should focus not only on acceptance and uptake facilitating interventions but also on ways to influence adherence. Further research should be conducted within routine health care settings with more representative samples of the target population.

Trial Registration

German Clinical Trial Registration DRKS00006183; http://www.drks.de/drks_web/navigate.do ?navigationId=trial.HTML&TRIAL_ID=DRKS00006183 (Archived by WebCite at http://www.webcitation.org/70ebHDhne)

Clinician experiences of healthy lifestyle promotion and perceptions of digital interventions as complementary tools for lifestyle behavior change in primary care

BACKGROUND

Evidence-based practice for healthy lifestyle promotion in primary health care is supported internationally by national policies and guidelines but implementation in routine primary health care has been slow. Referral to digital interventions could lead to a larger proportion of patients accessing structured interventions for healthy lifestyle promotion, but such referral might have unknown implications for clinicians with patients accessing such interventions. This qualitative study aimed to explore the perceptions of clinicians in primary care on healthy lifestyle promotion with or without digital screening and intervention.

METHODS

Focus group interviews were conducted at 10 primary care clinics in Sweden with clinicians from different health professions. Transcribed interviews were analyzed using content analysis, with inspiration from a phenomenological-hermeneutic method involving naïve understanding, structural analysis and comprehensive understanding.

RESULTS

Two major themes captured clinicians' perceptions on healthy lifestyle promotion: 1) the need for structured professional practice and 2) deficient professional practice as a hinder for implementation. Sub-themes in theme 1 were striving towards professionalism, which for participants meant working in a standardized fashion, with replicable routines regardless of clinic, as well as being able to monitor statistics on individual patient and group levels; and embracing the future with critical optimism, meaning expecting to develop professionally but also being concerned about the consequences of integrating digital tools into primary care, particularly regarding the importance of personal interaction between patient and provider. For theme 2, sub-themes were being in an unmanageable situation, meaning not being able to do what is perceived as best for the patient due to lack of time and resources; and following one's perception, meaning working from a gut feeling, which for our participants also meant deviating from clinical routines.

CONCLUSIONS

In efforts to increase evidence-based practice and lighten the burden of clinicians in primary care, decision- and policy-makers planning the introduction of digital tools for healthy lifestyle promotion will need to explicitly define their role as complements to face-to-face encounters. Our overriding hope is that this study will contribute to maintaining meaningfulness in the patient-clinician encounter, when digital tools are added to facilitate patient behavior change of unhealthy lifestyle behaviors.

Psychological distress following a motor vehicle crash: preliminary results of a randomised controlled trial investigating brief psychological interventions

BACKGROUND

The preliminary results of a randomised controlled trial are presented. The aim of the trial is to determine the efficacy, feasibility and acceptability of email-delivered psychological interventions with telephone support, for adults injured in a motor vehicle crash engaged in seeking compensation. The primary intention for this preliminary analysis was to investigate those who were psychologically distressed and to stop the trial midway to evaluate whether the safety endpoints were necessary.

METHODS

The analysis included 90 adult participants randomised to one of three groups, who were assessed at baseline and post-intervention at 3 months. Cognitive behaviour therapy (CBT) or healthy lifestyle interventions were delivered over 10 weeks, involving fortnightly emailed modules plus clinically focussed telephone support, with the aim of reducing psychological distress. An active waiting list of control subjects received non-clinically focussed telephone contact over the same period along with claim-related reading material. Depression Anxiety Stress Scales (DASS) and Impact of Events Scale (Revised) (IES-R) were used to assess psychological distress. Psychiatric interviews were used to diagnose major depressive disorder and post-traumatic stress disorder. Aspects of acceptability and feasibility were also assessed.

RESULTS

For those diagnosed with depression at baseline in the CBT group, psychological distress reduced by around 16%. For those with depression in the healthy lifestyle group, distress increased marginally. For those in the control group with depression, distress also decreased (by 18% according to DASS-21 and 1.2% according to IES-R). For those without depression, significant reductions in distress occurred, regardless of group (P < .05). The results suggest that for those with depression, a healthy lifestyle intervention is contraindicated, necessitating the cessation of recruitment to this intervention. The interventions were reported as acceptable by the majority and the data indicated that the study is feasible.

CONCLUSIONS

CBT with telephone support reduced psychological distress in physically injured people with depression who are engaged in seeking compensation. However, time plus fortnightly telephone contact with claim-related reading material may be sufficient to reduce distress in those who are depressed. For those who were not depressed, time plus telephone support is most likely sufficient enough to assist them to recover. The trial will continue with further recruitment to only the CBT and control groups, over longer follow-up periods.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry: Preventing psychological distress following a motor vehicle accident; ACTRN12615000326594 . Registered on 9 April 2015.

Opportunities and challenges of behavior change support systems for enhancing habit formation: A qualitative study

The formation of healthy habits is considered to play a fundamental role in health behavior change. A variety of studies on Health Behavior Change Support Systems (HBCSS) have been conducted recently, in which individuals use such systems to influence their own attitudes or behaviors to achieve their personal goals. However, comparatively much less research has been devoted to studying how the users of these systems form habits with the help of HBCSS, or to understanding how to design these systems to support habit formation.

OBJECTIVE

The objective of this article is to study HBCSS user experiences regarding habit formation through an intervention study targeted at establishing a healthier lifestyle. This study also aims to map habit formation stages, as suggested by Lally and Gardner, with the Persuasive System Design (PSD) model. The application domain is the prevention of metabolic syndrome, in which 5% weight loss can significantly reduce the prevalence of the syndrome.

METHODS

This study employs a web-based HBCSS named Onnikka, a lifestyle intervention designed for the prevention of metabolic syndrome for participants who are at risk of developing a metabolic syndrome or are already suffering from it. The system under investigation was designed according to the principles of the PSD model and Behavior Change Support System framework. Lally and Gardner's research on the stages of habit formation were used to study the extent to which the Onnikka system was able to enhance the development of new habits. A total of 43 Onnikka users were interviewed for this study during and after a 52-week intervention period. The research approach employed here was hermeneutics, which leans ontologically toward the social construction of reality, gained through language, consciousness, and shared meaning. In addition, the system's login data and participants' weight measurements were utilized to build an interpretation of the results.

RESULTS

The findings of this study suggest that IT habits appear to have a strong linkage with use adherence, whereas lifestyle habits did not seem to be directly related to the 5% weight loss among study participants. Moreover, habit formation stages provide a possible explanation for why self-monitoring, reminders, and tunneling were perceived as especially valuable features in this study.

CONCLUSIONS

For sustainable weight management, holistic e-health interventions are required, and the PSD model offers a practical approach for designing and developing them. Recognizing the stages of habit formation provides additional valuable guidance for designing systems that help shape an individual's habits.

Effect Evaluation of a Web-Based Coaching Intervention to Support Implementation of Sex Education Among Secondary School Teachers: Randomized Controlled Trial

BACKGROUND

The quality of implementation is important to ensure the effectiveness of behavioral change interventions in practice. Implementing such programs with completeness and adherence is not an automatic process and may require additional support. In school settings, the support teachers receive during implementation is often limited and appears to fall short when attempting to preserve completeness and adherence in program delivery. With the aim to improve completeness and adherence of teachers' delivery of a sexual health promoting intervention ("Long Live Love" [LLL]) in secondary education, a Web-based e-coach was developed ("lesgevenindeliefde.nl"or"teachinglove.nl"). The effectiveness of the e-coach, as part of a broader implementation strategy, in influencing teachers' implementation was evaluated.

OBJECTIVE

This study aimed to report on the effect evaluation to determine the effect of the Web-based e-coach on teacher implementation of a school-based sex education program called LLL and on its determinants.

METHODS

A cluster randomized controlled trial (e-coaching vs waiting list control) was conducted with a baseline assessment (T0) and follow-up (T1) 2 weeks after completing the LLL program. A total of 43 schools with 83 teachers participated in the study. In the follow-up, 38 schools participated, 23 in the e-coaching condition with 41 teachers and 15 in the control condition with 26 teachers. Multilevel regression analysis was used to evaluate the effect of the e-coaching website on implementation behavior, namely, completeness and adherence to LLL implementation, and on its determinants.

RESULTS

The e-coaching intervention was not found to have an effect on teachers' implementation behavior; teachers assigned to the experimental e-coaching website did not score higher on completeness (P=.60) or adherence (P=.67) as compared with teachers in the control condition. When comparing the 30 teachers who made actual use of the e-coaching website with the 37 teachers who did not, no significant differences were found either (P≥.54). In addition, there was no effect of e-coaching on the determinants of teacher implementation behavior (t_67-75≤0.69; P≥.22).

CONCLUSIONS

E-coaching was not found to be effective in enhancing completeness of and adherence to LLL by teachers. The lack of effect may be attributed to the intervention content, the limited use, or the study design itself. The e-coaching intervention may not have adequately addressed adherence and completeness of LLL to bring about behavioral change. Furthermore, the e-coaching intervention was not or insufficiently used by teachers. A possible biased sample of motivated, able teachers may have agreed to participate in the study, and a possible "ceiling effect" may have been present because of the high implementation grade. This, however, does not imply that Web-based coaching in itself is an ineffective strategy to promote adherence and completeness of program implementation. A process evaluation is required as follow-up.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN11754581; http://www.isrctn.com/ISRCTN11754581 (Archived by WebCite at http://www.webcitation.org/70C5TUOOh).

