Measuring Engagement in eHealth and mHealth Behavior Change Interventions: Viewpoint of Methodologies

Real-world Implementation of a Smartphone-Based Psychoeducation Program for Bipolar Disorder: Observational Ecological Study

BACKGROUND

SIMPLe is an internet-delivered self-management mobile app for bipolar disorder (BD) designed to combine technology with evidence-based interventions and facilitate access to psychoeducational content. The SIMPLe app was launched to the real world to make it available worldwide within the context of BD treatment.

OBJECTIVE

The main aims of this study are as follows: to describe app use, engagement, and retention rates based on server data; to identify patterns of user retention over the first 6-month follow-up of use; and to explore potential factors contributing to discontinuation of app use.

METHODS

This was an observational ecological study in which we pooled available data from a real-world implementation of the SIMPLe app. Participation was open on the project website, and the data-collection sources were a web-based questionnaire on clinical data and treatment history administered at inclusion and at 6 months, subjective data gathered through continuous app use, and the use patterns captured by the app server. Characteristics and engagement of regular users, occasional users, and no users were compared using 2-tailed t tests or analysis of variance or their nonparametric equivalent. Survival analysis and risk functions were applied to regular users' data to examine and compare use and user retention. In addition, a user evaluation analysis was performed based on satisfaction, perceived usefulness, and reasons to discontinue app use.

RESULTS

We included 503 participants with data collected between 2016 and 2018, of whom 77.5% (n=390) used the app. Among the app users, 44.4% (173/390) completed the follow-up assessment, and data from these participants were used in our analyses. Engagement declined gradually over the first 6 months of use. The probability of retention of the regular users after 1 month of app use was 67.4% (263/390; 95% CI 62.7%-72.4%). Age (P=.002), time passed since illness onset (P<.001), and years since diagnosis of BD (P=.048) correlate with retention duration. In addition, participants who had been diagnosed with BD for longer used the app on more days (mean 97.73, SD 69.15 days; P=.002) than those who had had a more recent onset (mean 66.49, SD 66.18 days; P=.002) or those who had been diagnosed more recently (mean 73.45, SD 66 days; P=.01).

CONCLUSIONS

The user retention rate of the app decreased rapidly after each month until reaching only one-third of the users at 6 months. There exists a strong association between age and app engagement of individuals with BD. Other variables such as years lived with BD, diagnosis of an anxiety disorder, and taking antipsychotics seem relevant as well. Understanding these associations can help in the definition of the most suitable user profiles for predicting trends of engagement, optimization of app prescription, and management.

Active Use and Engagement in an mHealth Initiative Among Young Men With Obesity: Mixed Methods Study

Background

The effectiveness of mobile health (mHealth) approaches that employ wearable technology to promote physical activity have been the subject of concern due to the declining active use observed in trial settings.

Objective

To better contextualize active use, this study aimed to identify the barriers and enablers to engagement in a tracker-based mHealth initiative among young men who had recently completed a 19-week residential weight loss program.

Methods

A mixed methods study was conducted among 167 young men who had voluntarily enrolled in the national steps challenge (NSC), an mHealth physical activity promotion initiative, following a residential weight loss intervention. A subsample of 29 enrollees with a body mass index of 29.6 (SD 3.1) participated in semistructured interviews and additional follow-up assessments. Quantitative systems data on daily step count rates were used to describe active use. Qualitative data were coded and analyzed to elicit barriers and enablers to microlevel engagement in relation to the NSC, focusing on tracker and smartphone use. We further elicited barriers and enablers to macrolevel engagement by exploring attitudes and behaviors toward the NSC. Using triangulation, we examined how qualitative engagement in the NSC could account for quantitative findings on active use. Using integration of findings, we discussed how the mHealth intervention might have changed physical activity behavior.

Results

Among the 167 original enrollees, active use declined from 72 (47%) in week 1 to 27 (17%) in week 21. Mean daily step counts peaked in week 1 at 10,576 steps per day and were variable throughout the NSC. Barriers to engagement had occurred in the form of technical issues leading to abandonment, device switching, and offline tracking. Passive attitudes toward step counting and disinterest in the rewards had also prevented deeper engagement. Enablers of engagement included self-monitoring and coaching features, while system targets and the implicit prospect of reward had fostered new physical activity behaviors.

Conclusions

Our study showed that as the NSC is implemented in this population, more emphasis should be placed on technical support and personalized activity targets to promote lasting behavior change.

A Digital Intervention for Respiratory Tract Infections (Internet Dr): Process Evaluation to Understand How to Support Self-care for Minor Ailments

Background

Approximately 57 million physician appointments annually in the United Kingdom are for minor ailments. These illnesses could be self-cared for, which would potentially lower patients’ anxiety, increase their confidence, and be more convenient. In a randomized controlled trial of the Internet Dr digital intervention, patients with access to the intervention had fewer consultations for respiratory tract infections (RTIs). Having established intervention efficacy, further examination of trial data is required to understand how the intervention works.

Objective

This paper reports a process evaluation of Internet Dr usage by the intervention group. The evaluation aims to demonstrate how meaningful usage metrics (ie, interactions that are specific and relevant to the intervention) can be derived from the theoretical principles underlying the intervention, then applied to examine whether these interactions are effective in supporting self-care for RTIs, for whom, and at what time.

Methods

The Internet Dr trial recorded patients’ characteristics and usage data over 24 weeks. At follow-up, users reported whether their levels of enablement to cope with their illness changed over the trial period. The Medical Research Council process evaluation guidance and checklists from the framework for Analyzing and Measuring Usage and Engagement Data were applied to structure research questions examining associations between usage and enablement.

Results

Viewing pages containing advice on caring for RTIs were identified as a meaningful metric for measuring intervention usage. Almost half of the users (616/1491, 42.31%) viewed at least one advice page, with most people (478/616, 77.6%) accessing them when they initially enrolled in the study. Users who viewed an advice page reported increased enablement to cope with their illness as a result of having participated in the study compared with users who did not (mean 2.12, SD 2.92 vs mean 1.65, SD 3.10; mean difference 0.469, 95% CI 0.082-0.856). The target population was users who had visited their general practitioners for an RTI in the year before the trial, and analyses revealed that this group was more likely to access advice pages (odds ratio 1.35, 95% CI 1.159-1.571; P<.001).

Conclusions

The process evaluation identifies viewing advice pages as associated with increased enablement to self-care, even when accessed in the absence of a RTI, meaning that dissemination activities need not be restricted to targeting users who are ill. The intervention was effective at reaching the target population of users who had previously consulted their general practitioners. However, attrition before reaching advice pages was high, highlighting the necessity of prioritizing access during the design phase. These findings provide guidance on how the intervention may be improved and disseminated and have wider implications for minor ailment interventions.

Combining Farmers' Preferences With Evidence-Based Strategies to Prevent and Lower Farmers' Distress: Co-design and Acceptability Testing of ifarmwell

Background

Farming is physically and psychologically hazardous. Farmers face many barriers to help seeking from traditional physical and mental health services; however, improved internet access now provides promising avenues for offering support.

Objective

This study aims to co-design with farmers the content and functionality of a website that helps them adopt transferable coping strategies and test its acceptability in the broader farming population.

Methods

Research evidence and expert opinions were synthesized to inform key design principles. A total of 18 farmers detailed what they would like from this type of website. Intervention logic and relevant evidence-based strategies were mapped. Website content was drafted and reviewed by 2 independent mental health professionals. A total of 9 farmers provided detailed qualitative feedback on the face validity of the draft content. Subsequently, 9 farmers provided feedback on the website prototype. Following amendments and internal prototype testing and optimization, prototype usability (ie, completion rate) was examined with 157 registered website users who were (105/157, 66.9%) female, aged 21-73 years; 95.5% (149/156) residing in inner regional to very remote Australia, and 68.2% (107/157) “sheep, cattle and/or grain farmers.” Acceptability was examined with a subset of 114 users who rated at least module 1. Interviews with 108 farmers who did not complete all 5 modules helped determine why, and detailed interviews were conducted with 18 purposively sampled users. Updates were then made according to adaptive trial design methodology.

Results

This systematic co-design process resulted in a web-based resource based on acceptance and commitment therapy and designed to overcome barriers to engagement with traditional mental health and well-being strategies—ifarmwell. It was considered an accessible and confidential source of practical and relevant farmer-focused self-help strategies. These strategies were delivered via 5 interactive modules that include written, drawn, and audio- and video-based psychoeducation and exercises, as well as farming-related jokes, metaphors, examples, and imagery. Module 1 included distress screening and information on how to speak to general practitioners about mental health–related concerns (including a personalized conversation script). Modules were completed fortnightly. SMS text messages offered personalized support and reminders. Qualitative interviews and star ratings demonstrated high module acceptability (average 4.06/5 rating) and suggested that additional reminders, higher quality audio recordings, and shorter modules would be useful. Approximately 37.1% (52/140) of users who started module 1 completed all modules, with too busy or not got to it yet being the main reason for non-completion, and previous module acceptability not predicting subsequent module completion.

Conclusions

Sequential integration of research evidence, expert knowledge, and farmers’ preferences in the co-design process allowed for the development of a self-help intervention that focused on important intervention targets and was acceptable to this difficult-to-engage group.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12617000506392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372526

The Development of iManage-PC, an Online Symptom Monitoring and Self-management Tool for Men With Clinically Localized Prostate Cancer

BACKGROUND

Prostate cancer (PC) often impacts 4 major aspects of health-related quality of life (HRQL): urinary, sexual, and bowel dysfunction, and anxiety. Online tools may be helpful in supporting the development of self-management skills that can improve HRQL.

OBJECTIVE

The aim of this study was to develop and pilot-test an online symptom monitoring and self-management program, iManage-PC.

METHODS

A literature search, input from experts, and feedback from patients were used to develop iManage-PC. A 4-week, single-arm pilot study was conducted with 96 men with prostate cancer. We evaluated system usability, acceptance, and satisfaction and examined preliminary effects on patient-reported outcomes.

RESULTS

Rates of retention (94.8%) and adherence to symptom monitoring (95.0%-97.0%) were high. Most participants rated the tool as satisfactory and acceptable (81.2%-94.3%). Related-samples Wilcoxon signed rank tests revealed that participants reported increased self-efficacy related to their ability to manage their adverse effects (T = 1772.0, P < .001, r = 0.39), physical discomfort (T = 1259.0, P < .001, r = 0.40), and stress and worry (T = 1108.5, P = .001, r = 0.34). Global mental and physical health also improved (T = 1322.0, P = .032, r = 0.23, and T = 1409.0, P = .001, r = 0.35, respectively).

CONCLUSIONS

Future research with such tools should examine the potential role of cut-score-derived management interventions to improve engagement, symptom management self-efficacy, and HRQL.

IMPLICATIONS FOR PRACTICE

Our findings are consistent with a growing body of literature that supports the feasibility and acceptability of remotely delivered interventions.

