Stages of change

Asynchronous online training increased knowledge, confidence, and intent to screen and treat substance use disorders among primary care clinicians practicing in Texas

INTRODUCTION

Despite increasing prevalence of substance use disorders (SUD), few patients are diagnosed and treated in primary care settings. This study evaluated changes in knowledge, confidence, and intention to implement screening and brief intervention (SBI) and SUD treatment after clinicians participated in an asynchronous online education course.

METHODS

A self-selected sample of primary care clinicians in Texas participated in online SBI and SUD education March 2021-July 2023. Baseline and post-training surveys evaluated changes in knowledge, confidence, and intent to implement SBI and SUD treatment. Changes were compared using paired t-tests. Multivariable linear regression examined factors potentially associated with confidence and intention to implement changes. Clinician feedback regarding the course was included.

RESULTS

Of 613 respondents, 50.9% were practicing family medicine clinicians. Knowledge of adolescent screening tools increased from 21.9% to 75.7% (p < 0.001). Knowledge about the number of drinks that define excessive drinking among non-pregnant women increased from 24.5% at baseline to 64.9% (p < 0.001). Clinicians reported lowest confidence in providing opioid use disorder pharmacotherapy, which improved after program participation. Intent to implement SBI and medication for alcohol, nicotine and opioid use disorders increased (p < 0.001) after training. No factors were associated with change in confidence or intention to implement in multivariable models (p > 0.05). Satisfaction was high and nearly 60% reported intention to change their clinical practice because of the program.

CONCLUSION

Knowledge, confidence, and intent to implement SBI and SUD treatment increased after completing the online course. Clinician satisfaction was high and demonstrated improved intention to implement SBI and SUD treatment.

Effect of self-efficacy among persons who inject drugs treated with direct-acting antivirals on Hepatitis C treatment initiation, duration, completion, adherence, and cure

BACKGROUND

Self-efficacy, a patient-level factor, has been shown to facilitate patient engagement in treatment and optimize treatment-related outcomes in various health contexts. Research on interventions supporting hepatitis C virus (HCV) direct-acting antiviral (DAA) treatment uptake and adherence among persons who inject drugs (PWID) is needed, but whether self-efficacy factors influence DAA treatment cascade outcomes in this population has been less studied.

METHODS

Using the HERO study data, we analyzed a subset of participants with any general health self-efficacy data (n=708) measured at baseline and end-of-treatment time points using a 5-items instrument (facets: 'goal setting', 'goal attainment', 'having a positive effect', 'being in control', and 'working to improve'). The cascade outcomes included DAA treatment initiation, duration, adherence, completion, and sustained virologic response (SVR). The effect of baseline and change (Δ) scores for composite and item-level self-efficacy on the cascade outcomes was assessed using logistic regression and generalized linear models.

RESULTS

Higher baseline composite self-efficacy [adjusted odds ratio (95 % confidence interval) =1.57 (1.07, 2.29)], 'goal attainment' [1.31 (1.03, 1.67)] and 'having a positive effect' [1.33 (1.03, 1.74)] were associated with greater likelihood of treatment initiation. 'Δ Goal attainment' was significantly associated with SVR [1.63 (1.04, 2.53)]. 'Δ Being in control' and 'Δ working to improve' were associated with treatment adherence and duration, respectively.

CONCLUSIONS

General health self-efficacy positively influences DAA treatment initiation among PWID. 'Goal attainment' facilitates the achievement of DAA treatment-related outcomes. Further studies should assess the effect of self-efficacy related to performing healthcare tasks specific to DAAs on the treatment-related outcomes.

Mediational pathways among drug use initiation, use-related consequences, and quit attempts

Background

Factors that predict attempts to discontinue drug use are clinically relevant and may inform treatment. This study investigated drug use-related consequences as a predictor of drug quit attempts and treatment seeking among two cohorts of persons who use drugs.

Methods

Drug use and clinical characteristics were assessed among persons who use cocaine (N=176; urine-verified; 'Cocaine Cohort') and among those who use heroin (N=166; urine-verified; 'Heroin Cohort'). Mediation analyses assessed relationships among age at initial drug use, adverse drug-specific use-related consequences, and drug-specific quit attempts, separately for each cohort. Forward conditional logistic regression models evaluated drug use and clinical symptom scores as predictors of drug-specific treatment seeking.