Applicability of a Web-Based, Individualized Exercise Intervention in Patients With Liver Disease, Cystic Fibrosis, Esophageal Cancer, and Psychiatric Disorders: Process Evaluation of 4 Ongoing Clinical Trials

Background

In the primary and secondary prevention of civilization diseases, regular physical activity is recommended in international guidelines to improve disease-related symptoms, delay the progression of the disease, or to enhance postoperative outcomes. In the preoperative context, there has been a paradigm shift in favor of using preconditioning concepts before surgery. Web-based interventions seem an innovative and effective tool for delivering general information, individualized exercise recommendations, and peer support.

Objective

Our first objective was to assess feasibility of our Web-based interventional concept and analyze similarities and differences in a sustained exercise implementation in different diseases. The second objective was to investigate the overall participants’ satisfaction with our Web-based concept.

Methods

A total of 4 clinical trials are still being carried out, including patients with esophageal carcinoma scheduled for oncologic esophagectomy (internet-based perioperative exercise program, iPEP, study), nonalcoholic fatty liver disease (hepatic inflammation and physical performance in patients with nonalcoholic steatohepatitis, HELP, study), depression (exercise for depression, EXDEP, study), and cystic fibrosis (cystic fibrosis online mentoring for microbiome, exercise, and diet, COMMED, study). During the intervention period, the study population had access to the website with disease-specific content and a disease-specific discussion forum. All participants received weekly, individual tailored exercise recommendations from the sports therapist. The main outcome was the using behavior, which was obtained by investigating the log-in rate and duration.

Results

A total of 20 participants (5 from each trial) were analyzed. During the intervention period, a regular contact and a consequent implementation of exercise prescription were easily achieved in all substudies. Across the 4 substudies, there was a significant decrease in log-in rates (P<.001) and log-in durations (P<.001) over time. A detailed view of the different studies shows a significant decrease in log-in rates and log-in durations in the HELP study (P=.004; P=.002) and iPEP study (P=.02; P=.001), whereas the EXDEP study (P=.58; P=.38) and COMMED study (P=.87; P=.56) showed no significant change over the 8-week intervention period. There was no significant change in physical activity within all studies (P=.31). Only in the HELP study, the physical activity level increased steadily over the period analyzed (P=.045). Overall, 17 participants (85%, 17/20) felt secure and were not scared of injury, with no major differences in the subtrials.

Conclusions

The universal use of the Web-based intervention appears to be applicable across the heterogonous collectives of our study patients with regard to age and disease. Although the development of physical activity shows only moderate improvements, flexible communication and tailored support could be easily integrated into patients’ daily routine.

Trial Registration

iPEP study: ClinicalTrials.gov NCT02478996; https://clinicaltrials.gov/ct2/show/NCT02478996 (Archived by WebCite at http://www.webcitation.org/6zL1UmHaW); HELP study: ClinicalTrials.gov NCT02526732; http://www.webcitation.org/6zJjX7d6K (Archived by WebCite at http://www.webcitation.org/6Nch4ldcL); EXDEP study: ClinicalTrials.gov NCT02874833; https://clinicaltrials.gov/ct2/show/NCT02874833 (Archived by WebCite at http://www.webcitation.org/6zJjj7FuA)

Engagement with INSPIRE, an Online Program for Hematopoietic Cell Transplantation Survivors

In a secondary analysis of a randomized controlled trial (RCT), we examined participants' engagement with INSPIRE, a personalized online program for hematopoietic cell transplantation (HCT) survivors that focuses on cancer-related distress, depression, fatigue, and health care needs. We approached all adult, 3- to 18-year HCT survivors treated for hematologic malignancy without relapse or second cancer in the previous 2 years for participation in an RCT with either immediate or delayed access to INSPIRE. Participants with immediate access could view the online material at any time. Data included page view tracking, medical records, and patient-reported outcomes, including the Short Form 36 and Cancer and Treatment Distress (CTXD) measures. Of 1322 eligible HCT survivors, 771 (58%) completed the baseline assessment, and 451 received immediate INSPIRE access and were included in analyses. The cohort was 56% male, with a mean age of 52 ± 12.2 years, and 26% received an autologous transplant. Most (77%) logged into the INSPIRE site at least once, and 48% viewed ≥8 pages. Survivors who viewed ≥2 pages were more likely to be age ≥40 years (relative risk [RR], 1.41; 95% confidence interval [CI], 1.10 to 1.80), to be female (RR, 1.22; 95% CI, 1.07 to 1.40), to have chronic graft-versus-host disease (RR, 1.28; 95% CI, 1.08 to 1.51), to be less than 10 years post-HCT (RR, 1.19; 95% CI, 1.01 to 1.39), and to have moderate CTXD distress (RR, 1.34; 95% CI, 1.14 to 1.57). Engagement did not differ by race, education, income, rural/urban residence, computer experience, donor type, or depression (all P ≥ .50). The INSPIRE online program was widely used, including by those who often have reduced access to care after treatment.

Key Intervention Characteristics in e-Health: Steps Towards Standardized Communication

PURPOSE

This paper reports expert opinion on e-health intervention characteristics that enable effective communication of characteristics across the diverse field of e-health interventions. The paper presents a visualization tool to support communication of the defining characteristics.

METHODS

An initial list of e-health intervention characteristics was developed through an iterative process of item generation and discussion among the 12 authors. The list was distributed to 123 experts in the field, who were emailed an invitation to assess and rank the items. Participants were asked to evaluate these characteristics in three separate ways.

RESULTS

A total of 50 responses were received for a response rate of 40.7%. Six respondents who reported having little or no expertise in e-health research were removed from the dataset. Our results suggest that 10 specific intervention characteristics were consistently supported as of central importance by the panel of 44 e-intervention experts. The weight and perceived relevance of individual items differed between experts; oftentimes, this difference is a result of the individual theoretical perspective and/or behavioral target of interest.

CONCLUSIONS

The first iteration of the visualization of salient characteristics represents an ambitious effort to develop a tool that will support communication of the defining characteristics for e-health interventions aimed to assist e-health developers and researchers to communicate the key characteristics of their interventions in a standardized manner that facilitates dialog.

Impact of Mental Health Screening on Promoting Immediate Online Help-Seeking: Randomized Trial Comparing Normative Versus Humor-Driven Feedback

BACKGROUND

Given the widespread availability of mental health screening apps, providing personalized feedback may encourage people at high risk to seek help to manage their symptoms. While apps typically provide personal score feedback only, feedback types that are user-friendly and increase personal relevance may encourage further help-seeking.

OBJECTIVE

The aim of this study was to compare the effects of providing normative and humor-driven feedback on immediate online help-seeking, defined as clicking on a link to an external resource, and to explore demographic predictors that encourage help-seeking.

METHODS

An online sample of 549 adults were recruited using social media advertisements. Participants downloaded a smartphone app known as "Mindgauge" which allowed them to screen their mental wellbeing by completing standardized measures on Symptoms (Kessler 6-item Scale), Wellbeing (World Health Organization [Five] Wellbeing Index), and Resilience (Brief Resilience Scale). Participants were randomized to receive normative feedback that compared their scores to a reference group or humor-driven feedback that presented their scores in a relaxed manner. Those who scored in the moderate or poor ranges in any measure were encouraged to seek help by clicking on a link to an external online resource.

RESULTS

A total of 318 participants scored poorly on one or more measures and were provided with an external link after being randomized to receive normative or humor-driven feedback. There was no significant difference of feedback type on clicking on the external link across all measures. A larger proportion of participants from the Wellbeing measure (170/274, 62.0%) clicked on the links than the Resilience (47/179, 26.3%) or Symptoms (26/75, 34.7%) measures (χ²=60.35, P<.001). There were no significant demographic factors associated with help-seeking for the Resilience or Wellbeing measures. Participants with a previous episode of poor mental health were less likely than those without such history to click on the external link in the Symptoms measure (P=.003, odds ratio [OR] 0.83, 95% CI 0.02-0.44), and younger adults were less likely to click on the link compared to older adults across all measures (P=.005, OR 0.44, 95% CI 0.25-0.78).

CONCLUSIONS

This pilot study found that there was no difference between normative and humor-driven feedback on promoting immediate clicks to an external resource, suggesting no impact on online help-seeking. Limitations included: lack of personal score control group, limited measures of predictors and potential confounders, and the fact that other forms of professional help-seeking were not assessed. Further investigation into other predictors and factors that impact on help-seeking is needed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616000707460; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370187 (Archived by WebCite at http://www.webcitation.org/6y8m8sVxr).

Evaluation of a Computer-Tailored Healthy Ageing Intervention to Promote Physical Activity among Single Older Adults with a Chronic Disease

This study explores the effectiveness of the Active Plus65 intervention designed to stimulate physical activity among single older adults with a chronic physical impairment. A quasi-experimental pre-test post-test study was performed. The intervention group (n = 411; mean age = 76.75; SD = 7.75) was assessed at baseline, three months, and six months. Data of comparable older adults who completed the original Active Plus intervention served as reference group (n = 87; mean age = 74.36; SD = 6.26). Multilevel regression analyses were applied: outcome measures were weekly minutes of moderate to vigorous physical activity (MVPA) and days per week with at least 30 minutes of MVPA. Although Active Plus65 did not outperform the original intervention, in itself Active Plus65 effectuated a significant increase in the weekly minutes of MVPA (B = 208.26; p < 0.001; Effect Size (ES) = 0.45) and in the days per week with sufficient MVPA (B = 1.20; p < 0.001; ES = 0.61) after three months. After six months, it effectuated a significant increase in the days per week with sufficient MVPA (B = 0.67; p = 0.001; ES = 0.34) but not for the weekly minutes of MVPA (p = 0.745). As Active Plus65 increased MVPA at three months with a higher ES than average interventions for this vulnerable target group, it potentially makes an interesting intervention. Further development should focus on long-term maintenance of effects.