Technology-supported strategies for promoting user engagement with digital mental health interventions: A systematic review

Background

Although digital mental health interventions (DMHIs) offer a potential solution for increasing access to mental health treatment, their integration into real-world settings has been slow. A key reason for this is poor user engagement. A growing number of studies evaluating strategies for promoting engagement with DMHIs means that a review of the literature is now warranted. This systematic review is the first to synthesise evidence on technology-supported strategies for promoting engagement with DMHIs.

Methods

MEDLINE, EmbASE, PsycINFO and PubMed databases were searched from 1 January 1995 to 1 October 2021. Experimental or quasi-experimental studies examining the effect of technology-supported engagement strategies deployed alongside DMHIs were included, as were secondary analyses of such studies. Title and abstract screening, full-text coding and quality assessment were performed independently by two authors. Narrative synthesis was used to summarise findings from the included studies.

Results

24 studies (10,266 participants) were included. Engagement strategies ranged from reminders, coaching, personalised information and peer support. Most strategies were disseminated once a week, usually via email or telephone. There was some empirical support for the efficacy of technology-based strategies towards promoting engagement. However, findings were mixed regardless of strategy type or study aim.

Conclusions

Technology-supported strategies appear to increase engagement with DMHIs; however, their efficacy varies widely by strategy type. Future research should involve end-users in the development and evaluation of these strategies to develop a more cohesive set of strategies that are acceptable and effective for target audiences, and explore the mechanism(s) through which such strategies promote engagement.

Estimating the impact of engagement with digital health interventions on patient outcomes in randomized trials

OBJECTIVE

Guidance is needed on studying engagement and treatment effects in digital health interventions, including levels required for benefit. We evaluated multiple analytic approaches for understanding the association between engagement and clinical outcomes.

MATERIALS AND METHODS

We defined engagement as intervention participants' response rate to interactive text messages, and considered moderation, standard regression, mediation, and a modified instrumental variable (IV) analysis to investigate the relationship between engagement and clinical outcomes. We applied each approach to two randomized controlled trials featuring text message content in the intervention: REACH (Rapid Encouragement/Education and Communications for Health), which targeted diabetes, and VERB (Vanderbilt Emergency Room Bundle), which targeted hypertension.

RESULTS

In REACH, the treatment effect on hemoglobin A1c was estimated to be -0.73% (95% CI: [-1.29, -0.21]; P = 0.008), and in VERB, the treatment effect on systolic blood pressure was estimated to be -10.1 mmHg (95% CI: [-17.7, -2.8]; P = 0.007). Only the IV analyses suggested an effect of engagement on outcomes; the difference in treatment effects between engagers and non-engagers was -0.29% to -0.51% in the REACH study and -1.08 to -3.25 mmHg in the VERB study.

DISCUSSION

Standard regression and mediation have less power than a modified IV analysis, but the IV approach requires specification of assumptions. This is the first review of the strengths and limitations of various approaches to evaluating the impact of engagement on outcomes.

CONCLUSIONS

Understanding the role of engagement in digital health interventions can help reveal when and how these interventions achieve desired outcomes.

Digital Interventions to Improve Health Literacy Among Parents of Children Aged 0 to 12 Years With a Health Condition: Systematic Review

Background

Parental health literacy is associated with child health outcomes. Parents are increasingly turning to the internet to obtain health information. In response, health care providers are using digital interventions to communicate information to assist parents in managing their child’s health conditions. Despite the emergence of interventions to improve parental health literacy, to date, no systematic evaluation of the effectiveness of the interventions has been undertaken.

Objective

The aim of this review is to examine the effect of digital health interventions on health literacy among parents of children aged 0-12 years with a health condition. This includes evaluating parents’ engagement (use and satisfaction) with digital health interventions, the effect of these interventions on parental health knowledge and health behavior, and the subsequent impact on child health outcomes.

Methods

This systematic review was registered a priori on PROSPERO (International Prospective Register of Systematic Reviews) and developed according to the Joanna Briggs Institute methodology for systematic reviews. The databases CINAHL, MEDLINE, and PsycINFO were searched for relevant literature published between January 2010 and April 2021. Studies were included if they were written in English. A total of 2 authors independently assessed the search results and performed a critical appraisal of the studies.

Results

Following the review of 1351 abstracts, 31 (2.29%) studies were selected for full-text review. Of the 31 studies, 6 (19%) studies met the inclusion criteria. Of the 6 studies, 1 (17%) was excluded following the critical appraisal, and the 5 (83%) remaining studies were quantitative in design and included digital health interventions using web-based portals to improve parents’ health knowledge and health behavior. Owing to heterogeneity in the reported outcomes, meta-analysis was not possible, and the findings were presented in narrative form. Of the 5 studies, satisfaction was measured in 3 (60%) studies, and all the studies reported high satisfaction with the digital intervention. All the studies reported improvement in parental health literacy at postintervention as either increase in disease-specific knowledge or changes in health behavior. Of the 5 studies, only 1 (20%) study included child health outcomes, and this study reported significant improvements related to increased parental health knowledge.

Conclusions

In response to a pandemic such as COVID-19, there is an increased need for evidence-based digital health interventions for families of children living with health conditions. This review has shown the potential of digital health interventions to improve health knowledge and behavior among parents of young children with a health condition. However, few digital health interventions have been developed and evaluated for this population. Future studies with robust research designs are needed and should include the potential benefits of increased parent health literacy for the child.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020192386; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=192386

Factors predicting engagement of older adults with a coach-supported eHealth intervention promoting lifestyle change, and associations between engagement and changes in cardiovascular and dementia risk: secondary analysis of an 18-month multinational randomized controlled trial

Background

Digital health interventions could help to prevent age-related diseases, but little is known about how older adults engage with such interventions, especially in the long term, or whether engagement is associated with changes in clinical, behavioral, or biological outcomes in this population. Disparities in engagement levels with digital health interventions may exist among older people and be associated with health inequalities.

Objective

This study aimed to describe older adults’ engagement with an eHealth intervention, identify factors associated with engagement, and examine associations between engagement and changes in cardiovascular and dementia risk factors (blood pressure, cholesterol, BMI, physical activity, diet, and cardiovascular and dementia risk scores).

Methods

This was a secondary analysis of the 18-month randomized controlled Healthy Ageing Through Internet Counselling in the Elderly trial of a tailored internet-based intervention encouraging behavior changes, with remote support from a lifestyle coach, to reduce cardiovascular and cognitive decline risk in 2724 individuals aged ≥65 years, recruited offline in the Netherlands, Finland, and France. Engagement was assessed via log-in frequency, number of lifestyle goals set, measurements entered and messages sent to coaches, and percentage of education materials read. Clinical and biological data were collected during in-person visits at baseline and 18 months. Lifestyle data were self-reported on a web-based platform.

Results

Of the 1389 intervention group participants, 1194 (85.96%) sent at least one message. They logged in a median of 29 times, and set a median of 1 goal. Higher engagement was associated with significantly greater improvement in biological and behavioral risk factors, with evidence of a dose-response effect. Compared with the control group, the adjusted mean difference (95% CI) in 18-month change in the primary outcome, a composite z-score comprising blood pressure, BMI, and cholesterol, was −0.08 (−0.12 to −0.03), −0.04 (−0.08 to 0.00), and 0.00 (−0.08 to 0.08) in the high, moderate, and low engagement groups, respectively. Low engagers showed no improvement in any outcome measures compared with the control group. Participants not using a computer regularly before the study engaged much less with the intervention than those using a computer up to 7 (adjusted odds ratio 5.39, 95% CI 2.66-10.95) or ≥7 hours per week (adjusted odds ratio 6.58, 95% CI 3.21-13.49). Those already working on or with short-term plans for lifestyle improvement at baseline, and with better cognition, engaged more.

Conclusions

Greater engagement with an eHealth lifestyle intervention was associated with greater improvement in risk factors in older adults. However, those with limited computer experience, who tended to have a lower level of education, or who had poorer cognition engaged less. Additional support or forms of intervention delivery for such individuals could help minimize potential health inequalities associated with the use of digital health interventions in older people.

E-&mHealth interventions targeting nutrition, physical activity, sedentary behavior, and/or obesity among children: A scoping review of systematic reviews and meta-analyses

Childhood obesity is a public health concern. Electronic and mobile health (e-&mHealth) approaches can facilitate the delivery of interventions for obesity prevention and treatment. Synthesizing reviews of e-&mHealth interventions to improve weight and weight-related behaviors (physical activity, sedentary behavior, and diet) is useful to characterize the current scope of the literature and identify opportunities for future reviews and studies. Using a scoping review methodology, we aimed to evaluate the breadth and methodological quality of systematic reviews and meta-analyses of e-&mHealth interventions targeting weight and weight-related behaviors in children and adolescents aged <19 years. A systematic search of seven databases was conducted, including reviews published between 2000 and 2019. Review characteristics were extracted, and methodological quality was assessed using the AMSTAR 2 tool. Forty-five systematic reviews and meta-analyses were included. All reviews evaluated intervention efficacy (100%), but few assessed other aspects (20% in total) such as cost-effectiveness. Smartphone applications (47%), text messages (44%), and websites (35%) were the main modalities. Weight (60%), physical activity (51%), and diet (44%) were frequently assessed, unlike sedentary behavior (8%). Most reviews were rated as having critically low or low methodological quality (97%). Reviews that identify the effective active ingredients of interventions and explore metrics beyond efficacy are recommended.

Predicting college student prescription stimulant misuse: An analysis from ecological momentary assessment

Prescription stimulant misuse (PSM) is common in young adult college students, at over 10% in the past year, and it is associated with other substance use and risk behaviors. Research focused on the real-time drivers of PSM is absent, impeding prevention and intervention. This research aimed to fill that gap by examining the relationships between affect, global stress, or academic stress and PSM via ecological momentary assessment (EMA); we also investigated baseline predictors of PSM frequency during the 21-day EMA period. Forty-one full-time college students (mean age: 20.5, 66% female) who endorsed current PSM (≥ 6 past-year episodes) participated. Participants were asked to complete EMA questions in response to 3 daily investigator-initiated prompts and after every PSM episode. Assessments were selected based on affect regulation (e.g., positive affect [PA], negative affect [NA]) and drug instrumentalization (e.g., academic stress and/or demands) theories of substance use. Mixed-effects linear models examined EMA data, and negative binomial regression analyses examined baseline predictors of PSM episode frequency. PA was higher on PSM days and increased post-PSM, whereas NA was unrelated to PSM. Although global and academic stress were largely unrelated to PSM, when the motive endorsed for PSM was "to study," pre-PSM ratings of academic demand and stress were significantly higher. Finally, a history of recreational motives (e.g., to get high) or higher levels of attention-deficit/hyperactivity disorder symptoms predicted a greater number of PSM episodes over the EMA period. The results offered mixed support for both affect regulation and instrumentalization as applied to PSM. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effect of Engagement With Digital Interventions on Mental Health Outcomes: A Systematic Review and Meta-Analysis

Digital mental health interventions (DMHIs) present a promising way to address gaps in mental health service provision. However, the relationship between user engagement and outcomes in the context of these interventions has not been established. This study addressed the current state of evidence on the relationship between engagement with DMHIs and mental health outcomes. MEDLINE, PsycINFO, and EmBASE databases were searched from inception to August 1, 2021. Original or secondary analyses of randomized controlled trials (RCTs) were included if they examined the relationship between DMHI engagement and post-intervention outcome(s). Thirty-five studies were eligible for inclusion in the narrative review and 25 studies had sufficient data for meta-analysis. Random-effects meta-analyses indicated that greater engagement was significantly associated with post-intervention mental health improvements, regardless of whether this relationship was explored using correlational [r = 0.24, 95% CI (0.17, 0.32), Z = 6.29, p < 0.001] or between-groups designs [Hedges' g = 0.40, 95% CI (0.097, 0.705), p = 0.010]. This association was also consistent regardless of intervention type (unguided/guided), diagnostic status, or mental health condition targeted. This is the first review providing empirical evidence that engagement with DMHIs is associated with therapeutic gains. Implications and future directions are discussed.