Results

Controlling for age, mediation models showed that drug use consequences fully mediated the relationship between age at initial drug use and number of drug-specific quit attempts for the 'Cocaine Cohort' and 'Heroin Cohort' (R2=0.30, p<.001; R2=0.17, p<.001; respectively). Reporting more consequences predicted more quit attempts in each cohort, accounting for duration of use (ps<.001). Reporting more consequences also predicted greater likelihood of seeking drug use treatment (ps<.001) and was associated with more severe clinical symptoms in each cohort (ps<.05).

Conclusions

Using a parallel analysis design, we showed that reporting more drug-specific use-related consequences predicted more drug-specific quit attempts and greater likelihood to seek treatment in two cohorts: persons who use cocaine and those who use heroin. Our findings suggest that experiencing more drug use consequences predicts more attempts to seek drug abstinence and that assessment of consequences may be informative for treatment.

A self-determination theory perspective on the relationship between emotion regulation styles, mindfulness facets, and well-being in adults with self-injury

BACKGROUND

The relevance of emotion regulation (ER) difficulties to nonsuicidal self-injury (NSSI; the deliberate destruction of one's bodily tissue without suicidal intent) has been repeatedly documented. Recently, specific mindfulness facets (i.e., awareness, nonjudging, describing) have been proposed as mechanisms that explain this relationship. The present study sought to extend this line of inquiry by exploring the mediating role of mindfulness facets in the relation between self-determination theory-based ER styles (i.e., integrative ER, suppressive ER, emotion dysregulation) and indices of positive and negative well-being (i.e., subjective vitality, NSSI difficulties), while controlling for gender, in adults with recent NSSI engagement.

METHODS

US adults with a history of more than one occurrence of NSSI within the last year (n = 222) completed online measures of ER styles, mindfulness facets, subjective vitality, and NSSI difficulties.

RESULTS

A mediation model indicated that the effects of ER styles on positive and negative well-being were explained by specific mindfulness facets (i.e., awareness, nonjudging, nonreactivity, describing).

CONCLUSIONS

The present study provides preliminary evidence that facets of dispositional mindfulness may be mechanisms through which ER styles impact positive and negative indices of well-being in adults with lived experience of NSSI.

Impact of a Discontinuous Training Program on Sedentary Behavior in Italian Type 2 Diabetes Older Patients: The Results of the TRIPL-A Randomized Controlled Trial

Background: Physical activity is an important predictor of quality of life in older adults with type 2 diabetes (T2D). Unfortunately, most T2D adults adopt a sedentary lifestyle. The randomized, controlled TRIPL-A trial aims to verify the effect of a personalized, discontinuous exercise program on a sedentary lifestyle of T2D older adults. Methods: A total of 305 T2D patients (mean age ± SD: 68.8 ± 3.3 years) were divided into a control arm receiving only behavioral counseling and an intervention arm of an 18-month supervised discontinuous exercise program (ERS). The primary outcomes were the changes in sitting time (ST) and metabolic equivalent (MET) values, both evaluated by the International Physical Activity Questionnaire short form. A repeated measures ANOVA with Bonferroni correction for multiple comparisons was used to compare study outcomes. Results: The ST and MET differed significantly during the study compared to the control group (p = 0.028 and p = 0.004, respectively). In the intervention group, a decrease from baseline in ST at 6 months (p = 0.01) and an increase in MET values at 6 months (p = 0.01) up to 12 months (p < 0.01) were found. No significant differences were found for the other variables. Conclusions: Beneficial lifestyle changes were found within the first year of intervention. These results align with the theory of change.

Treatment of aggression regulation problems with virtual reality: study protocol for a randomized controlled trial

Background

Aggressive conduct among delinquents presents a pervasive issue, bearing substantial implications for not only society at large but also for the victims and the individuals displaying the aggression. Traditional approaches to treating aggression regulation deficiencies generally employ Cognitive Behavioral Therapy (CBT) in conjunction with analog role-playing exercises. A body of research supports the efficacy of various therapeutic models for aggression regulation, including Responsive Aggression Regulation Therapy (Re-ART). Role-playing within a therapeutic context has been shown to contribute significantly to reductions in violent reoffending. However, the practical application of these skills in real-world settings remains challenging due to the inherent risk of aggressive outbreaks. Additionally, the conventional role-playing scenarios, often conducted in a therapy room, lack contextual realism and may induce role confusion between the patient and the therapist. Virtual Reality (VR) technology could offer a viable solution to these limitations by allowing for skill training in both behavioral and cognitive domains within a realistic yet safe and controlled setting. The technology also facilitates real-time awareness of emotional states and tension levels in the patient. This paper describes the study protocol of a randomized controlled trial in which Re-ART offered in a virtual environment (Re-ART VR) is compared to Re-ART offered as treatment as usual.