What makes online substance-use interventions engaging? A systematic review and narrative synthesis

Background

Online substance-use interventions are effective in producing reductions in harmful-use. However, low user engagement rates with online interventions reduces overall effectiveness of interventions. Identifying optimal strategies with which to engage users with online substance-use interventions may improve usage rates and subsequent effectiveness.

Objectives

(1) To identify the most prevalent engagement promoting strategies utilised to increase use of online substance-use interventions. (2) To determine whether the identified engagement promoting strategies increased said use of online substance-use interventions.

Review methods

The reviewed followed Cochrane methodology. Databases were searched for online substance-use interventions and engagement promoting strategies limited by study type (randomised controlled trial). Due to heterogeneity between engagement promoting strategies and engagement outcomes, meta-analytic techniques were not possible. Narrative synthesis methods were used.

Results

Fifteen studies were included. Five different engagement promoting strategies were identified: (1) tailoring; (2) delivery strategies; (3) incentives; (4) reminders; (5) social support. The most frequently reported engagement promoting strategies was tailoring (47% of studies), followed by reminders and social support (40% of studies) and delivery strategies (33% of studies). The narrative synthesis demonstrated that tailoring, multimedia delivery of content and reminders are potential techniques for promoting engagement. The evidence for social support was inconclusive and negative for incentives.

Conclusions

This review was the first to examine engagement promoting strategies in solely online substance-use interventions. Three strategies were identified that may be integral in promoting engagement with online substance-use interventions. However, the small number of eligible extracted studies, inconsistent reporting of engagement outcomes and diversity of engagement features prevent firmer conclusions. More high-quality trials examining engagement are required.

Digital Health Interventions for Adults With Type 2 Diabetes: Qualitative Study of Patient Perspectives on Diabetes Self-Management Education and Support

BACKGROUND

The prevalence of type 2 diabetes is increasing globally, and health services in many countries are struggling with the morbidity, mortality, and costs associated with the complications of this long-term condition. Diabetes self-management education (DSME) and behavioral support can reduce the risks of developing diabetes-related complications and improve glycemic control. However, their uptake is low. Digital health interventions (DHI) can provide sustained support and may overcome challenges associated with attending diabetes self-management sessions. They have the potential for delivery at multiple locations at convenient times, anonymity, and presentation of content in attractive and tailored formats. This study investigates the needs and wants of patients with type 2 diabetes to inform the development of digital self-management education and support.

OBJECTIVE

The objective of this study was to explore patient perspectives on unmet needs for self-management and support and the role of DHI in adults living with type 2 diabetes.

METHODS

This study used a qualitative approach based on data generated from 4 focus groups with 20 patients.

RESULTS

The data generated by the focus groups illustrated the significant burden that the diagnosis of diabetes places on many patients and the negative impacts on their emotional well-being, work, social life, and physical health. Although patients' experiences of the health care services varied, there was agreement that even the best services were unable to meet all users' needs to support the emotional regulation, psychological adjustment, and behavioral changes needed for successful self-management.

CONCLUSIONS

By focusing on medical management and information provision, existing health care services and education programs may not be adequately meeting all the needs of patients with type 2 diabetes. DHIs have the potential to improve access to DSME and behavioral support and extend the range of content offered by health services to fit with a wider range of patient needs. Features that could help DHIs address some of the unmet needs described by participants in this study included placing an emphasis on emotional and role management, being available at all times, having up-to-date evidence-based guidance for patients, and providing access to peer-generated and professional advice.

The effectiveness of a web 2.0 physical activity intervention in older adults - a randomised controlled trial

BACKGROUND

Interactive web-based physical activity interventions using Web 2.0 features (e.g., social networking) have the potential to improve engagement and effectiveness compared to static Web 1.0 interventions. However, older adults may engage with Web 2.0 interventions differently than younger adults. The aims of this study were to determine whether an interaction between intervention (Web 2.0 and Web 1.0) and age group (<55y and ≥55y) exists for website usage and to determine whether an interaction between intervention (Web 2.0, Web 1.0 and logbook) and age group (<55y and ≥55y) exists for intervention effectiveness (changes in physical activity).

METHODS

As part of the WALK 2.0 trial, 504 Australian adults were randomly assigned to receive either a paper logbook (n = 171), a Web 1.0 (n = 165) or a Web 2.0 (n = 168) physical activity intervention. Moderate to vigorous physical activity was measured using ActiGraph monitors at baseline 3, 12 and 18 months. Website usage statistics including time on site, number of log-ins and number of step entries were also recorded. Generalised linear and intention-to-treat linear mixed models were used to test interactions between intervention and age groups (<55y and ≥55y) for website usage and moderate to vigorous physical activity changes.

RESULTS

Time on site was higher for the Web 2.0 compared to the Web 1.0 intervention from baseline to 3 months, and this difference was significantly greater in the older group (OR = 1.47, 95%CI = 1.01-2.14, p = .047). Participants in the Web 2.0 group increased their activity more than the logbook group at 3 months, and this difference was significantly greater in the older group (moderate to vigorous physical activity adjusted mean difference = 13.74, 95%CI = 1.08-26.40 min per day, p = .03). No intervention by age interactions were observed for Web 1.0 and logbook groups.

CONCLUSIONS

Results partially support the use of Web 2.0 features to improve adults over 55 s' engagement in and behaviour changes from web-based physical activity interventions.

TRIAL REGISTRATION

ACTRN ACTRN12611000157976 , Registered 7 March 2011.

eHealth in Treatment of Offenders in Forensic Mental Health: A Review of the Current State

BACKGROUND

Treatment of offenders in forensic mental health is complex. Often, these in- or outpatients have low treatment motivation, suffer from multiple disorders, and have poor literacy skills. eHealth may be able to improve treatment outcomes because of its potential to increase motivation and engagement, and it can overcome the predominant one-size-fits-all approach by being tailored to individual patients.

OBJECTIVE

To examine its potential, this systematic review studies the way that eHealth has been used and studied in forensic mental health and identifies accompanying advantages and disadvantages for both patients and treatment, including effectiveness.

METHODS

A systematic search in Scopus, PsycINFO, and Web of Science was performed up until December 2017. Studies were included if they focused on technological interventions to improve the treatment of forensic psychiatric patients.

RESULTS

The search resulted in 50 studies in which eHealth was used for treatment purposes. Multiple types of studies and technologies were identified, such as virtual reality, web-based interventions, and videoconferencing. The results confirmed the benefits of technology, for example, the acquisition of unique information about offenders, effectiveness, and tailoring to specific characteristics, but indicated that these are not fully taken advantage of.

DISCUSSION

To overcome the barriers and obtain the benefits, eHealth has to have a good fit with patients and the forensic psychiatric context. It has to be seamlessly integrated in existing care and should not be added as an isolated element. To bridge the gap between the current situation and eHealth's potential, further research on development, implementation, and evaluation should be conducted.

Specific features of current and emerging mobile health apps: user views among people with and without mental health problems

BACKGROUND

Despite widespread development of mobile health apps, there is a paucity of research investigating user views of apps and their features, particularly among people with mental health problems. This study aimed to gain an understanding of the acceptability of specific features of current and emerging mobile health apps among people with and without mental health problems.

METHODS

Adults living in Australia were recruited to complete a self-report questionnaire regarding demographic characteristics, mental health, technology use, and attitudes regarding specific features of mobile health apps.

RESULTS

A total of 284 participants were recruited, including 53% with a history of mental illness. Few concerns were reported with mobile app features (mean =1.8 features; SD =2.19) and statistical analyses found that age, gender, income, rurality, mental health status and technology use did not affect the expression of these concerns. Key issues identified included privacy and security of personal information, apps acting automatically, sharing personal information and the invasive nature of some features.

CONCLUSIONS

These results suggest that mental illness may not be a barrier to widespread use of mobile technologies for health purposes. It is hoped that this research will assist developers and clinicians to develop and integrate mobile health apps into everyday care more effectively.

Characteristics of Adults Seeking Health Care Provider Support Facilitated by Mobile Technology: Secondary Data Analysis

Background

Mobile health technology is rapidly evolving with the potential to transform health care. Self-management of health facilitated by mobile technology can maximize long-term health trajectories of adults. Little is known about the characteristics of adults seeking Web-based support from health care providers facilitated by mobile technology.

Objective

This study aimed to examine the following: (1) the characteristics of adults who seek human support from health care providers for health concerns using mobile technology rather than from family members and friends or others with similar health conditions and (2) the use of mobile health technology among adults with chronic health conditions. Findings of this study were interpreted in the context of the Efficiency Model of Support.

Methods

We first described characteristics of adults seeking Web-based support from health care providers. Using chi-square tests for categorical variables and t test for the continuous variable of age, we compared adults seeking Web-based and conventional support by demographics. The primary aim was analyzed using multivariate logistic regression to examine whether chronic health conditions and demographic factors (eg, sex, income, employment status, race, ethnicity, education, and age) were associated with seeking Web-based support from health care providers.