Systematic Review Registration: PROSPERO, identifier: CRD 42020184706.

Contextual Predictors of Engagement in a Tailored mHealth Intervention for Adolescent and Young Adult Cancer Survivors

BACKGROUND

Despite the promise of mobile health (mHealth), engagement is often too low for durable health behavior change, and little is known regarding why certain individuals abandon mHealth tools.

PURPOSE

Guided by a mHealth engagement framework, we evaluated contextual predictors of objective engagement with an app for adolescents and young adults (AYA) who survived cancer.

METHODS

One hundred and ten AYA survivors (M age = 20.5, 43% female, 30% racial/ethnic minority) were randomized to receive a disease self-management app that delivered 1-2 tailored messages/day for 16 weeks, and contained a survivorship care plan (SCP). Demographic, disease, psychosocial, and setting characteristics were examined as predictors of three objective engagement outcomes: (a) % of active app days, (b) % of messages read, and (c) viewed SCP in the app versus not. A subsample (n = 10) completed qualitative interviews to further assess engagement barriers.

RESULTS

Self-reported uninterrupted app access (β = -0.56, p < .001), iPhone (vs. Android) ownership (β = 0.30, p < .001), and receiving the intervention in the summer (β = -0.20, p = .01) predicted more active days. Lower depressed mood (β = -0.30, p = .047) and uninterrupted app access (β = -0.50, p < .001) predicted more messages read. Qualitatively, technical glitches and competing priorities were described as engagement barriers, whereas certain types of messages (e.g., health goal messages) were perceived as engaging. Among participants who had uninterrupted app access (n = 76), higher baseline motivation to change, better health perceptions, using the app during the summer, and iPhone ownership predicted higher engagement.

CONCLUSIONS

Findings demonstrate the importance of comprehensively assessing and planning for multi-level ecological determinants of mHealth engagement in future trials.

CLINICALTRIALS.GOV IDENTIFIER

NCT03363711.

Digital Interventions on Healthy Lifestyle Management: Systematic Review

BACKGROUND

Digital interventions have tremendous potential to improve well-being and health care conveyance by improving adequacy, proficiency, availability, and personalization. They have gained acknowledgment in interventions for the management of a healthy lifestyle. Therefore, we are reviewing existing conceptual frameworks, digital intervention approaches, and associated methods to identify the impact of digital intervention on adopting a healthier lifestyle.

OBJECTIVE

This study aims to evaluate the impact of digital interventions on weight management in maintaining a healthy lifestyle (eg, regular physical activity, healthy habits, and proper dietary patterns).

METHODS

We conducted a systematic literature review to search the scientific databases (Nature, SpringerLink, Elsevier, IEEE Xplore, and PubMed) that included digital interventions on healthy lifestyle, focusing on preventing obesity and being overweight as a prime objective. Peer-reviewed articles published between 2015 and 2020 were included. We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and a framework for an evidence-based systematic review. Furthermore, we improved the review process by adopting the Rayyan tool and the Scale for the Assessment of Narrative Review Articles.

RESULTS

Our initial searches identified 780 potential studies through electronic and manual searches; however, 107 articles in the final stage were cited following the specified inclusion and exclusion criteria. The identified methods for a successful digital intervention to promote a healthy lifestyle are self-monitoring, self-motivation, goal setting, personalized feedback, participant engagement, psychological empowerment, persuasion, digital literacy, efficacy, and credibility. In this study, we identified existing conceptual frameworks for digital interventions, different approaches to provide digital interventions, associated methods, and execution challenges and their impact on the promotion of healthy lifestyle management.

CONCLUSIONS

This systematic literature review selected intervention principles (rules), theories, design features, ways to determine efficient interventions, and weaknesses in healthy lifestyle management from established digital intervention approaches. The results help us understand how digital interventions influence lifestyle management and overcome the existing shortcomings. It serves as a basis for further research with a focus on designing, developing, testing, and evaluating the generation of personalized lifestyle recommendations as a part of digital health interventions.

Sensor technology to monitor health, well-being and movement among healthcare personnel at workplace: a systematic scoping review protocol

INTRODUCTION

The well-being and health of healthcare personnel is becoming increasingly important in the delivery of high-quality healthcare. The recent developments in technology have provided new opportunities for the objective detection of a wide variety of real-world properties and movement. However, technologies that are used to monitor health, well-being and movement among healthcare personnel have not been fully synthesised. The overall aim of this scoping review is to examine what type of sensor technology is available to monitor the health, well-being and movement of healthcare personnel in healthcare settings. More specifically, we want to explore what types of sensor technology applications, for what purposes and how they have been used to monitor health, well-being and movement among healthcare personnel in different workplace settings.

METHODS AND ANALYSIS

This scoping review protocol will follow Arksey and O'Malley's methodology, complemented by the approach of the Joanna Briggs Institute to scoping reviews and guidance for conducting systematic scoping reviews. Peer-reviewed literature will be identified using a search strategy developed by a librarian, and a wide range of electronic datasets of medical, computer and information systems disciplines will be used. Eligibility of the articles will be determined using a two-stage screening process consisting of (1) a title and abstract scan, and (2) a full-text review. Extracted data will be thematically analysed and validated by an expert of sensor technology and a group of nurses as stakeholders. Descriptive statistics will be calculated when necessary.

ETHICS AND DISSEMINATION

The results obtained from the review will inform what technology has been used, how it has been used in healthcare settings and what types of technology might still be needed for future innovations. Findings of the scoping review will be published in a peer-reviewed journal.

REGISTRATION

This review was submitted in Open Science Framework on 12 December 2020.

Mechanisms of Smartphone Apps for Cigarette Smoking Cessation: Results of a Serial Mediation Model From the iCanQuit Randomized Trial

BACKGROUND

Engagement with digital interventions is a well-known predictor of treatment outcomes, but this knowledge has had limited actionable value. Instead, learning why engagement with digital interventions impact treatment outcomes can lead to targeted improvements in their efficacy.

OBJECTIVE

This study aimed to test a serial mediation model of an Acceptance and Commitment Therapy (ACT) smartphone intervention for smoking cessation.

METHODS

In this randomized controlled trial, participants (N=2415) from 50 US states were assigned to the ACT-based smartphone intervention (iCanQuit) or comparison smartphone intervention (QuitGuide). Their engagement with the apps (primary measure: number of logins) was measured during the first 3 months, ACT processes were measured at baseline and 3 months (acceptance of internal cues to smoke, valued living), and smoking cessation was measured at 12 months with 87% follow-up retention.

RESULTS

There was a significant serial mediation effect of iCanQuit on smoking cessation through multiple indicators of intervention engagement (ie, total number of logins, total number of minutes used, and total number of unique days of use) and in turn through increases in mean acceptance of internal cues to smoke from baseline to 3 months. Analyses of the acceptance subscales showed that the mediation was through acceptance of physical sensations and emotions, but not acceptance of thoughts. There was no evidence that the effect of the iCanQuit intervention was mediated through changes in valued living.

CONCLUSIONS

In this first study of serial mediators underlying the efficacy of smartphone apps for smoking cessation, our results suggest the effect of the iCanQuit ACT-based smartphone app on smoking cessation was mediated through multiple indicators of engagement and in turn through increases in the acceptance of physical sensations and emotions that cue smoking.

TRIAL REGISTRATION

Clinical Trials.gov NCT02724462; https://clinicaltrials.gov/ct2/show/NCT02724462.

Strengthening the Impact of Digital Cognitive Behavioral Interventions through a Dual Intervention: Proficient Motivational Interviewing-based Health Coaching Plus In-Application Techniques (Preprint)

Background

The COVID-19 pandemic has accelerated the adoption of digital tools to support individuals struggling with their mental health. The use of a digital intervention plus human coaching (“dual” intervention) is gaining momentum in increasing overall engagement in digital cognitive behavioral interventions (dCBIs). However, there is limited insight into the methodologies and coaching models used by those deploying dual interventions. To achieve a deeper understanding, we need to identify and promote effective engagement that leads to clinical outcomes versus simply monitoring engagement metrics. Motivational interviewing (MI) is a collaborative, goal-oriented communication approach that pays particular attention to the language of change and is an effective engagement approach to help people manage mental health issues. However, this approach has been traditionally used for in-person or telephonic interventions, and less is known about the application of MI to digital interventions.

Objective

We sought to provide a dual intervention approach and address multiple factors across two levels of engagement to operationalize a dCBI that combined cognitive behavioral therapy–based techniques and MI-based interactions between the digital health coach (DHC) and user.

Methods

We reviewed hundreds of digital exchanges between DHCs and users to identify and improve training and quality assurance activities for digital interventions.

Results

We tested five hypotheses and found that: (1) users of a dual digital behavioral health intervention had greater engagement levels than users of a noncoached intervention (P<.001); (2) DHCs with a demonstrated competency in applying MI to digital messages had more engaged users, as measured by the DHC-to-user message exchange ratio (P<.001); (3) the DHC-to-user message exchange ratio was correlated with more engagement in app activities (r=0.28, 95% CI 0.23-0.33); (4) DHCs with demonstrated MI proficiency elicited a greater amount of “change talk” from users than did DHCs without MI proficiency (H=25.12, P<.001); and (5) users who were engaged by DHCs with MI proficiency had better clinical outcomes compared to users engaged by DHCs without MI proficiency (P=.02).

Conclusions

To our knowledge, this pilot was the first of its kind to test the application of MI to digital coaching protocols, and it demonstrated the value of MI proficiency in digital health coaching for enhanced engagement and health improvement. Further research is needed to establish coaching models in dCBIs that incorporate MI to promote effective engagement and optimize positive behavioral outcomes.

eHealth interventions targeting nutrition, physical activity, sedentary behavior, or obesity in adults: A scoping review of systematic reviews

A vast body of evidence regarding eHealth interventions for nutrition, physical activity, sedentary behavior, and obesity exists. This scoping review of systematic reviews aimed to evaluate the current level of evidence in this growing field. Seven electronic databases were searched for systematic reviews published until October 27, 2019. The systematic reviews must have included adult participants only and have evaluated eHealth behavioral interventions with the primary aim of changing nutrition, physical activity, and sedentary behavior or treating or preventing overweight and obesity. One hundred and six systematic reviews, published from 2006 to 2019, were included. Almost all (n = 98) reviews evaluated the efficacy of interventions. Over half (n = 61) included interventions focused on physical activity, followed by treatment of obesity (n = 28), nutrition (n = 22), prevention of obesity (n = 18), and sedentary behavior (n = 6). Many reviews (n = 46) evaluated one type of eHealth intervention only, while 60 included two or more types. Most reviews (n = 67) were rated as being of critically low methodological quality. This scoping review identified an increasing volume of systematic reviews evaluating eHealth interventions. It highlights several evidence gaps (e.g., evaluation of other outcomes, such as reach, engagement, or cost effectiveness), guiding future research efforts in this area.