Methods and analysis

Adult forensic outpatients with aggression regulation problems are randomly assigned to either Re-ART VR or Re-ART. The Controlling Skills, Influence of Thinking and Handling Conflicts modules will be offered to both groups during 3-6 months. Pre- and post-intervention measurements are performed. The primary outcome measurement is the degree of aggression regulation, while secondary outcome measurements include impulsivity and cognitive biases. Additionally, patient motivation and therapist motivation are expected to act as moderating factors.

Discussion

To date, scarcely previous research has been done on the effectiveness of VR in treatment of aggression regulation problems in forensic outpatients. Forensic outpatients who do not benefit sufficiently from mainly CBT-based interventions may benefit more from experiential learning. The unique capabilities of VR in this regard have the potential to enhance the treatment effect.Clinical trial registration: [https://clinicaltrials.gov/], identifier [NL78265.018.21].

The role of multidisciplinary MS care teams in supporting lifestyle behaviour changes to optimise brain health among people living with MS: A qualitative exploration of clinician perspectives

INTRODUCTION

Healthcare professionals have an important role in advocating for the adoption of a brain-healthy lifestyle for optimal multiple sclerosis (MS) care. Nonetheless, studies to date have mainly focussed on the consumer perspective. Herein, we aimed to explore the current practices of how healthcare professionals support protective, lifestyle-related behaviour changes to optimise brain health among people living with MS (plwMS), and their perspectives of professional roles.

METHODS

Australian healthcare professionals were recruited via study advertisements, purposive and snowball sampling, to participate in an online, semi-structured and audio-recorded interview. Clinicians were eligible if they had a minimum of a tertiary Bachelor's degree and 12-months experience working with plwMS, access to the Internet and sufficient time to participant. An inductive, data-driven form of reflexive thematic analysis was undertaken before thematic categorisation of the quotes from transcripts. Data analysis was guided by the methods of Braun and Clark and the study's underpinnings drew on the constructs of the Social Cognitive Theory (SCT).

RESULTS

Six physicians, 10 MS nurses, 18 allied health professionals, one exercise therapist and one alternative therapist were interviewed. Three primary themes encompassing the perceived role of healthcare professionals in supporting a brain-healthy lifestyle were identified: (1) the empowering role, (2) collaborative role and (3) communicative role. External factors/forces including time constraints, professional expertise, training and skill set, power dynamics, consumer readiness, health literacy, self-efficacy and motivation are at play, and affect how/when healthcare professionals may support behaviour change to optimise lifelong brain health for plwMS.

CONCLUSION

Healthcare professionals recognise their critical role in encouraging and supporting the adoption of a brain-healthy lifestyle to optimise lifelong brain health for plwMS. However, discord is evident when they underestimate the complexity of translating knowledge of lifestyle-related behaviour change(s) into action. Greater awareness must be made in recognising and addressing the bidirectionality of external factors such as those in the SCT, that may influence how behaviour change occurs.

PUBLIC CONTRIBUTION

Healthcare professionals volunteered to be interviewed as part of the data collection phase of this study.

Blending Behavioural Theory and Narrative Analysis to Explore the Lived Experience of Obesity and Assess Potential Engagement in a UK Weight Management Service: Theory and Narrative Approaches in Weight Management

BACKGROUND

Current treatments for people with obesity emphasise the need for person-centred approaches that consider complex biopsychosocial factors and value the lived experience of people when attempting to lose weight.

METHODS

Narrative interviews (n = 20) were conducted with people living with obesity to explore the causes of their weight gain and their expectations and engagement with treatment at a Weight Management Clinic. A mixed inductive and deductive qualitative analysis identified utterances that represented psychological constructs used to understand self-appraisal and health behaviour. A narrative analysis was used to situate these findings in the context of a participant's life story.

RESULTS

Locus of control was a dominant construct evidenced through a person's attributional style and self-efficacy. Transcripts represented a heightened sense of self-understanding and shifts in control, and styles of attribution and efficacy resulted in either stasis or self-actualisation. The Stages of Change model could be applied to narratives to ascertain a patient's motivation to access treatment. Importantly, narrative interviews also allowed for the consideration of how a person's systemic context influenced their weight.

CONCLUSION

Narrative interaction supports both self- and shared understandings of the causes and consequences of obesity for individuals, in a non-blaming or shaming manner. It provides an opportunity to enhance engagement through tailored, person-centred treatments.