Results

The sample included adults (N=1453), the majority of whom were female 57.60% (837/1453), white 75.02% (1090/1453), and non-Hispanic 89.13% (1295/1453). The age of the participants ranged from 18 to 92 years (mean 48.6, standard deviation [SD] 16.8). The majority 76.05% (1105/1453) of participants reported college or higher level of education. A disparity was found in access to health care providers via mobile technology based on socioeconomic status. Adults with annual income of US $30,000 to US $100,000 were 1.72 times more likely to use Web-based methods to contact a health care provider, and adults with an annual income above US $100,000 were 2.41 to 2.46 times more likely to access health care provider support on the Web, compared with those with an annual income below US $30,000. After adjusting for other demographic covariates and chronic conditions, age was not a significant factor in Web-based support seeking.

Conclusions

In this study, the likelihood of seeking Web-based support increased when adults had any or multiple chronic health conditions. A higher level of income and education than the general population was found to be related to the use of mobile health technology among adults in this survey. Future study is needed to better understand the disparity in Web-based support seeking for health issues and the clinicians’ role in promoting access to and use of mobile health technology.

Implementation of a Web-Based Organ Donation Educational Intervention: Development and Use of a Refined Process Evaluation Model

Background

The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of Web-based behavioral interventions. Implementing Internet interventions, however, presents challenges including preventing fraudulent respondents and ensuring intervention uptake. Although Web-based organ donation interventions have increased in recent years, process evaluation models appropriate for Web-based interventions are lacking.

Objective

The aim of this study was to describe a refined process evaluation model adapted for Web-based settings and used to assess the implementation of a Web-based intervention aimed to increase organ donation among African Americans.

Methods

We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website that addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process evaluation constructs, we adapted reach (the extent to which individuals were found eligible, and participated in the study), recruitment (online recruitment mechanism), dose received (intervention uptake), and context (how the Web-based setting influenced study implementation) for Internet settings and used the adapted model to assess the implementation of our Web-based intervention.

Results

With regard to reach, 1415 individuals completed the eligibility screener; 948 (67.00%) were determined eligible, of whom 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the posttest (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the Internet protocol (IP) address analysis, only 23 of the 772 valid entries (3.0%) were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. With respect to recruitment, 517 of the 772 valid entries (67.0%) of participants were recruited from a Web recruiter. Regarding dose received, no videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. With respect to context, context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the Craigslist website advertisement may have contributed the largest volume of fraudulent responses.

Conclusions

We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants’ IP addresses before study initiation, selecting software that allows for automatic duplicate protection, and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of Web-based studies.

Effectiveness of a Web 2.0 Intervention to Increase Physical Activity in Real-World Settings: Randomized Ecological Trial

BACKGROUND

The translation of Web-based physical activity intervention research into the real world is lacking and becoming increasingly important.

OBJECTIVE

To compare usage and effectiveness, in real-world settings, of a traditional Web 1.0 Web-based physical activity intervention, providing limited interactivity, to a Web 2.0 Web-based physical activity intervention that includes interactive features, such as social networking (ie, status updates, online "friends," and personalized profile pages), blogs, and Google Maps mash-ups.

METHODS

Adults spontaneously signing up for the freely available 10,000 Steps website were randomized to the 10,000 Steps website (Web 1.0) or the newly developed WALK 2.0 website (Web 2.0). Physical activity (Active Australia Survey), quality of life (RAND 36), and body mass index (BMI) were assessed at baseline, 3 months, and 12 months. Website usage was measured continuously. Analyses of covariance were used to assess change over time in continuous outcome measures. Multiple imputation was used to deal with missing data.

RESULTS

A total of 1328 participants completed baseline assessments. Only 3-month outcomes (224 completers) were analyzed due to high attrition at 12 months (77 completers). Web 2.0 group participants increased physical activity by 92.8 minutes per week more than those in the Web 1.0 group (95% CI 28.8-156.8; P=.005); their BMI values also decreased more (-1.03 kg/m2, 95% CI -1.65 to -0.41; P=.001). For quality of life, only the physical functioning domain score significantly improved more in the Web 2.0 group (3.6, 95% CI 1.7-5.5; P<.001). The time between the first and last visit to the website (3.57 vs 2.22 weeks; P<.001) and the mean number of days the website was visited (9.02 vs 5.71 days; P=.002) were significantly greater in the Web 2.0 group compared to the Web 1.0 group. The difference in time-to-nonusage attrition was not statistically significant between groups (Hazard Ratio=0.97, 95% CI 0.86-1.09; P=.59). Only 21.99% (292/1328) of participants (n=292 summed for both groups) were still using either website after 2 weeks and 6.55% (87/1328) were using either website after 10 weeks.

CONCLUSIONS

The website that provided more interactive and social features was more effective in improving physical activity in real-world conditions. While the Web 2.0 website was visited significantly more, both groups nevertheless displayed high nonusage attrition and low intervention engagement. More research is needed to examine the external validity and generalizability of Web-based physical activity interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12611000253909; https://anzctr.org.au /Trial/Registration/TrialReview.aspx?id=336588&isReview=true (Archived by WebCite at http://www.webcitation.org/6ufzw 2HxD).

Impact of telephone prompts on the adherence to an Internet-based aftercare program for women with bulimia nervosa: A secondary analysis of data from a randomized controlled trial

INTRODUCTION

Poor adherence is a common challenge in self-directed mental health interventions. Research findings indicate that telephone prompts may be useful to increase adherence.

METHOD

Due to poor adherence in a randomized controlled trial evaluating an Internet-based aftercare program for women with bulimia nervosa we implemented regular short telephone prompts into the study protocol halfway through the trial period. Of the 126 women in the intervention group, the first 63 women were not prompted by telephone (unprompted group) and compared with 63 women who subsequently enrolled into the study and were attempted to prompt bimonthly by a research assistant (telephone prompt group). Completed telephone calls took less than 5 min and did not include any symptom-related counseling.

RESULTS

Most of the women in the telephone prompt group (67%) were reached only once or twice during the intervention period. However, overall adherence in the telephone prompt group was significantly higher than in the unprompted group (T = - 3.015, df = 124, p = 0.003).

CONCLUSION

Our findings from this secondary analysis suggest that telephone prompts can positively affect adherence to an Internet-based aftercare intervention directed at patients with bulimia nervosa.

Effectiveness of a Video-Versus Text-Based Computer-Tailored Intervention for Obesity Prevention after One Year: A Randomized Controlled Trial

Computer-tailored programs may help to prevent overweight and obesity, which are worldwide public health problems. This study investigated (1) the 12-month effectiveness of a video- and text-based computer-tailored intervention on energy intake, physical activity, and body mass index (BMI), and (2) the role of educational level in intervention effects. A randomized controlled trial in The Netherlands was conducted, in which adults were allocated to a video-based condition, text-based condition, or control condition, with baseline, 6 months, and 12 months follow-up. Outcome variables were self-reported BMI, physical activity, and energy intake. Mixed-effects modelling was used to investigate intervention effects and potential interaction effects. Compared to the control group, the video intervention group was effective regarding energy intake after 6 months (least squares means (LSM) difference = -205.40, p = 0.00) and 12 months (LSM difference = -128.14, p = 0.03). Only video intervention resulted in lower average daily energy intake after one year (d = 0.12). Educational role and BMI did not seem to interact with this effect. No intervention effects on BMI and physical activity were found. The video computer-tailored intervention was effective on energy intake after one year. This effect was not dependent on educational levels or BMI categories, suggesting that video tailoring can be effective for a broad range of risk groups and may be preferred over text tailoring.

Examining Factors of Engagement With Digital Interventions for Weight Management: Rapid Review

BACKGROUND

Digital interventions for weight management provide a unique opportunity to target daily lifestyle choices and eating behaviors over a sustained period of time. However, recent evidence has demonstrated a lack of user engagement with digital health interventions, impacting on the levels of intervention effectiveness. Thus, it is critical to identify the factors that may facilitate user engagement with digital health interventions to encourage behavior change and weight management.

OBJECTIVE

The aim of this study was to identify and synthesize the available evidence to gain insights about users' perspectives on factors that affect engagement with digital interventions for weight management.

METHODS

A rapid review methodology was adopted. The search strategy was executed in the following databases: Web of Science, PsycINFO, and PubMed. Studies were eligible for inclusion if they investigated users' engagement with a digital weight management intervention and were published from 2000 onwards. A narrative synthesis of data was performed on all included studies.

RESULTS

A total of 11 studies were included in the review. The studies were qualitative, mixed-methods, or randomized controlled trials. Some of the studies explored features influencing engagement when using a Web-based digital intervention, others specifically explored engagement when accessing a mobile phone app, and some looked at engagement after text message (short message service, SMS) reminders. Factors influencing engagement with digital weight management interventions were found to be both user-related (eg, perceived health benefits) and digital intervention-related (eg, ease of use and the provision of personalized information).

CONCLUSIONS

The findings highlight the importance of incorporating user perspectives during the digital intervention development process to encourage engagement. The review contributes to our understanding of what facilitates user engagement and points toward a coproduction approach for developing digital interventions for weight management. Particularly, it highlights the importance of thinking about user-related and digital tool-related factors from the very early stages of the intervention development process.