Evaluating the use of a recommender system for selecting optimal messages for smoking cessation: patterns and effects of user-system engagement

Background

Motivational messaging is a frequently used digital intervention to promote positive health behavior changes, including smoking cessation. Typically, motivational messaging systems have not actively sought feedback on each message, preventing a closer examination of the user-system engagement. This study assessed the granular user-system engagement around a recommender system (a new system that actively sought user feedback on each message to improve message selection) for promoting smoking cessation and the impact of engagement on cessation outcome.

Methods

We prospectively followed a cohort of current smokers enrolled to use the recommender system for 6 months. The system sent participants motivational messages to support smoking cessation every 3 days and used machine learning to incorporate user feedback (i.e., user’s rating on the perceived influence of each message, collected on a 5-point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement on perceiving the influence on quitting smoking) to improve the selection of the following message. We assessed user-system engagement by various metrics, including user response rate (i.e., the percent of times a user rated the messages) and the perceived influence of messages. We compared retention rates across different levels of user-system engagement and assessed the association between engagement and the 7-day point prevalence abstinence (missing outcome = smoking) by using multiple logistic regression.

Results

We analyzed data from 731 participants (13% Black; 73% women). The user response rate was 0.24 (SD = 0.34) and user-perceived influence was 3.76 (SD = 0.84). The retention rate positively increased with the user response rate (trend test P < 0.001). Compared with non-response, six-month cessation increased with the levels of response rates: low response rate (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.07–3.23), moderate response rate (OR = 2.30, 95% CI: 1.36–3.88), high response rate (OR = 2.69, 95% CI: 1.58–4.58). The association between perceived message influence and the outcome showed a similar pattern.

Conclusions

High user-system engagement was positively associated with both high retention rate and smoking cessation, suggesting that investigation of methods to increase engagement may be crucial to increase the impact of the recommender system for smoking cessation.

Trial registration

Registration Identifier: NCT03224520. Registration date: July 21, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11803-8.

[Adherence to digital health interventions: definitions, methods, and open questions]

Many digital interventions rely on the participation of their users to have a positive impact. In various areas it can be observed that the use of digital interventions is often reduced or fully discontinued by the users after a short period of time. This is seen as one of the main factors that can limit the effectiveness of digital interventions. In this context, the concept of adherence to digital interventions is becoming increasingly important. Adherence to digital interventions is roughly defined as "the degree to which the user followed the program as it was designed," which can also be paraphrased as "intended use" or "use as it is designed." However, both the theoretical-conceptual and practical discussions regarding adherence to digital interventions still receive too little attention.The aim of this narrative review article is to shed more light on the concept of adherence to digital interventions and to distinguish it from related concepts. It also discusses the methods and metrics that can be used to operationalize adherence and the predictors that positively influence adherence. Finally, needs for action to better address adherence are considered critically.

Développement et tests utilisateurs de l’application Web PRATICAdr : Plateforme de Retour Au Travail axée sur les Interactions et la Communication entre les Acteurs, intégrant un programme Durable favorisant le Rétablissement

Introduction Les troubles mentaux courants (TMC) représentent de 30 % à 50 % des absences maladies toutes confondues. Le succès du retour au travail (RAT) n’est pas dû au seul fait de l’individu, mais plutôt au résultat de l’interaction entre les acteurs impliqués dans le processus. De nombreuses applications en santé mentale ont été développées pour améliorer la prise en charge des patients et optimiser la communication entre les professionnels, sans toutefois être validées. De plus, aucune solution technologique n’a été développée à ce jour pour faciliter à la fois la concertation des acteurs du RAT (p. ex. gestionnaire, professionnels de la santé) et l’accompagnement systématique de l’employé dans son RAT.

Objectif Pour combler ces lacunes, l’objectif de cet article est double : 1) décrire le développement de l’application PRATICAdr, Plateforme de Retour Au Travail axée sur les Interactions et la Communication entre les Acteurs : un programme Durable favorisant le Rétablissement ; 2) documenter les tests utilisateurs de l’application PRATICAdr.

Méthode Le développement de PRATICAdr se décline en 3 phases : 1) l’analyse des besoins ; 2) la conceptualisation des mécanismes internes à l’application et des techniques de programmation ; 3) le test de l’application en situation réelle. L’application est évaluée par des questionnaires et entrevues pour mesurer la satisfaction des utilisateurs.

Résultats PRATICAdr permet de suivre en temps réel le parcours des acteurs impliqués dans l’accompagnement personnalisé de l’employé dans son RAT. La schématisation du processus de RAT et l’inclusion d’outils d’évaluation validés systématisent la concertation et la prise de décision partagée des acteurs, ainsi que le suivi et les actions posées en vue d’entreprendre un RAT favorisant le rétablissement. L’interface de PRATICAdr a été développée pour simplifier l’expérience utilisateur de l’employé en absence maladie et des acteurs du RAT. Les résultats de satisfaction des premiers utilisateurs de PRATICAdr, 16 employés d’une grande organisation dans le domaine de la santé en processus de RAT à la suite d’un TMC, apprécient (moyenne > 9/10) non seulement la Plateforme Web, mais également la participation des acteurs du RAT et les questionnaires inclus dans PRATICAdr. Des éléments d’amélioration sont aussi proposés.

Conclusion PRATICAdr est implantée dans 2 grandes organisations (> 15 000 employés) afin d’évaluer son efficacité auprès d’employés en absence maladie en raison d’un TMC et en processus de RAT. Dans le cadre de cet article, l’objectif était de présenter non seulement le développement de PRATICAdr, mais aussi de mesurer la satisfaction des utilisateurs. Les premiers résultats indiquent une appréciation élevée chez les employés en absence maladie, utilisateurs de PRATICAdr. En termes de pistes futures, l’intégration de l’apprentissage automatique sera abordée dans l’objectif de personnaliser le programme de RAT selon les prédictions de durée d’absence maladie et de RAT durable.

A Smartphone App to Support Adherence to Inhaled Corticosteroids in Young Adults With Asthma: Multi-Methods Feasibility Study

Background

Young adults with asthma often report low adherence to inhaled corticosteroids (ICS), leading to uncontrolled symptoms and poor disease outcomes. Technology-enabled digital supports such as mobile health (mHealth) asthma smartphone apps have the potential to support adherence to ICS and asthma self-management. There is a need for feasibility studies to determine the usability, acceptability, and feasibility of these interventions. In addition, it is essential to determine the feasibility of recruiting and retaining young adults to plan future efficacy and effectiveness trials and therefore, establish evidence-based asthma apps.

Objective

This study aimed to determine (1) the feasibility of recruiting and retaining young adults to a trial and (2) the usability, acceptability, and feasibility of using the AsthmaMD app to support adherence to ICS in a population of young adults living with asthma.

Methods

A multi-methods feasibility study was conducted. Young adults aged 18-30 years with asthma and current prescription for ICS were eligible and invited to take part through a university circular email, social media, and general practice sites. Participation involved completing a baseline self-report questionnaire, downloading and using the AsthmaMD app for 2 weeks, and completing the follow-up assessment, including self-report and open-ended questions about participants’ experience of using the app. Primary outcomes included participant recruitment and retention and the usability, acceptability, and feasibility of using AsthmaMD. Quantitative self-report data were analyzed using descriptive statistics, and qualitative open-ended data were analyzed using inductive reflexive thematic analysis.

Results

A total of 122 young adults (females, n=101, 82.8%) with a mean age of 24.4 (SD 3.8) years were recruited and they completed baseline measures. Of the 122 young adults, 59 (48.4%) completed the study. The AsthmaMD app received a mean score of 63.1/100 (SD 20.1) on the System Usability Scale (ie, a standardized measure of usability for technology-based apps), and an overall user satisfaction score of 5.8/10 (SD 2.2). Of the 59 participants who completed the study, 49 (83%) participants used the app ≥1 day per week. Two main themes were identified in the qualitative analysis of user experiences: (1) learning how to use the app to suit the individual and (2) benefits and relevance of using the app.

Conclusions

The findings from this study indicate that it is feasible to recruit and retain young adults to examine efficacy and effectiveness in a future trial and that young adults living with asthma may find AsthmaMD to be usable, acceptable, and feasible to support adherence to ICS. Our findings also identified opportunities to further optimize the usability of AsthmaMD and similar apps. Based on our findings, we recommend providing more accessible information on how to use the app and replacing medical terminology with simplified language within the app to improve usability.

Trial Registration

ISRCTN Registry ISRCTN11295269; https://www.isrctn.com/ISRCTN11295269

Targeting subjective engagement in experimental therapeutics for digital mental health interventions

Engagement is a multifaceted construct and a likely mechanism by which digital interventions achieve clinical improvements. To date, clinical research on digital mental health interventions (DMHIs) has overwhelmingly defined engagement and assessed its association with clinical outcomes through the objective/behavioral metrics of use of or interactions with a DMHI, such as number of log-ins or time spent using the technology. However, engagement also entails users' subjective experience. Research is largely lacking that tests the relationship between subjective metrics of engagement and clinical outcomes. The purpose of this study is to present a proof-of-concept exploratory evaluation of the association between subjective engagement measures of a mobile DMHI with changes in depression and anxiety. Adult primary care patients (N = 146) who screened positive for depression or anxiety were randomized to receive a DMHI, IntelliCare, immediately or following an 8-week waitlist. Subjective engagement was measured via the Usefulness, Satisfaction, and Ease of Use (USE) Questionnaire. Across both conditions, results showed that individuals who perceived a mobile intervention as more useful, easy to use and learn, and satisfying had greater improvements in depression and anxiety over eight weeks. Findings support our proposed experimental therapeutics framework that hypothesizes objective/behavioral and subjective engagement metrics as mechanisms that lead to changes in clinical outcomes, as well as support directing intervention design efforts for DMHIs to target the user experience.

Contrasting a Mobile App with a Conversational Chatbot for Reducing Alcohol Consumption: A Pilot Trial (Preprint)

Background

Mobile apps have shown considerable promise for reducing alcohol consumption among problem drinkers, but like many mobile health apps, they frequently report low utilization, which is an important limitation, as research suggests that effectiveness is related to higher utilization. Interactive chatbots have the ability to provide a conversational interface with users and may be more engaging and result in higher utilization and effectiveness, but there is limited research into this possibility.

Objective

This study aimed to develop a chatbot alcohol intervention based on an empirically supported app (Step Away) for reducing drinking and to conduct a pilot trial of the 2 interventions. Included participants met the criteria for hazardous drinking and were interested in reducing alcohol consumption. The study assessed utilization patterns and alcohol outcomes across the 2 technology conditions, and a waitlist control group.