[Internet- and mobile-based approaches : Psycho-social diagnostics and treatment in medical rehabilitation]

Technology-based approaches for psychosocial diagnostics and interventions provide an attractive opportunity to optimize medical rehabilitation. Based on an Internet- and mobile-based assessment of existing functional health impairments, appropriate planning, implementation of corresponding courses of action as well as outcome assessment can take place. This can be implemented in the form of Internet- and mobile-based interventions (IMI).The present article provides an overview of the basic knowledge of IMI and their evidence base both in general and in particular for their use in medical rehabilitation. Important aspects of internet and mobile-based psycho-social diagnostics are discussed subsequently. Finally, an outlook for the use of Internet- and mobile-based diagnostics and interventions in medical rehabilitation is given.

An Internet-Based Intervention for Chronic Pain

BACKGROUND

Persons with chronic pain can be treated effectively with acceptance and commitment therapy (ACT). In this trial, we examined the effectiveness of guided and unguided ACT-based online treatment (ACTonPain) for chronic pain patients.

METHODS

302 individuals were randomly assigned to ACTonPain with or without guidance (n = 100/101) or to a waiting-list control group (n=101). The primary outcome was pain interference as measured by the Multidimensional Pain Inventory. The secondary outcomes were physical and emotional functioning, pain intensity, ACT process variables, quality of life, satisfaction with the intervention, adherence, and participants' rating of overall improvement. The online measurements were carried out before randomization (T0) and 9 weeks and 6 months after randomization (T1 and T2, respectively). Intention-to-treat (ITT) data analysis was supplemented with additional per-protocol analyses.

RESULTS

The guided ACTonPain group showed significantly less pain interference than the control group in the ITT analysis (p = 0.01), with a moderate effect size at T1 and T2 (d = 0.58 respectively), corresponding to a number needed to treat (NNT) of 3.14 for both time points. Participants in the guided ACTonPain group also indicated higher pain acceptance (T1: d = 0.59; T2: d = 0.76). The unguided ACTonPain group showed to be significantly less depressed in comparison to the control group at at time T2 (d = 0.50). No significant differences with respect to effectiveness were found between the two ACTonPain groups (p>0.05).

CONCLUSION

The online intervention ACTonPain is effective for persons with chronic pain when the program is guided. Further research in a variety of settings of health care is needed in order to determine whether and how ACTonPain can be implemented.

HealthyDads.ca: What Do Men Want in a Website Designed to Promote Emotional Wellness and Healthy Behaviors During the Transition to Parenthood?

BACKGROUND

Up to 18% of men experience depression and/or anxiety during the transition to parenthood. Interventions designed specifically to promote the mental health of men during the transition to parenthood are scarce. Internet-delivered interventions may be acceptable and far-reaching in enhancing mental health, parenting knowledge, and healthy behaviors in expectant or new fathers.

OBJECTIVE

To guide the development of Healthydads.ca, a website designed to enhance mental health and healthy behaviors in expectant fathers, a needs assessment was conducted to identify fathers' perspectives of barriers to seeking help for emotional wellness, informational needs, and factors affecting the decision to visit such a website.

METHODS

One hundred and seventy-four men whose partners were expecting, or had recently given birth, in 3 Canadian provinces (Quebec, Ontario, and Alberta) completed a Web-based survey inquiring about information needs related to psychosocial aspects of the transition to parenthood, lifestyle behaviors, parenting, and factors associated with the decision to visit a father-focused website.

RESULTS

Most men (155/174, 89.1%) reported accessing the Internet to obtain information on pregnancy and spent an average of 6.2 hours online per month. Seeking information about parenting on the Internet was reported by 67.2% (117/174) of men, with a mean of 4.4 hours per month of online searching. Top barriers to seeking help to improve emotional wellness during the perinatal period were: no time to seek help/assistance (130/174, 74.7%), lack of resources available in the health care system (126/174, 72.4%), financial costs associated with services (118/174, 67.8%), and feeling that one should be able to do it alone (113/174, 64.9%). Information needs that were rated highly included: parenting/infant care (52.9-81.6%), supporting (121/174, 69.5%) and improving (124/174, 71.3%) relationship with their partner, work-family balance (120/174, 69.0%), improving sleep (100/174, 57.5%), and managing stress (98/174, 56.3%). Perceiving the website as personally relevant (151/174, 86.8%), credible (141/174, 81.0%), effective (140/145, 80.5%), and having an easy navigation structure (141/174, 81.0%) were identified as important factors related to a first website visit. Providing useful (134/174, 77.0%) and easy to understand (158/174, 90.8%) information, which was also free of charge (156/174, 89.7%), were considered important for deciding to prolong a website visit. Providing the possibility to post questions to a health professional (133/174, 76.4%), adding new content regularly (119/174, 68.4%), and personal motivation (111/174, 63.8%) were factors identified that would encourage a revisit.

CONCLUSIONS

Our findings demonstrate that there is substantial interest among expectant and new fathers for using Internet-delivered strategies to prepare for the transition to parenthood and support their mental health. Specific user and website features were identified to optimize the use of father-focused websites.

The effect of programme testimonials on registrations for an online cognitive behaviour therapy intervention: a randomised trial

Objective

Suboptimal visit-to-registration rates limit the reach and potential impact of online health interventions. In this study, we examined whether testimonials presented during a new-user registration process could increase the uptake rates of MoodGYM, an open-access automated intervention designed to reduce the symptoms of depression.

Methods

We conducted a three-armed parallel randomised controlled trial on the MoodGYM website involving variations of the first page of the registration process. Spontaneous visitors saw either the current pre-registration content, the current content supplemented by a first-person past user testimonial or the current content accompanied by a testimonial from a third-party health professional. The primary outcome measure was the proportion of visitors seeing each version who completed registration.

Results

A total of 14,267 visits were recorded across the three conditions. The past user, health professional and control condition registration rates were 45.6%, 45.5% and 45.5% respectively, indicating that there was no effect of registration content on registration rate. (p > 0.05)

Conclusions

There may be limited use for testimonials in well-established interventions that have programme benefits clearly stated and presented in other forms. However, we cannot exclude the possibility that testimonial effects might be moderated by positioning or other elements within the registration flow or by visitor source. Further research is required to examine these factors and, more broadly, assess whether modifications to other aspects of the registration process can improve visit-to-registration rates.

The implementation of web-based cognitive rehabilitation in adult cancer survivors: examining participant engagement, attrition and treatment fidelity

PURPOSE

Low engagement and high attrition are common challenges in web-based interventions. Typical measures of engagement reported in the literature are not meaningful for describing participant activity within the intervention and can be misleading. This research aimed to develop a more meaningful method of measuring engagement in an online cognitive rehabilitation program whilst monitoring treatment fidelity.

METHODS

A pilot study and randomised controlled trial (RCT) were conducted. Data from 60 participants were analysed from three intervention groups: pilot cancer group, pilot non-cancer group and RCT cancer group. Groups completed the 4-week eReCog program comprised of four online modules. Engagement scores were calculated based on activities completed in each module. Attrition, interaction with the program facilitator and correlations with outcome measures were analysed.

RESULTS

Overall engagement in the intervention was high. The non-cancer group participated significantly less than the cancer groups (p = < 0.001), whereby the percentage of activity items completed was 92, 87 and 78% in the pilot cancer, RCT cancer and pilot non-cancer groups, respectively. Attrition was higher in the pilot non-cancer group (24%) compared to the pilot cancer group (8%) and the RCT cancer group (16%). Total engagement was correlated with fewer prospective memory problems on instrumental activities of daily living (p = 0.018).

CONCLUSIONS

Measuring completed activities in online interventions appears a more meaningful measure of engagement than other conventional methods described in the literature and has the potential to increase treatment fidelity in web-based research.

Addressing engagement in technology-based behavioural HIV interventions through paradata metrics

PURPOSE OF REVIEW

The goal of this review was to examine how often researchers report participants' online engagement using paradata (i.e. intervention usage metrics) when describing the outcomes of online behavioural HIV prevention and care interventions. We also highlight the utility of paradata collection and analysis in future technology-based trials.

RECENT FINDINGS

We focused on studies indexed on PubMed and published between 1 January 2016 and 31 March 2017 that reported the development and testing of online behavioural interventions for HIV prevention and/or care. Of the 705 extracted citations, six met study criteria.

SUMMARY

Only one study reported paradata reflecting participants' engagement with a technology-based intervention. Researchers should systematically collect and analyse paradata to strengthen the evidence base for technology-based interventions (do they work?), advance the use of behaviour change theory across modalities and platforms (how/why do they work?) and inform reach and scale-up efforts (for whom do they work?). Researchers may also rely on paradata to examine dose-response relationships due to user engagement, to identify replicable core components linked to behaviour change outcomes, to allocate resources judiciously and drive down development costs, and to pool these metrics for use in future meta-analyses.

Computer-based versus in-person interventions for preventing and reducing stress in workers

BACKGROUND

Chronic exposure to stress has been linked to several negative physiological and psychological health outcomes. Among employees, stress and its associated effects can also result in productivity losses and higher healthcare costs. In-person (face-to-face) and computer-based (web- and mobile-based) stress management interventions have been shown to be effective in reducing stress in employees compared to no intervention. However, it is unclear if one form of intervention delivery is more effective than the other. It is conceivable that computer-based interventions are more accessible, convenient, and cost-effective.