Methods

Participants were recruited using Facebook advertisements. Those who met the criteria for hazardous consumption and expressed an interest in changing their drinking habits were randomly assigned to three conditions: the Step Away app, Step Away chatbot, and waitlist control condition. Participants were assessed on the web using the Alcohol Use Disorders Identification Test, Adapted for Use in the United States, Readiness to Change Questionnaire, Short Inventory of Problems-Revised, and Timeline Followback at baseline and at 12 weeks follow-up.

Results

A total of 150 participants who completed the baseline and follow-up assessments were included in the final analysis. ANOVA results indicated that participants in the 3 conditions changed their drinking from baseline to follow-up, with large effect sizes noted (ie, η²=0.34 for change in drinks per day across conditions). However, the differences between groups were not significant across the alcohol outcome variables. The only significant difference between conditions was in the readiness to change variable, with the bot group showing the greatest improvement in readiness (F_2,147=5.6; P=.004; η²=0.07). The results suggested that the app group used the app for a longer duration (mean 50.71, SD 49.02 days) than the bot group (mean 27.16, SD 30.54 days; P=.02). Use of the interventions was shown to predict reduced drinking in a multiple regression analysis (β=.25, 95% CI 0.00-0.01; P=.04).

Conclusions

Results indicated that all groups in this study reduced their drinking considerably from baseline to the 12-week follow-up, but no differences were found in the alcohol outcome variables between the groups, possibly because of a combination of small sample size and methodological issues. The app group reported greater use and slightly higher usability scores than the bot group, but the bot group demonstrated improved readiness to change scores over the app group. The strengths and limitations of the app and bot interventions as well as directions for future research are discussed.

Trial Registration

ClinicalTrials.gov NCT04447794; https://clinicaltrials.gov/ct2/show/NCT04447794

Predictors of engagement in an internet-based cognitive behavioral therapy program for veterans with chronic low back pain

Internet-based interventions for chronic pain have demonstrated efficacy and may address access barriers to care. Participant characteristics have been shown to affect engagement with these programs; however, limited information is available about the relationship between participant characteristics and engagement with internet-based programs for self-management of chronic pain. The current study examined relationships between demographic and clinical characteristics and engagement with the Pain EASE program, a self-directed, internet-based cognitive behavioral therapy intervention for veterans with chronic low back pain (cLBP). Veterans with cLBP were enrolled in a 10 week trial of the Pain EASE program. Engagement measures included the number of logins, access to coping skill modules, and completed study staff-initiated weekly check-in calls. Regression analyses were conducted to identify significant predictors of engagement from hypothesized predictors (e.g., race/ethnicity, age, depressive symptom severity, and pain interference). Participants (N = 58) were 93% male, 60.3% identified as White, and had a mean age of 54.5 years. Participants logged into the program a median of 3.5 times, accessed a median of 2 skill modules, and attended a median of 6 check-in calls. Quantile regression revealed that, at the 50th percentile, non-White-identified participants accessed fewer modules than White-identified participants (p = .019). Increased age was associated with increased module use (p = .001). No clinical characteristics were significantly associated with engagement measures. White-identified race/ethnicity and increased age were associated with greater engagement with the Pain EASE program. Results highlight the importance of defining and increasing engagement in internet-delivered pain care.

Engagement with a digital therapeutic for smoking cessation designed for persons with psychiatric illness fully mediates smoking outcomes in a pilot randomized controlled trial

Understanding the mechanisms of change of digital therapeutics is a critical step to improve digital health outcomes and optimize their development. Access to and engagement with digital content is arguably a core mechanism of change of these interventions. However, the mediational role of app engagement has been largely unexamined. To evaluate the mediational effect of engaging with a digital therapeutic for smoking cessation designed for adults with psychiatric disorders. Secondary analysis of a pilot clinical trial of 62 adults with serious mental illness who were randomized to receive either a tailored digital therapeutic (Learn to Quit) or a digital therapeutic for the general public (NCI QuitGuide). Engagement was captured using background analytics of app utilization, including (a) number of interactions with app content, (b) minutes/day of app use, and (c) number of days used. The main outcome was reductions in cigarettes per day from baseline to the four-month endpoint. Mediational analysis followed the Preacher and Hayes bootstrap method. Number of application interactions fully mediated reductions in cigarettes per day in the Learn to Quit application but not in QuitGuide (Average Causal Mediation Effect = .31, p = .02). Minutes/day of app use played an uncertain role, and number of days used was not a significant mediator. Results suggest that one of the mechanisms of action of the Learn to Quit device, engagement with theory-based content, functioned as intended. Future research of digital therapeutics should emphasize granular approaches to evaluating apps' mechanisms of action.

Does Dynamic Tailoring of A Narrative-Driven Exergame Result in Higher User Engagement among Adolescents? Results from A Cluster-Randomized Controlled Trial

Physical activity interventions for youth are direly needed given low adherence to physical activity guidelines, but many interventions suffer from low user engagement. Exergames that require bodily movement while played may provide an engaging form of physical activity intervention but are not perceived as engaging to all. This study aimed to evaluate whether dynamic tailoring in a narrative-driven mobile exergame for adolescents played in leisure settings, can create higher user engagement compared to a non-tailored exergame. A cluster-randomized controlled trial assessed differences in user engagement between a dynamically tailored (based on an accelerometer sensor integrated in a T-shirt) and non-tailored condition. In total, 94 participants (M age = 14.61 ± 1.93; 35% female) participated and were assigned to one of the two conditions. User engagement was measured via a survey and game metric data. User engagement was low in both conditions. Narrative sensation was higher in the dynamically tailored condition, but the non-tailored condition showed longer play-time. User suggestions to create a more appealing game included simple and more colorful graphics, avoiding technical problems, more variety and shorter missions and multiplayer options. Less cumbersome or more attractive sensing options than the smart T-shirt may offer a more engaging solution, to be tested in future research.

A systematic review of the engagement with social media-delivered interventions for improving health outcomes among sexual and gender minorities

BACKGROUND

Sexual and gender minority (SGM) persons face a number of physical and mental health disparities closely linked to discrimination, social stigma, and victimization. Despite the acceptability and increasing number of digital health interventions focused on improving health outcomes among SGM people, there is a lack of reviews summarizing whether and how researchers assess engagement with social media-delivered health interventions for this group.

OBJECTIVE

The objective of this systematic review was to synthesize and critique the evidence on evaluation of engagement with social media-delivered interventions for improving health outcomes among SGM persons.

METHODS

We conducted a literature search for studies published between January 2003 and June 2020 using 4 electronic databases. Articles were included if they were peer-reviewed, in English language, assessed engagement with a social media-delivered health intervention for improving health outcomes among sexual and gender minorities. A minimum of two authors independently extracted data from each study using an a priori developed abstraction form. We assessed quality of data reporting using the CONSORT extension for pilot and feasibility studies and CONSORT statement parallel group randomized trials.

RESULTS

We included 18 articles in the review; 15 were feasibility studies and 3 were efficacy or effectiveness randomized trials. The quality of data reporting varied considerably. The vast majority of articles focused on improving HIV-related outcomes among men who have sex with men. Only three studies recruited cisgender women and/or transgender persons. We found heterogeneity in how engagement was defined and assessed. Intervention usage from social media data was the most frequently used engagement measure.

CONCLUSION

In addition to the heterogeneity in defining and assessing engagement, we found that the focus of assessment was often on measures of intervention usage only. More purposeful recruitment is needed to learn about whether, how, and why different SGM groups engage with social media-interventions. This leaves significant room for future research to expand evaluation criteria for cognitive and emotional aspects of intervention engagement in order to develop effective and tailored social media-delivered interventions for SGM people. Our findings also support the need for developing and testing social media-delivered interventions that focus on improving mental health and outcomes related to chronic health conditions among SGM persons.

Usage activity, perceived usefulness, and satisfaction in a web-based acceptance and commitment therapy program among Finnish ninth-grade adolescents

Understanding adolescent usage activity and experiences in web-based psychological intervention programs helps in developing universal programs that can be adopted for promotion of adolescent well-being and prevention of mental health problems. This study examined the usage activity, perceived usefulness (i.e., learning of mindfulness, acceptance and value-related skills), and program satisfaction of 157 Finnish ninth-grade adolescents, who participated in a school-based five-week universal acceptance and commitment therapy web intervention called Youth Compass. Individual and growth environment-related antecedents were measured before the five-week intervention, adolescents' usage activity during the intervention, and perceived usefulness and satisfaction after the intervention. The results showed that female adolescents and adolescents with high self-regulation were more active program users and had more positive experiences of the program. Most of the adolescents used the program on at least a moderate level and perceived it to be moderately or highly useful and satisfactory. Four subgroups of adolescents were identified based on their usage activity, perceived usefulness, and satisfaction: adolescents in the satisfied group (41%) had average activity and high perceived usefulness and intervention satisfaction, the dissatisfied group (18%) had low activity and very low perceived usefulness and intervention satisfaction, the active group (8%) had very high activity and average perceived usefulness and intervention satisfaction, and the moderate group (33%) had average activity, perceived usefulness and intervention satisfaction. Gender, academic achievement, closeness to mother and teacher, and conflict with teacher were significantly related to subgroup membership. The results suggested that adolescent usage activity, perceived usefulness, and satisfaction with the Youth Compass program may to some extent be predicted based on different factors.

The Association Between Logging Steps Using a Website, App, or Fitbit and Engaging With the 10,000 Steps Physical Activity Program: Observational Study

Background

Engagement is positively associated with the effectiveness of digital health interventions. It is unclear whether tracking devices that automatically synchronize data (eg, Fitbit) produce different engagement levels compared with manually entering data.

Objective

This study examines how different step logging methods in the freely available 10,000 Steps physical activity program differ according to age and gender and are associated with program engagement.

Methods

A subsample of users (n=22,142) of the free 10,000 Steps physical activity program were classified into one of the following user groups based on the step-logging method: Website Only (14,617/22,142, 66.01%), App Only (2100/22,142, 9.48%), Fitbit Only (1705/22,142, 7.7%), Web and App (2057/22,142, 9.29%), and Fitbit Combination (combination of web, app, and Fitbit; 1663/22,142, 7.51%). Generalized linear regression and binary logistic regression were used to examine differences between user groups’ engagement and participation parameters. The time to nonusage attrition was assessed using Cox proportional hazards regression.

Results

App Only users were significantly younger and Fitbit user groups had higher proportions of women compared with other groups. The following outcomes were significant and relative to the Website Only group. The App Only group had fewer website sessions (odds ratio [OR] −6.9, 95% CI −7.6 to −6.2), whereas the Fitbit Only (OR 10.6, 95% CI 8.8-12.3), Web and App (OR 1.5, 95% CI 0.4-2.6), and Fitbit Combination (OR 8.0; 95% CI 6.2-9.7) groups had more sessions. The App Only (OR −0.7, 95% CI −0.9 to −0.4) and Fitbit Only (OR −0.5, 95% CI −0.7 to −0.2) groups spent fewer minutes on the website per session, whereas the Fitbit Combination group (OR 0.2, 95% CI 0.0-0.5) spent more minutes. All groups, except the Fitbit Combination group, viewed fewer website pages per session. The mean daily step count was lower for the App Only (OR −201.9, 95% CI −387.7 to −116.0) and Fitbit Only (OR −492.9, 95% CI −679.9 to −305.8) groups but higher for the Web and App group (OR 258.0, 95% CI 76.9-439.2). The Fitbit Only (OR 5.0, 95% CI 3.4-6.6), Web and App (OR 7.2, 95% CI 5.9-8.6), and Fitbit Combination (OR 15.6, 95% CI 13.7-17.5) groups logged a greater number of step entries. The App Only group was less likely (OR 0.65, 95% CI 0.46-0.94) and other groups were more likely to participate in Challenges. The mean time to nonusage attrition was 35 (SD 26) days and was lower than average in the Website Only and App Only groups and higher than average in the Web and App and Fitbit Combination groups.

Conclusions

Using a Fitbit in combination with the 10,000 Steps app or website enhanced engagement with a real-world physical activity program. Integrating tracking devices that synchronize data automatically into real-world physical activity interventions is one strategy for improving engagement.

Is Fun For Wellness Engaging? Evaluation of User Experience of an Online Intervention to Promote Well-Being and Physical Activity

Online well-being interventions demonstrate great promise in terms of both engagement and outcomes. Fun For Wellness (FFW) is a novel online intervention grounded in self-efficacy theory and intended to improve multidimensional well-being and physical activity through multi-modal methods. These strategies include capability-enhancing opportunities, learning experiences such as games, video vignettes, and self-assessments. RCT studies have suggested that FFW is efficacious in improving subjective and domain-specific well-being, and effective in improving mental health, physical health, physical activity, and self-efficacy in United States. adults who are overweight and in the general population. The present study uses qualitative and quantitative user experience data collected during two RCT trials to understand and evaluate engagement with FFW, its drivers, and its outcomes. Results suggest that FFW is enjoyable, moderately engaging, and easy to use; and contributes to positive outcomes including skill development and enhanced confidence, for both overweight individuals and the general adult population. Drivers of engagement appear to include rewards, gamification, scenario-based learning, visual tracking for self-monitoring, ease of use and simple communications, and the entertaining, interactive nature of program activities. Findings indicate that there are opportunities to streamline and simplify the experience. These results can help improve FFW and contribute to the science of engagement with online interventions designed to improve well-being.

Adaptive learning algorithms to optimize mobile applications for behavioral health: guidelines for design decisions

OBJECTIVE

Providing behavioral health interventions via smartphones allows these interventions to be adapted to the changing behavior, preferences, and needs of individuals. This can be achieved through reinforcement learning (RL), a sub-area of machine learning. However, many challenges could affect the effectiveness of these algorithms in the real world. We provide guidelines for decision-making.

MATERIALS AND METHODS

Using thematic analysis, we describe challenges, considerations, and solutions for algorithm design decisions in a collaboration between health services researchers, clinicians, and data scientists. We use the design process of an RL algorithm for a mobile health study "DIAMANTE" for increasing physical activity in underserved patients with diabetes and depression. Over the 1.5-year project, we kept track of the research process using collaborative cloud Google Documents, Whatsapp messenger, and video teleconferencing. We discussed, categorized, and coded critical challenges. We grouped challenges to create thematic topic process domains.

RESULTS

Nine challenges emerged, which we divided into 3 major themes: 1. Choosing the model for decision-making, including appropriate contextual and reward variables; 2. Data handling/collection, such as how to deal with missing or incorrect data in real-time; 3. Weighing the algorithm performance vs effectiveness/implementation in real-world settings.

CONCLUSION

The creation of effective behavioral health interventions does not depend only on final algorithm performance. Many decisions in the real world are necessary to formulate the design of problem parameters to which an algorithm is applied. Researchers must document and evaulate these considerations and decisions before and during the intervention period, to increase transparency, accountability, and reproducibility.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03490253.

Acupressure for Cancer-fatigue in Ovarian Cancer Survivor (AcuOva) Study: A community-based clinical trial study protocol examining the impact of self-acupressure on persistent cancer-related fatigue in ovarian cancer survivors

Background Persistent cancer-related fatigue is one of the most common and burdensome symptoms experienced by ovarian cancer survivors. Despite the high burden of fatigue in ovarian cancer survivors, there are few available treatments. Previous research has shown self-acupressure to be a safe method for improving persistent fatigue, sleep, and quality of life among fatigued breast cancer survivors, yet there are no studies examining self-acupressure for fatigue in ovarian cancer survivors. Methods A three group parallel, randomized controlled trial will be conducted to evaluate the efficacy of self-acupressure taught and delivered via a patient-designed, custom-built mobile app ("MeTime") and accompanying hand-held device ("AcuWand") to help guide correct pressure application. A sample of 165 ovarian cancer survivors, who have completed primary cancer treatment will be recruited from tumor registries in Michigan and Los Angeles. Participants will be mailed a tablet preloaded with the app and a device, and all visits will be conducted remotely. Participants will be randomized to 6-weeks of daily self-acupressure via the app and device, or a sham app and device, or no care group. Self-report measures will be completed at baseline, 6-weeks (post-intervention), 3-, and 6-months. Primary outcome is the Brief Fatigue Inventory; secondary outcomes are sleep, quality of life, and symptoms commonly associated with persistent fatigue. Discussion An app based self-acupressure treatment may be an easily-accessible and inexpensive treatment to reduce fatigue in ovarian cancer survivors. The results of the study will provide information on the possible benefits of app-based self-acupressure for fatigue in ovarian cancer survivors. Trial registration: This study is registered at ClinicalTrials.gov Identifier: NCT03763838, date registered on December 4, 2018.

Ethical challenges in argumentation and dialogue in a healthcare context

As the average age of the population increases, so too do the number of people living with chronic illnesses. With limited resources available, the development of dialogue-based e-health systems that provide justified general health advice offers a cost-effective solution to the management of chronic conditions. It is however imperative that such systems are responsible in their approach. We present in this paper two main challenges for the deployment of e-health systems, that have a particular relevance to dialogue and argumentation: collecting and handling health data, and trust. For both challenges, we look at specific issues therein, outlining their importance in general, and describing their relevance to dialogue and argumentation. Finally, we go on to propose six recommendations for handling these issues, towards addressing the main challenges themselves, that act both as general advice for dialogue and argumentation research in the e-health domain, and as a foundation for future work on this topic.

Engagement with online psychosocial interventions for psychosis: A review and synthesis of relevant factors

BACKGROUND

Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis.

METHODS

Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis.

RESULTS

Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects.

CONCLUSION

While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis.

Promoting recovery in daily life: study protocol for a randomized controlled trial

BACKGROUND

Work-related stress shows steadily increasing prevalence rates and has tangible consequences for individual workers, their organizations, and society as a whole. One mechanism that may help offset the negative outcomes of work-related stress on employees' well-being is recovery. Recovery refers to the experience of unwinding from one's job when not at work. However, employees who experience high levels of work-related stress and are thus particularly in need of recovery tend to struggle to switch-off. Due to the detrimental effects of this prolonged and sustained mental representation of job stressors, interventions promoting recovery may contribute to improvements in employees' mental health.

METHODS

In this randomized, waitlist controlled trial, we will investigate the effectiveness of two 6-week online training programs (cognitive behavioral and mindfulness-based). The sample will include employees working at least part-time during regular work hours. Besides the pre-post-follow-up assessments, the trial will include measurement bursts with the goal of examining the underlying mechanisms. We expect that both interventions will reduce work-related perseverative thinking (PT) compared with the waitlist control groups (primary outcome). Also, we expect that both interventions will result in similar improvements, but the underlying mechanisms will differ (process outcomes). In the cognitive-behavioral intervention group, we expect that the main mechanism responsible for lower PT levels will be an increase in recovery experiences across time. In the mindfulness-based group, we expect that the main mechanism responsible for lower PT levels will be an increase in facets of mindfulness across time.

DISCUSSION

In the present study, we will investigate mechanisms underlying assumed changes in work-related PT in great detail. Besides evaluating the overall effectiveness of the two interventions in terms of pre-post-follow-up changes, we will look at the underlying processes at different levels-that is, within days, within weeks, across weeks, and between individuals. Accordingly, our study will offer a fine-grained approach to investigating potential determinants, mediators, and moderators of the processes that may, in the end, be responsible for work-related strain. From a public health perspective, if effective, the online training programs may offer valuable, low-threshold, and low-intensity interventions for a broad range of occupations. Trial registration German Clinical Trials Registration: DRKS00024933. Registered prospectively 7 April 2021. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00024933.

Use and usability of the dr. Bart app and its relation with health care utilisation and clinical outcomes in people with knee and/or hip osteoarthritis

Background

Self-management is of paramount importance in the non-surgical treatment of knee/hip osteoarthritis (OA). Modern technologies offer the possibility of 24/7 self-management support. We developed an e-self-management application (dr. Bart app) for people with knee/hip OA.

The aim of this study was to document the use and usability of the dr. Bart app and its relation with health care utilisation and clinical outcomes in people with knee/hip OA.

Methods

For this study we used backend data for the first 26 weeks of use by the intervention group (N = 214) of an RCT examining the effectiveness of the dr. Bart app. A central element of the dr. Bart app is that it proposes a selection of 72 preformulated goals for health behaviours based on the ‘tiny habits method’ (e.g. after lunch I rise 12 times from my chair to train my leg muscles). The usability of the app was measured using the System Usability Scale questionnaire (SUS), on a scale of 0–100. To assess the association between the intensity of use of the app and health care utilisation (i.e., consultations in primary or secondary health care) and clinical outcomes (i.e., self-management behaviour, physical activity, health-related quality of life, illness perceptions, symptoms, pain, activities of daily living) we calculated Spearman rank correlation coefficients.

Results

Of the 214 participants, 171 (80%) logged in at least once with 151 (71%) choosing at least one goal and 114 (53%) completing at least one goal during the 26 weeks. Of those who chose at least one goal, 56 participants (37%) continued to log in for up to 26 weeks, 12 (8%) continued to select new goals from the offered goals and 37 (25%) continued to complete goals. Preformulated goals in the themes of physical activity (e.g., performing an exercise from the exercises library in the app) and nutrition (e.g., ‘eat two pieces of fruit today’) were found to be most popular with users. The mean usability scores (standard deviation) at the three and six month follow-ups were 65.9 (16.9) and 64.5 (17.5), respectively. The vast majority of associations between the intensity of use of the dr. Bart app and target outcomes were weak at ρ < (−) 0.25.

Conclusions

More than one-third of people with knee/hip OA who started using the app, continued to use it up to 26 weeks, though usability could be improved. Patients appear to have preferences for goals related to physical activity and nutrition, rather than for goals related to vitality and education. We found weak/no associations between the intensity of use of the dr. Bart app and health care utilisation and clinical outcomes.

Trial registration

(21 September 2017): Dutch Trial Register (Trial Number NTR6693/NL6505)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06440-1.