OBJECTIVES

To compare the effects of computer-based interventions versus in-person interventions for preventing and reducing stress in workers.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and two trials registers up to February 2017.

SELECTION CRITERIA

We included randomised controlled studies that compared the effectiveness of a computer-based stress management intervention (using any technique) with a face-to-face intervention that had the same content. We included studies that measured stress or burnout as an outcome, and used workers from any occupation as participants.

DATA COLLECTION AND ANALYSIS

Three authors independently screened and selected 75 unique studies for full-text review from 3431 unique reports identified from the search. We excluded 73 studies based on full-text assessment. We included two studies. Two review authors independently extracted stress outcome data from the two included studies. We contacted study authors to gather additional data. We used standardised mean differences (SMDs) with 95% confidence intervals (CIs) to report study results. We did not perform meta-analyses due to variability in the primary outcome and considerable statistical heterogeneity. We used the GRADE approach to rate the quality of the evidence.

MAIN RESULTS

Two studies met the inclusion criteria, including a total of 159 participants in the included arms of the studies (67 participants completed computer-based interventions; 92 participants completed in-person interventions). Workers were primarily white, Caucasian, middle-aged, and college-educated. Both studies delivered education about stress, its causes, and strategies to reduce stress (e.g. relaxation or mindfulness) via a computer in the computer-based arm, and via small group sessions in the in-person arm. Both studies measured stress using different scales at short-term follow-up only (less than one month). Due to considerable heterogeneity in the results, we could not pool the data, and we analysed the results of the studies separately. The SMD of stress levels in the computer-based intervention group was 0.81 standard deviations higher (95% CI 0.21 to 1.41) than the in-person group in one study, and 0.35 standard deviations lower (95% CI -0.76 to 0.05) than the in-person group in another study. We judged both studies as having a high risk of bias.

AUTHORS' CONCLUSIONS

We found very low-quality evidence with conflicting results, when comparing the effectiveness of computer-based stress management interventions with in-person stress management interventions in employees. We could include only two studies with small sample sizes. We have very little confidence in the effect estimates. It is very likely that future studies will change these conclusions.

Increasing engagement with an occupational digital stress management program through the use of an online facilitated discussion group: Results of a pilot randomised controlled trial

INTRODUCTION

Rates of work-related stress, depression and anxiety are high, resulting in reduced work performance and absenteeism. There is evidence that digital mental health interventions delivered in the workplace are an effective way of treating these conditions, but intervention engagement and adherence remain a challenge. Providing guidance can lead to greater engagement and adherence; an online facilitated discussion group may be one way of providing that guidance in a time efficient way. This study compares engagement with a minimally guided digital mental health program (WorkGuru) delivered in the workplace with a discussion group (DG) and without a discussion group (MSG), and with a wait list control (WLC); it was conducted as a pilot phase of a definitive trial.

METHODS

Eighty four individuals with elevated levels of stress from six organisations were recruited to the study and randomised to one of two active conditions (DG or MSG) or a WLC. The program WorkGuru is a CBT based, eight-week stress management intervention that is delivered with minimal guidance from a coach. Data was collected at baseline, post-intervention and at 16-week follow-up via online questionnaires. The primary outcome measure was number of logins. Secondary measures included further engagement measures, and measures of depression, anxiety, stress, comfort and enthusiasm. Quality measures including satisfaction and system usability were also collected.

RESULTS

A greater number of logins was observed for the DG compared with the MSG; this was a medium between group effect size (d = 0.51; 95% CI: - 0.04, 1.05). Small to medium effect size differences were found at T2 in favour of the active conditions compared with the control on the DASS subscales depression, anxiety and stress, and the IWP subscales enthusiasm and comfort. This was largely maintained at T3. Satisfaction with the intervention was high with individuals in the MSG reporting greater satisfaction than individuals in the DG.

CONCLUSIONS

This study shows that access to an online facilitated discussion group increases engagement with a minimally supported occupational digital mental health intervention (as defined by the number of logins), but that this doesn't necessarily result in improved psychological outcomes or increased satisfaction when compared to access to the intervention without the group. Access to the web-based program was associated with lower levels of depression, anxiety and stress and an increase in comfort and enthusiasm post intervention; these changes were largely maintained at follow-up.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov on March the 18th 2016 NCT02729987 (website link https://clinicaltrials.gov/ct2/show/NCT02729987?term=NCT02729987&rank=1).

Promoting Engagement With a Digital Health Intervention (HeLP-Diabetes) Using Email and Text Message Prompts: Mixed-Methods Study

Background

Engagement with digital health interventions (DHIs) may be regarded as a prerequisite for the intervention to achieve positive health or behavior change outcomes. One method employed to promote engagement is the use of prompts such as emails and text messages. However, little is known about the characteristics of prompts that promote engagement. This study explored the association between the content and delivery mode of prompts and the users’ engagement with HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a DHI that aimed to promote self-management in adults with type 2 diabetes.

Objective

The objective of this study was to identify the characteristics of prompts, specifically the content and delivery mode, which were associated with increased engagement.

Methods

This was a mixed-methods study. Email and text message prompts were sent to the registered users of HeLP-Diabetes. Use of the intervention was recorded and examined to identify which email and text message prompts were associated with subsequent visits to the DHI. Characteristics of prompts that were identified as particularly effective or ineffective were explored through think-aloud interviews with the participants.

Results

Of a total of 39 email prompts, 49% (19/39) prompts showed a significant association with subsequent visits to the DHI. However, none of the text message prompts were associated with subsequent visits to the DHI. Furthermore, think-aloud interviews were carried out with 6 experienced participants with type 2 diabetes. The findings suggest that these participants preferred email prompts that were clear, relatively short, and empowering; used nondirective advice; included health professional references; were visually appealing; and contained news and updates.

Conclusions

The findings of this study contribute to the existing evidence supporting the role of email prompts in promoting and maintaining engagement with DHIs. This study described the content of prompts that may be engaging. However, the results should be interpreted with caution, as prompts may be context-specific interventions and the results may not be generalizable across other DHIs or other types of interventions targeting self-management of type 2 diabetes.

A novel web-support intervention to promote recovery following Anterior Cruciate Ligament reconstruction: A pilot randomised controlled trial

BACKGROUND

Self-efficacy is positively associated with adherence behaviours and rehabilitation outcomes following Anterior Cruciate Ligament (ACL) reconstruction. An internet resource can be an effective way to provide information, goal setting, patient monitoring and hence support overall self-management.

PURPOSE

This study examined the feasibility of a three month 'internet-based intervention' (mobile-oriented site) to enhance recovery for patients following ACL reconstruction. The potential effect of the internet-based intervention on knee pain, function, self-efficacy and fear of pain were also assessed.

METHOD

This was a pilot randomised controlled trial (RCT) with pre and post intervention design (assessments at one week and three months following ACL reconstruction) comparing: (1) a control group and (2) an intervention group (internet-based intervention). A set of qualitative and quantitative assessments were included to evaluate potential improvements in self-efficacy, pain and function and perception of the internet intervention.

RESULTS AND CONCLUSION

Seventeen participants were available for analysis (n = 10 intervention and n = 7 control group). Participants reported the internet-based intervention to be a useful tool for information, reminder and reinforcement for performing their exercise rehabilitation with 30.3% (±35.3%) adherence to the internet-based intervention. No differences were observed between the groups over time on the outcome questionnaires (p > 0.05). Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001379404.

The Impact of Participant Characteristics on Use and Satisfaction of a Web-Based Computer-Tailored Chronic Obstructive Pulmonary Disease Self-Management Intervention: A Process Evaluation

BACKGROUND

A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results.

OBJECTIVES

The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction.

METHODS

Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention.

RESULTS

The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (P<.001). Application use was low. Of all participants in the intervention group, 52.9% (348/658) initiated use of one or both modules, 36.0% (237/658) completed an intervention component (prolonged use), and 16.6% (109/658) revisited one of the modules after completing an intervention component (sustained use). Older age, established diagnosis of COPD, or experiencing breathlessness predicted sustained use. Participant satisfaction with the 2 modules was 6.7 (SD 1.6) on a scale from 0 to 10. The interviews revealed that a computer application was believed not to be sufficient and the help of a health care professional was necessary. Participants with a greater intention to change were more satisfied with the application.

CONCLUSIONS

The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with the intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider.

The Impact of Participant Characteristics on Use and Satisfaction of a Web-Based Computer-Tailored Chronic Obstructive Pulmonary Disease Self-Management Intervention: A Process Evaluation

BACKGROUND

A randomized controlled trial (RCT) showed that a Web-based computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease (COPD) did not have a significant treatment effect. Process evaluation measures such as application use and satisfaction with the intervention can help understand these results.

OBJECTIVES

The aim of this paper is to uncover reasons for suboptimal application use, evaluate satisfaction with the intervention, and investigate which participant characteristics predict application use and user satisfaction.

METHODS

Participants were recruited through 2 different channels: an online panel and general practice. The intervention group received the intervention, which consisted of 2 modules (smoking cessation and physical activity). The control group received no intervention. The study employed a mixed methods design. Quantitative and qualitative data were gathered assessing participant characteristics, application use, reasons for not using the application, and satisfaction with the intervention.

RESULTS

The RCT included 1325 participants. The proportion of individuals who participated was significantly higher in the online group (4072/6844, 59.5%) compared to the general practice group (43/335, 12.8%) (P<.001). Application use was low. Of all participants in the intervention group, 52.9% (348/658) initiated use of one or both modules, 36.0% (237/658) completed an intervention component (prolonged use), and 16.6% (109/658) revisited one of the modules after completing an intervention component (sustained use). Older age, established diagnosis of COPD, or experiencing breathlessness predicted sustained use. Participant satisfaction with the 2 modules was 6.7 (SD 1.6) on a scale from 0 to 10. The interviews revealed that a computer application was believed not to be sufficient and the help of a health care professional was necessary. Participants with a greater intention to change were more satisfied with the application.

CONCLUSIONS

The application was not used sufficiently. Study materials should be further tailored to younger individuals, those at risk for COPD, and those who do not experience breathlessness in order to increase sustained use among them. Involvement of a health care professional could improve satisfaction with the intervention and potentially increase engagement with the intervention materials. However, to make this possible, recruitment in general practice needs to be improved. Recommendations are made for improving the study design, strengthening the intervention (eg, practice facilitation), and linking the computer application to interaction with a health care provider.

DIAMOND (DIgital Alcohol Management ON Demand): a mixed methods feasibility RCT and embedded process evaluation of a digital health intervention to reduce hazardous and harmful alcohol use

Background

Alcohol is a major risk factor for preventable illness, with huge cost to healthcare economies. There is a role for alcohol-specific digital health interventions (DHI), but there have been few randomised controlled trials (RCT) comparing DHI with face-to-face treatment. Such trials are complex and face obstacles in recruitment and retention.

Methods

Mixed-methods feasibility RCT of an alcohol DHI, testing recruitment, online data-collection and randomisation processes, with an embedded process evaluation. Recruitment ran from October 2014 for 9 months. Participants were adults drinking at hazardous and harmful levels, attending four community drug and alcohol services (CDAS) in London. Participants completed baseline demographic, alcohol-related and other psychological questionnaires online and were randomised to HeLP-Alcohol, a six-module DHI with weekly reminder prompts (phone, email or text message), which mirrors face-to-face treatment, or to face-to-face treatment at CDAS. Alcohol counsellors took part in qualitative interviews at the end of the study.

Results

Alcohol counsellors screened 1253 patients. One thousand one hundred eighty-nine did not meet inclusion criteria so were excluded: 579 were dependent drinkers, 548 had health conditions that made them ineligible to take part and 62 were ineligible for other reasons including homelessness. Of the 64 patients who were eligible to take part, 54 declined to participate, with 36 stating a preference for face-to-face treatment, 13 gave no reason, and 5 gave other reasons including not wanting to use a computer. Ten consented but then 3 changed their minds, so we were able to randomise 7 participants to the study (11% of eligible).

Five alcohol counsellors agreed to be interviewed for the process evaluation and provided the following feedback: Although most of their colleagues were enthusiastic about the trial, some were not at equipoise in recruiting; potential participants also declared strong preference to intervention arm from the outset. These factors affected recruitment. Counsellors also lacked time to undertake the data inputting and follow-up of participants in addition to their everyday work.

Conclusions

This feasibility study aimed to test recruitment, randomisation, retention and data collection methods but recruited only 7 participants so these aims were not fully achieved. This illustrates to all researchers of complex interventions the importance of conducting feasibility studies and is generalisable to areas other than alcohol research.

CDAS were seeing larger numbers of non-dependent drinkers with complex additional problems than alcohol commissioners expected. CDAS clients and some counsellors were not at equipoise for recruitment. Alternative settings for recruitment need to be explored in future trials.

Trial registration

International Standard Randomized Controlled Trial Number: ISRCTN31789096, DOI 10.1186/ISRCTN31789096

Free smoking cessation mobile apps available in Australia: a quality review and content analysis

OBJECTIVES

This review aimed to identify free, high-quality, smoking cessation mobile applications (apps) that adhere to Australian smoking cessation treatment guidelines.

METHODS

A systematic search of smoking cessation apps was conducted using Google. The technical quality of relevant apps was rated using the Mobile Application Rating Scale. The content of apps identified as high quality was assessed for adherence to smoking cessation treatment guidelines.

RESULTS

112 relevant apps were identified. The majority were of poor technical quality and only six 'high-quality' apps were identified. These apps adhered to Australian treatment guidelines in part. The efficacy of two apps had been previously evaluated.

CONCLUSIONS

In lieu of more substantial research in this area, it is suggested that the high-quality apps identified in this review may be more likely than other available apps to encourage smoking cessation. Implications for public health: Smoking cessation apps have the potential to address many barriers that prevent smoking cessation support being provided; however few high-quality smoking cessation apps are currently available in Australia, very few have been evaluated and the app market is extremely volatile. More research to evaluate smoking cessation apps, and sustained funding for evidence-based apps, is needed.

Improving Employee Well-Being and Effectiveness: Systematic Review and Meta-Analysis of Web-Based Psychological Interventions Delivered in the Workplace

Background

Stress, depression, and anxiety among working populations can result in reduced work performance and increased absenteeism. Although there is evidence that these common mental health problems are preventable and treatable in the workplace, uptake of psychological treatments among the working population is low. One way to address this may be the delivery of occupational digital mental health interventions. While there is convincing evidence for delivering digital psychological interventions within a health and community context, there is no systematic review or meta-analysis of these interventions in an occupational setting.

Objective

The aim of this study was to identify the effectiveness of occupational digital mental health interventions in enhancing employee psychological well-being and increasing work effectiveness and to identify intervention features associated with the highest rates of engagement and adherence.

Methods

A systematic review of the literature was conducted using Cochrane guidelines. Papers published from January 2000 to May 2016 were searched in the PsychINFO, MEDLINE, PubMed, Science Direct, and the Cochrane databases, as well as the databases of the researchers and relevant websites. Unpublished data was sought using the Conference Proceedings Citation Index and the Clinical Trials and International Standard Randomized Controlled Trial Number (ISRCTN) research registers. A meta-analysis was conducted by applying a random-effects model to assess the pooled effect size for psychological well-being and the work effectiveness outcomes. A positive deviance approach was used to identify those intervention features associated with the highest rates of engagement and adherence.

Results

In total, 21 randomized controlled trials (RCTs) met the search criteria. Occupational digital mental health interventions had a statistically significant effect post intervention on both psychological well-being (g=0.37, 95% CI 0.23-0.50) and work effectiveness (g=0.25, 95% CI 0.09-0.41) compared with the control condition. No statistically significant differences were found on either outcome between studies using cognitive behavioral therapy (CBT) approaches (as defined by the authors) compared with other psychological approaches, offering guidance compared with self-guidance, or recruiting from a targeted workplace population compared with a universal workplace population. In-depth analysis of the interventions identified by the positive deviance approach suggests that interventions that offer guidance are delivered over a shorter time frame (6 to 7 weeks), utilize secondary modalities for delivering the interventions and engaging users (ie, emails and text messages [short message service, SMS]), and use elements of persuasive technology (ie, self-monitoring and tailoring), which may achieve greater engagement and adherence.

Conclusions

This review provides evidence that occupational digital mental health interventions can improve workers’ psychological well-being and increase work effectiveness. It identifies intervention characteristics that may increase engagement. Recommendations are made for future research, practice, and intervention development.

A Self-Regulation-Based eHealth Intervention to Promote a Healthy Lifestyle: Investigating User and Website Characteristics Related to Attrition

BACKGROUND

eHealth interventions can reach large populations and are effective in increasing physical activity (PA) and fruit and vegetable intake. Nevertheless, the effects of eHealth interventions are overshadowed by high attrition rates. Examining more closely when users decide to leave the intervention can help eHealth developers to make informed decisions about which intervention components should be reshaped or simply removed. Investigating which users are more likely to quit an intervention can inform developers about whether and how their intervention should be adapted to specific subgroups of users.

OBJECTIVE

This study investigated the pattern of attrition in a Web-based intervention to increase PA, fruit, and vegetable intake. The first aim was to describe attrition rates according to different self-regulation components. A second aim was to investigate whether certain user characteristics are predictors for start session completion, returning to a follow-up session and intervention completion.

METHODS

The sample consisted of 549 adults who participated in an online intervention, based on self-regulation theory, to promote PA and fruit and vegetable intake, called "MyPlan 1.0." Using descriptive analysis, attrition was explored per self-regulation component (eg, action planning and coping planning). To identify which user characteristics predict completion, logistic regression analyses were conducted.

RESULTS

At the end of the intervention program, there was an attrition rate of 78.2% (330/422). Attrition rates were very similar for the different self-regulation components. However, attrition levels were higher for the fulfillment of questionnaires (eg, to generate tailored feedback) than for the more interactive components. The highest amount of attrition could be observed when people were asked to make their own action plan. There were no significant predictors for first session completion. Yet, two subgroups had a lower chance to complete the intervention, namely male users (OR: 2.24, 95% CI=1.23-4.08) and younger adults (OR: 1.02, 95% CI=1.00-1.04). Furthermore, younger adults were less likely to return to the website for the first follow-up after one week (OR: 1.03, 95% CI=1.01-1.04).

CONCLUSIONS

This study informs us that eHealth interventions should avoid the use of extensive questionnaires and that users should be provided with a rationale for several components (eg, making an action plan and completing questions). Furthermore, future interventions should focus first on motivating users for the behavior change before guiding them through action planning. Though, this study provides no evidence for removal of one of the self-regulation techniques based on attrition rates. Finally, strong efforts are needed to motivate male users and younger adults to complete eHealth interventions.