Process Evaluation of the 'No Money No Time' Healthy Eating Website Promoted Using Social Marketing Principles. A Case Study

Background: Reaching and engaging individuals, especially young adults, in web-based prevention programs is challenging. ‘No Money No Time’ (NMNT) is a purpose built, healthy eating website with content and a social marketing strategy designed to reach and engage a young adult (18–34 year olds) target group. The aim of the current study was to conduct a process evaluation of the 12-month social marketing strategy to acquire and engage NMNT users, particularly young adults. Methods: a process evaluation framework for complex interventions was applied to investigate the implementation of the social marketing strategy component, mechanisms of impact and contextual factors. Google Analytics data for the first 12 months of operation (17 July 2019 to 17 July 2020) was evaluated. Results: in year one, 42,413 users from 150+ countries accessed NMNT, with 47.6% aged 18–34 years. The most successful channel for acquiring total users, young adults and return users was via organic search, demonstrating success of our marketing strategies that included a Search Engine Optimisation audit, a content strategy, a backlink strategy and regular promotional activities. For engagement, there was a mean of 4.46 pages viewed per session and mean session duration of 3 min, 35 s. Users clicked a ‘call-to-action’ button to commence the embedded diet quality tool in 25.1% of sessions. The most common device used to access NMNT (63.9%) was smartphone/mobile. Engagement with ‘quick, cheap and healthy recipes’ had the highest page views. Conclusions: findings can inform online nutrition programs, particularly for young adults, and can apply to other digital health programs.

Assessing the usability and user engagement of Thought Spot - A digital mental health help-seeking solution for transition-aged youth

OBJECTIVE

To evaluate the perceived usability of and user engagement with a digital platform (Thought Spot) designed to enhance mental health and wellness help-seeking among transition-aged youth (TAY; 17-29-years old).

MATERIALS AND METHODS

Survey responses and usage patterns were collected as part of a randomized controlled trial evaluating the efficacy of Thought Spot. Participants given Thought Spot completed an adapted Usefulness, Satisfaction, and Ease of Use (USE) Questionnaire to measure perceived usability of the platform. User engagement patterns on Thought Spot were examined using analytics data collected throughout the study (March 2018-June 2019).

RESULTS

A total of 131 transition-aged participants completed the USE questionnaire and logged on to Thought Spot at least once. Ease of learning scored higher than ease of use, usefulness and satisfaction. Participants identified numerous strengths and challenges related to usability, visual appeal, functionality and usefulness of the content. In terms of user engagement, most participants stopped using the platform after 3 weeks. Participants searched and were interested in a variety of resources, including mental health, counselling and social services.

DISCUSSION

Participants reported mixed experiences while using Thought Spot and exhibited low levels of long-term user engagement. User satisfaction, the willingness to recommend Thought Spot to others, and the willingness for future use appeared to be influenced by content relevance, ease of learning, available features, and other contextual factors. Analysis of the types of resources viewed and searches conducted by TAY end-users provided insight into their behaviour and needs.

CONCLUSION

Users had mixed perceptions about the usability of Thought Spot, which may have contributed to the high attrition rate. User satisfaction and engagement appears to be influenced by content relevance, ease of learning, and the types of features available. Further investigation to understand the contextual factors that affect TAYs' adoption and engagement with digital mental health tools is required.

A Mobile Patient-Facing App for Tracking Patient-Reported Outcomes in Head and Neck Cancer Survivors: Single-Arm Feasibility Study

BACKGROUND

Patients with head and neck cancer (HNC) frequently experience disease-related symptoms and treatment adverse effects that impact their overall quality of life. Cancer-specific mobile health apps for patient-related outcomes allow patients to communicate with their clinicians and proactively track their symptoms, which have been shown to improve clinical management and disease outcomes.

OBJECTIVE

The purpose of this study was to evaluate the feasibility of LogPAL, a novel iPhone-based mobile health app designed to help HNC survivors track and manage their posttreatment symptoms.

METHODS

Patients who completed curative treatment for HNC in the preceding 24 months were recruited from 2 clinical sites within a single institution. Upon enrollment, participants completed a brief sociodemographic survey, downloaded the app onto their iPhone devices, and were asked to complete a series of biweekly questionnaires (based on the Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events) via the app for an 8-week study period. The primary feasibility endpoints included retention (retaining >80% of the enrolled participants for the duration of the study period), adherence (>50% of the participants completing 100% of the questionnaires over the study period), and usability (a mean system usability scale [SUS] score >68). Additional postintervention questions were collected to assess perceived usefulness, acceptance, and overall satisfaction.

RESULTS

Between January and October 2019, 38 participants were enrolled in the study. Three participants dropped out, and 3 were classified as nonusers. The remaining 32 (87%) were eligible for analysis. Their mean age was 57.8 (SD 12.3) years (range 24-77 years, 81% [26/32] male). Overall, 375 of 512 (73.2%) questionnaires were completed, with 17 (53%) of the 32 participants adherent. Participant-reported usability was acceptable; the mean SUS score was 71.9 (95% CI 64.3-79.5) with high satisfaction of LogPAL usefulness and likelihood to recommend to other cancer survivors.

CONCLUSIONS

This single-arm prospective pilot study showed that LogPAL is a feasible, regularly used, accepted app for HNC survivors, justifying a full-scale pilot. Based on the findings from this study, future iterations will aim to improve usability and test intervention efficacy.

Effects of Information Architecture on the Effectiveness and User Experience of Web-Based Patient Education in Middle-Aged and Older Adults: Online Randomized Experiment

Background

Web-based patient education is increasingly offered to improve patients’ ability to learn, remember, and apply health information. Efficient organization, display, and structural design, that is, information architecture (IA), can support patients’ ability to independently use web-based patient education. However, the role of IA in the context of web-based patient education has not been examined systematically.

Objective

To support intervention designers in making informed choices that enhance patients’ learning, this paper describes a randomized experiment on the effects of IA on the effectiveness, use, and user experience of a patient education website and examines the theoretical mechanisms that explain these effects.

Methods

Middle-aged and older adults with self-reported hip or knee joint complaints were recruited to use and evaluate 1 of 3 patient education websites containing information on total joint replacement surgery. Each website contained the same textual content based on an existing leaflet but differed in the employed IA design (tunnel, hierarchical, or matrix design). Participants rated the websites on satisfaction, engagement, control, relevance, trust, and novelty and completed an objective knowledge test. Analyses of variance and structural equation modeling were used to examine the effects of IA and construct a theoretical model.

Results

We included 215 participants in our analysis. IA did not affect knowledge gain (P=.36) or overall satisfaction (P=.07) directly. However, tunnel (mean 3.22, SD 0.67) and matrix (mean 3.17, SD 0.69) architectures were found to provide more emotional support compared with hierarchical architectures (mean 2.86, SD 0.60; P=.002). Furthermore, increased perceptions of personal relevance in the tunnel IA (β=.18) were found to improve satisfaction (β=.17) indirectly. Increased perceptions of active control in the matrix IA (β=.11) also improved satisfaction (β=.27) indirectly. The final model of the IA effects explained 74.3% of the variance in satisfaction and 6.8% of the variance in knowledge and achieved excellent fit (χ²_17,215=14.7; P=.62; root mean square error of approximation=0.000; 95% CI [0.000-0.053]; comparative fit index=1.00; standardized root mean square residual=0.044).

Conclusions

IA has small but notable effects on users’ experiences with web-based health education interventions. Web-based patient education designers can employ tunnel IA designs to guide users through sequentially ordered content or matrix IA to offer users more control over navigation. Both improve user satisfaction by increasing user perceptions of relevance (tunnel) and active control (matrix). Although additional research is needed, hierarchical IA designs are currently not recommended, as hierarchical content is perceived as less supportive, engaging, and relevant, which may diminish the use and, in turn, the effect of the educational intervention.

Acceptability and feasibility of survivorship care plans and an accompanying mobile health intervention for adolescent and young adult survivors of childhood cancer

BACKGROUND

Self-management interventions for adolescent and young adult (AYA) survivors of childhood cancer are needed. The present study reports on the acceptability and feasibility of delivering survivorship care plans (SCPs) and an accompanying app to AYA.

PROCEDURE

AYA (n = 224) ages 15-29 who completed treatment for cancer were randomized and received a digital SCP only or an SCP plus a mobile app intended to enhance self-management. For 16 weeks, the app delivered one to two daily messages complementing information in their SCP and tailored based on age, treatment, and health goal. Data are presented on feasibility, self-reported acceptability (including satisfaction and perceived benefits) and its relationship to app engagement (for those in app group), and feedback from qualitative interviews conducted with 10 AYA.

RESULTS

The SCP and app proved feasible as evidenced by high recruitment and retention, access to technology, time analysis, moderate app engagement, and minimal technical issues. However, 12% reported never reading the SCP and 8% never used the app. The app and SCP were acceptable to AYA, and SCP acceptability ratings did not differ between groups. For those with the app, acceptability was positively related to message engagement. AYA recommended enhanced individualization and design features of the SCP and app.

CONCLUSIONS

Results support the use of tailored SCPs and mobile health interventions for most AYA, as well as the need for further refinement and research. Delivery of SCPs and digital interventions are acceptable and feasible to AYA survivors, and may help promote health-related knowledge and survivorship self-management.

User Engagement With Smartphone Apps and Cardiovascular Disease Risk Factor Outcomes: Systematic Review

Background

The use of mobile health (mHealth) interventions, including smartphone apps, for the prevention of cardiovascular disease (CVD) has demonstrated mixed results for obesity, hypercholesterolemia, diabetes, and hypertension management. A major factor attributing to the variation in mHealth study results may be mHealth user engagement.

Objective

This systematic review aims to determine if user engagement with smartphone apps for the prevention and management of CVD is associated with improved CVD health behavior change and risk factor outcomes.

Methods

We conducted a comprehensive search of PubMed, CINAHL, and Embase databases from 2007 to 2020. Studies were eligible if they assessed whether user engagement with a smartphone app used by an individual to manage his or her CVD risk factors was associated with the CVD health behavior change or risk factor outcomes. For eligible studies, data were extracted on study and sample characteristics, intervention description, app user engagement measures, and the relationship between app user engagement and the CVD risk factor outcomes. App user engagement was operationalized as general usage (eg, number of log-ins or usage days per week) or self-monitoring within the app (eg, total number of entries made in the app). The quality of the studies was assessed.

Results

Of the 24 included studies, 17 used a randomized controlled trial design, 4 used a retrospective analysis, and 3 used a single-arm pre- and posttest design. Sample sizes ranged from 55 to 324,649 adults, with 19 studies recruiting participants from a community setting. Most of the studies assessed weight loss interventions, with 6 addressing additional CVD risk factors, including diabetes, sleep, stress, and alcohol consumption. Most of the studies that assessed the relationship between user engagement and reduction in weight (9/13, 69%), BMI (3/4, 75%), body fat percentage (1/2, 50%), waist circumference (2/3, 67%), and hemoglobin A_1c (3/5, 60%) found statistically significant results, indicating that greater app user engagement was associated with better outcomes. Of 5 studies, 3 (60%) found a statistically significant relationship between higher user engagement and an increase in objectively measured physical activity. The studies assessing the relationship between user engagement and dietary and diabetes self-care behaviors, blood pressure, and lipid panel components did not find statistically significant results.

Conclusions

Increased app user engagement for prevention and management of CVD may be associated with improved weight and BMI; however, only a few studies assessed other outcomes, limiting the evidence beyond this. Additional studies are needed to assess user engagement with smartphone apps targeting other important CVD risk factors, including dietary behaviors, hypercholesterolemia, diabetes, and hypertension. Further research is needed to assess mHealth user engagement in both inpatient and outpatient settings to determine the effect of integrating mHealth interventions into the existing clinical workflow and on CVD outcomes.

Development and feasibility of a mobile phone application designed to support physically inactive employees to increase walking

Background

Physical inactivity is a global health concern. mHealth interventions have become increasingly popular, but to date, principles of effective communication from Self-Determination Theory have not been integrated with behavior change techniques to optimize app effectiveness. We outline the development of the START app, an app combining SDT principles and 17 purposefully chosen BCTs to support inactive office employees to increase their walking during a 16-week randomized controlled trial. We also explored acceptability, engagement with, associations between app usage and behavioral engagement, and perceived impact of the app in supporting behavior change.

Methods

Following development, fifty insufficiently physically active employees (M age = 44.21 ± 10.95 years; BMI = 29.02 ± 5.65) were provided access and instructions on use of the app. A mixed methods design was used to examine feasibility of the app, including the User Mobile App Rating Scale, app engagement data, step counts, and individual interviews. Linear mixed modeling and inductive thematic analysis were used to analyze quantitative and qualitative data, respectively.

Results

Walkers rated the app quality favorably (M = 3.68 out of 5). Frequency of entering step counts (i.e., frequency of self-monitoring) on a weekly basis positively predicted weekly step counts measured via Fitbits at both the between-and within-individual levels. App features (entering daily step counts, reminders, and motivational messages) were perceived to assist walkers in fostering goal achievement by building competence and via self-monitoring.

Conclusions

The START app may be a useful component of walking interventions designed to increase walking in the workplace. Apps designed to promote walking behavior may be effective if they target users’ competence and integrate BCTs.

Trial Registration: This study was part of a pilot larger randomized controlled trial, in which a component of the intervention involved the use of the mobile app. The trial was retrospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12618000807257) on 11 May 2018 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375049&isReview=true.

Engaging youth in mHealth: what works and how can we be sure?

BACKGROUND

Youth participating in mobile health (mHealth) intervention trials often engage with the technologies [e.g., applications (app) or mobile-optimized websites] only partially, often prematurely discontinuing use altogether. Limited engagement can impact the interventions effect on behavior change and compromise researchers' ability to test and estimate the true efficacy of their interventions. While mHealth interventions have been shown to be feasible and acceptable to youth, across diverse health conditions, strategies to increase engagement have been less well studied. Specifically, within HIV prevention and care mHealth interventions, there is not consensus as to which components represent the "key ingredients" to support maximal engagement of youth. Further, successful intervention evaluation requires the ability to systematically track users' engagement with intervention components (i.e., paradata) to evaluate its effects on behavior change.

METHODS

As part of the Adolescent Medicine Trials Network UNC/Emory Center for Innovative Technology (iTech) portfolio of HIV/AIDS Interventions, we present diverse strategies used across five mHealth protocols seeking to promote youth engagement, track and measure engagement through paradata, and incorporate these components into mHealth intervention evaluations.

RESULTS

We describe the importance of defining and measuring engagement using case studies from iTech to illustrate how different research teams select mHealth features to promote youth engagement over time, taking into account features embedded in the technology design, key mechanisms of change and trial outcomes (e.g., HIV testing, pre-exposure prophylaxis uptake and adherence, HIV treatment adherence). Finally, we discuss how the research teams plan to evaluate engagement's role on their intervention's outcomes.

CONCLUSIONS

Based on this synthesis, we discuss strategies to enhance mHealth engagement during intervention development and design, ensure its monitoring and reporting throughout the trial, and evaluate its impact on trial outcomes.

Status and Recommendations of Technological and Data-Driven Innovations in Cancer Care: Focus Group Study

BACKGROUND

The status of the data-driven management of cancer care as well as the challenges, opportunities, and recommendations aimed at accelerating the rate of progress in this field are topics of great interest. Two international workshops, one conducted in June 2019 in Cordoba, Spain, and one in October 2019 in Athens, Greece, were organized by four Horizon 2020 (H2020) European Union (EU)-funded projects: BOUNCE, CATCH ITN, DESIREE, and MyPal. The issues covered included patient engagement, knowledge and data-driven decision support systems, patient journey, rehabilitation, personalized diagnosis, trust, assessment of guidelines, and interoperability of information and communication technology (ICT) platforms. A series of recommendations was provided as the complex landscape of data-driven technical innovation in cancer care was portrayed.

OBJECTIVE

This study aims to provide information on the current state of the art of technology and data-driven innovations for the management of cancer care through the work of four EU H2020-funded projects.

METHODS

Two international workshops on ICT in the management of cancer care were held, and several topics were identified through discussion among the participants. A focus group was formulated after the second workshop, in which the status of technological and data-driven cancer management as well as the challenges, opportunities, and recommendations in this area were collected and analyzed.

RESULTS

Technical and data-driven innovations provide promising tools for the management of cancer care. However, several challenges must be successfully addressed, such as patient engagement, interoperability of ICT-based systems, knowledge management, and trust. This paper analyzes these challenges, which can be opportunities for further research and practical implementation and can provide practical recommendations for future work.

CONCLUSIONS

Technology and data-driven innovations are becoming an integral part of cancer care management. In this process, specific challenges need to be addressed, such as increasing trust and engaging the whole stakeholder ecosystem, to fully benefit from these innovations.

Health Care Staff's Experiences of Engagement When Introducing a Digital Decision Support System for Wound Management: Qualitative Study

Background

eHealth solutions such as digital decision support systems (DDSSs) have the potential to assist collaboration between health care staff to improve matters for specific patient groups. Patients with hard-to-heal ulcers have long healing times because of a lack of guidelines for structured diagnosis, treatment, and follow-up. Multidisciplinary collaboration in wound management teams is essential. A DDSS could offer a way of aiding improvement within wound management. The introduction of eHealth solutions into health care is complicated, and the engagement of the staff seems crucial. Factors influencing and affecting engagement need to be understood and considered for the introduction of a DDSS to succeed.

Objective

This study aims to describe health care staff’s experiences of engagement and barriers to and influencers of engagement when introducing a DDSS for wound management.

Methods

This study uses a qualitative approach. Interviews were conducted with 11 health care staff within primary (n=4), community (n=6), and specialist (n=1) care during the start-up of the introduction of a DDSS for wound management. The interviews focused on the staff’s experiences of engagement. Content analysis by Burnard was used in the data analysis process.

Results

A total of 4 categories emerged describing the participants’ experiences of engagement: a personal liaison, a professional commitment, an extended togetherness, and an awareness and understanding of the circumstances.

Conclusions

This study identifies barriers to and influencers of engagement, reinforcing that staff experience engagement through feeling a personal liaison and a professional commitment to make things better for their patients. In addition, engagement is nourished by sharing with coworkers and by active support and understanding from leadership.

Patterns of Use of Smartphone-Based Interventions Among Latina Breast Cancer Survivors: Secondary Analysis of a Pilot Randomized Controlled Trial

BACKGROUND

Latina breast cancer survivors experience poorer health-related quality of life (HRQoL), greater symptom burden, and more psychosocial needs compared to non-Latina breast cancer survivors. eHealth platforms such as smartphone apps are increasingly being used to deliver psychosocial interventions to cancer survivors. However, few psychosocial eHealth interventions have been developed specifically for Latina breast cancer survivors. Further, little is known about how Latinas, in general, engage with eHealth interventions and whether specific participant characteristics are associated with app use in this population. We evaluated the use of 2 culturally informed, evidence-based smartphone apps for Latina breast cancer survivors-one that was designed to improve HRQoL and reduce symptom burden (My Guide) and the other to promote healthy lifestyle behaviors (My Health).

OBJECTIVE

The objectives of our study were to explore the patterns of use of the My Guide intervention app and My Health attention-control app among Latina breast cancer survivors.

METHODS

Eighty Latina breast cancer survivors were randomized to use the My Guide or My Health app for 6 weeks. Assessments were collected at baseline (T1), immediately after the 6-week intervention (T2), and 2 weeks after T2 (T3). Specific study outcomes included subdomains of HRQoL, symptom burden, cancer-specific distress, cancer-relevant self-efficacy, and breast cancer knowledge.

RESULTS

On average, participants used their assigned app for more than 1 hour per week. Sociodemographic or psychological characteristics were not significantly associated with app use, except for employment status in the My Health group. Content related to common physical and emotional symptoms of breast cancer survivors as well as recommendations for nutrition and physical activity were most frequently accessed by My Guide and My Health participants, respectively. Lastly, clinically meaningful improvements were demonstrated in breast cancer well-being among low app users (ie, <60 minutes of use/week) of My Guide and social well-being among high app users (ie, ≥60 minutes of use/week) of My Health.

CONCLUSIONS

The favorable rates of participant use across both apps suggest that Latina breast cancer survivors are interested in the content delivered across both My Guide and My Health. Furthermore, since sociodemographic variables, excluding employment status, and baseline HRQoL (psychological variable) were not related to app use, My Guide and My Health may be accessible to diverse Latina breast cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03645005; https://clinicaltrials.gov/ct2/show/NCT03645005.

Comparison of different mobile health applications for intervention in children and adolescent with overweight: a protocol for systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

Overweight in children is increasing worldwide. Innovative smartphone health applications (mHealth apps) have either sought to deliver single or multi-component interventions for the management of overweight in children. However, the clinical effects of these apps are poorly explored. The objective of the review will be to compare the benefits and harms of different categories of mHealth apps for intervention of overweight in children.

METHODS AND ANALYSIS

We will include randomised clinical trials irrespective of publication type, year, status or language. Children and adolescents between 0 to 18 years will be referred to as children in the remaining part of the paper. Children with all degrees of overweight included obesity and morbidly obese in the remaining part of the paper will be referred to as overweight. We plan to classify different apps according to type of intervention, measurement device, coaching and reward system. The following databases will be used: Cochrane Library, Excerpta Medica database (Embase), PsycINFO, PubMed, IEEE Explore and Web of Science, CINAHL and LILACS. Primary outcomes will be body mass index z-score, quality of life and serious adverse event. Secondary outcomes will be body weight, self-efficacy, anxiety, depression and adverse event not considered serious. Study inclusion, data extraction and bias risk assessment will be conducted independently by at least two authors. We will assess the risk of bias through eight domains and control risks of random errors with Trial Sequential Analysis. The quality of the evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation Tool (GRADE).

ETHICS AND DISSEMINATION

As the protocol is for a systematic reviews, we have not included any patient data and we do not require ethical approval. This review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019120266.