Long-term effectiveness and moderators of a web-based tailored intervention for cancer survivors on social and emotional functioning, depression, and fatigue: randomized controlled trial

Purpose

The web-based computer-tailored Kanker Nazorg Wijzer (Cancer Aftercare Guide) supports cancer survivors with psychosocial issues during cancer recovery. The current study investigates whether the 6-month effects in increasing emotional and social functioning and reducing depression and fatigue hold at 12 months from baseline. Moreover, it explores whether patient characteristics moderate the 6- and 12-month intervention effectiveness.

Methods

Cancer survivors from 21 Dutch hospitals (November 2013–June 2014) were randomized to an intervention (n = 231) or a wait-list control group (n = 231). Intervention effects on emotional and social functioning (EORTC QLQ-C30), depression (HADS), and fatigue (CIS) were evaluated through multilevel linear regression analyses.

Results

At 12 months from baseline, the intervention group no longer differed from the control group in emotional and social functioning, depression, and fatigue. Moderator analyses indicated that, at 6 months, the intervention was effective in improving social functioning for men (d = 0.34), reducing fatigue for participants ≤56 years (d = 0.44), and reducing depression for participants who received chemotherapy (d = 0.36). At 12 months, participants with a medium educational level reported higher social functioning (d = 0.19), while participants with a low educational level reported lower social functioning (d = 0.22) than participants with a similar educational level in the control group.

Conclusions

The intervention gave cancer patients a head start to psychological recovery after the end of cancer treatment. The control group caught up in the long run.

Implications for cancer survivors

The Cancer Aftercare Guide expedited recovery after cancer treatment. Being a low intensity, easy accessible, and relatively low cost intervention, it could serve as a relevant step in recovery and stepped care.

Electronic supplementary material

The online version of this article (doi:10.1007/s11764-017-0625-0) contains supplementary material, which is available to authorized users.

Social exclusion and psychopathology in an online cohort of Moroccan-Dutch migrants: Results of the MEDINA-study

Introduction

Migration is seen as a risk factor for developing psychiatric symptoms and experiencing social exclusion. In the Netherlands, the Moroccan-Dutch population is the second largest migrant group. 70% of all young Moroccan-Dutch people meet each other in the online community www.marokko.nl. Within this community, we investigated the association between experiences of social exclusion and self-reported depressive symptoms and psychotic experiences.

Materials and methods

Participants were recruited via the website www.marokko.nl. They completed an online survey, with screening instruments for depressive symptoms (K10) and psychotic experiences (PQ-16), measures of social exclusion (perceived discrimination, social defeat and social support), and questions about demographical information. With regression analysis the association between social exclusion and psychiatric symptoms was investigated.

Results

We included 267 participants; 87% were female. 27% of the sample has received mental healthcare in the past. Over 50% of these people screened positive for depressive symptoms and psychotic experiences. Perceived discrimination and social defeat were significantly associated with psychotic experiences and social defeat was associated with depressive symptoms. Social support and higher education were associated with less depressive symptoms and psychotic experiences.

Discussion

Our findings suggest that the online environment allows for epidemiological research and early symptom detection. Levels of psychopathology were high in our sample. This suggests that a part of this young ethnic minority population might not get adequate mental healthcare. Since this population can be reached through Internet, the online environment may therefore also offer an appropriate setting for intervention, to increase resilience towards social exclusion.

Designing more engaging computer-tailored physical activity behaviour change interventions for breast cancer survivors: lessons from the iMove More for Life study

BACKGROUND

Participating in regular physical activity is a recommended cancer recovery strategy for breast cancer survivors. However, tailored support services are not widely available and most survivors are insufficiently active to obtain health benefits. Delivering tailored programs via the Internet offers one promising approach. However, recent evaluations of such programs suggest that major improvements are needed to ensure programs meet the needs of users and are delivered in an engaging way. Understanding participants' experiences with current programs can help to inform the next generation of systems.

PURPOSE

The purposes of this study are to explore breast cancer survivor's perspectives of and experiences using a novel computer-tailored intervention and to describe recommendations for future iterations.

METHODS

Qualitative data from a sub-sample of iMove More for Life study participants were analysed thematically to identify key themes. Participants long-term goals for participating in the program were explored by analysing open-ended data extracted from action plans completed during the intervention (n = 370). Participants negative and positive perceptions of the website and recommendations for improvement were explored using data extracted from open-ended survey items collected at the immediate intervention follow-up (n = 156).

RESULTS

The majority of participants reported multi-faceted goals, consisting of two or more outcomes they hoped to achieve within a year. While clear themes were identified (e.g. 'being satisfied with body weight'), there was considerable variability in the scope of the goal (e.g. desired weight loss ranged from 2 to 30 kg). Participants' perceptions of the website were mixed, but clear indications were provided of how intervention content and structure could be improved.

CONCLUSIONS

This study provides insight into how to better accommodate breast cancer survivors in the future and ultimately design more engaging computer-tailored interventions.

Young People, Adult Worries: Randomized Controlled Trial and Feasibility Study of the Internet-Based Self-Support Method "Feel the ViBe" for Adolescents and Young Adults Exposed to Family Violence

BACKGROUND

Adolescents and young adults (AYAs) are of special interest in a group of children exposed to family violence (FV). Past-year prevalence of exposure to FV is known to be highest in AYAs and has severe consequences. Peer support is an effective approach to behavior change and the Internet is considered suitable as a mode of delivery.

OBJECTIVE

The study aimed to evaluate both effectiveness and feasibility of a randomized controlled trial (RCT) and feasibility study of the Internet-based self-support method "Feel the ViBe" (FtV) using mixed-methods approach to fully understand the strengths and weaknesses of a new intervention.

METHODS

AYAs aged 12-25 years and exposed to FV were randomized in an intervention group (access to FtV + usual care) and a control group (minimally enhanced usual care) after they self-registered themselves. From June 2012 to July 2014, participants completed the Impact of Event Scale (IES) and Depression (DEP) and Anxiety (ANX) subscales of the Symptom CheckList-90-R (SCL-90) every 6 weeks. The Web Evaluation Questionnaire was completed after 12 weeks. Quantitative usage data were collected using Google analytics and content management system (CMS) logs and data files. A univariate analysis of variance (UNIANOVA) and mixed model analysis (intention-to-treat [ITT], complete case) were used to compare groups. Pre-post t tests were used to find within-group effects. Feasibility measures structurally address the findings. The CONsolidated Standards Of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth (CONSORT-EHEALTH) checklist was closely followed.

RESULTS

In total, 31 out of 46 participants in the intervention group and 26 out of 47 participants in the control group started FtV. Seventeen participants (intervention: n=8, control: n=9) completed all questionnaires. Mixed model analysis showed significant differences between groups on the SCL-90 DEP (P=.04) and ANX (P=.049) subscales between 6 and 12 weeks after participation started. UNIANOVA showed no significant differences. Pre-post paired sample t tests showed significant improvements after 12 weeks for the SCL-90 DEP (P=.03) and ANX (P=.046) subscales. Reported mean Web-based time per week was 2.83 with a session time of 36 min. FtV was rated a mean 7.47 (1-10 Likert scale) with a helpfulness score of 3.16 (1-5 Likert scale). All participants felt safe. Two-thirds of the intervention participants started regular health care.

CONCLUSIONS

No changes on the IES were found. SCL-90 DEP and ANX showed promising results; however, the calculated sample size was not reached (n=18). FtV functions best as a first step for adolescents and young adults in an early stage of change. FtV can be easily implemented without extensive resources and fits best in the field of public health care or national governmental care.

TRIAL REGISTRATION

Netherlands National Trial Register (NTR): NTR3692; http://www.trialregister.nl/trialreg/admin/ rctview.asp?TC=3692 (Archived by WebCite at http://www.webcitation.org/6qIeKyjA4).

Conceptualising engagement with digital behaviour change interventions: a systematic review using principles from critical interpretive synthesis

"Engagement" with digital behaviour change interventions (DBCIs) is considered important for their effectiveness. Evaluating engagement is therefore a priority; however, a shared understanding of how to usefully conceptualise engagement is lacking. This review aimed to synthesise literature on engagement to identify key conceptualisations and to develop an integrative conceptual framework involving potential direct and indirect influences on engagement and relationships between engagement and intervention effectiveness. Four electronic databases (Ovid MEDLINE, PsycINFO, ISI Web of Knowledge, ScienceDirect) were searched in November 2015. We identified 117 articles that met the inclusion criteria: studies employing experimental or non-experimental designs with adult participants explicitly or implicitly referring to engagement with DBCIs, digital games or technology. Data were synthesised using principles from critical interpretive synthesis. Engagement with DBCIs is conceptualised in terms of both experiential and behavioural aspects. A conceptual framework is proposed in which engagement with a DBCI is influenced by the DBCI itself (content and delivery), the context (the setting in which the DBCI is used and the population using it) and the behaviour that the DBCI is targeting. The context and "mechanisms of action" may moderate the influence of the DBCI on engagement. Engagement, in turn, moderates the influence of the DBCI on those mechanisms of action. In the research literature, engagement with DBCIs has been conceptualised in terms of both experience and behaviour and sits within a complex system involving the DBCI, the context of use, the mechanisms of action of the DBCI and the target behaviour.