Readiness and Personality Disorders: Considering Patients' Readiness for Change and Our System's Readiness for Patients

ABSTRACT

The culture around personality disorder treatment has changed drastically in the past generation. While once perceived as effectively untreatable, there are now numerous evidence-based treatment approaches for personality disorders (especially borderline personality disorder). The questions, however, of who should be matched to which treatment approach, and when, remain largely unanswered. In other areas of psychiatry, particularly substance use disorders and eating disorders, assessing patient treatment readiness is viewed as indispensable for treatment planning. Despite this, relatively little research has been done with respect to readiness and personality disorder treatment. In this article, we propose multiple explanations for why this may be the case, relating to both the unique features of personality disorders and the current cultural landscape around their treatment. While patients with personality disorders often face cruel stigmatization, and much more work needs to be done to expand access to care (i.e., our system's readiness for patients), even gold-standard treatment options are unlikely to work if a patient is not ready for treatment. Further study of readiness in the context of personality disorders could help more effectively match patients to the right treatment, at the right time. Such research could also aid development of strategies to enhance patient readiness.

Effectiveness of applied and casual games for young people's mental health: A systematic review of randomised controlled studies

Many youth experience mental health problems and digital games hold potential as mental health interventions. This systematic review provides an overview of randomised controlled studies assessing the effectiveness of digital applied and casual games for improving mental health in youth aged 6-24 years. A systematic search of PsycINFO, Web of Science and Pubmed yielded 145 eligible studies. Studies on (sub)clinical participant samples (n = 75) most often focused on attention-deficit/hyperactivity disorder (ADHD), autism and anxiety. Applied games were found most effective for improving social skills, verbal memory and anxiety, whereas casual games were found most effective for improving depression, anxiety and ADHD. Studies involving healthy youth (n = 70) were grouped into papers examining anxiety in medical settings, momentary effects on positive and negative affect, and papers employing a longitudinal design measuring mental health trait outcomes. Promising results were found for the use of games as distraction tools in medical settings, and for applied and casual games for improving momentary affect. Overall, our findings demonstrate the potential of digital games for improving mental health. Implications and recommendations for future research are discussed, such as developing evaluation guidelines, clearly defining applied games, harmonising outcome measures, including positive outcomes, and examining nonspecific factors that may influence symptom improvement as well.

Two-Sided Messages Promote Openness for a Variety of Deeply Entrenched Attitudes

Prior research showed that people holding attitudes on relatively moral topics became more open to two- rather than one-sided messages as the moral basis of their attitudes increased. Across three studies (N = 963), we extend this finding to relatively non-moral topics by demonstrating that two-sided messages can encourage people with strong attitudes indexed by various non-moral attitude strength measures to be more open to contrary positions. Study 1 demonstrated this for four indicators of attitude strength (e.g., certainty). As the strength of one's attitude increased, two-sided messages increased in relative effectiveness over one-sided communication. This was mediated by perceived appreciation for the speaker acknowledging one's view. Study 2 replicated this finding in a preregistered experiment. Study 3 conceptually replicated and extended it to people holding attitudes based on their political identity. Finally, evidence was obtained supporting perceived appreciation (rather than source evaluation) as the key driver of this interactive effect.

Order Matters When Using Two-Sided Messages to Influence Morally Based Attitudes

Contrary to common beliefs, sometimes downplaying or even undermining one's case can enhance impact, especially for people with strong attitudes. Across four studies (N = 1,548), we demonstrate that the placement of the undermining information within a two-sided message matters. By manipulating message order within a two-sided message, Study 1 showed that the relative effectiveness of two- over one-sided messages for people with a moral attitude primarily occurred when the two-sided message acknowledged the recipient's side at the end rather than at the beginning of the message. Studies 2A/B showed that this effect was associated with positive source perceptions, such that placing the acknowledgment at the end results in people with a higher moral basis perceiving the source as more thoughtful and sincere. Furthermore, this inference process was more likely to occur when motivation to think was relatively high. Study 3, a preregistered experiment, replicated these findings using a different topic.

mHealth intervention including text messaging and behaviour change techniques to support maintenance of physical activity after cardiac rehabilitation: A single-arm feasibility study

Objective

To evaluate the feasibility of a mobile health-supported intervention in patients with cardiovascular diseases after completion of a cardiac rehabilitation programme.

Methods

The feasibility study was performed in two hospitals and one municipality in Region Zealand, Denmark. Eligible participants were ≥18 years old, participated in a supervised cardiac rehabilitation programme, had access to a mobile phone, and could walk 3 m independently. Participants received a 12-week intervention utilizing behaviour change techniques, consisting of action planning, text messages, and phone support. Feasibility was assessed using pre-defined progression criteria, which included recruitment (≥75%), retention (≥80%), accelerometer data completeness (≥80%), coordinator (phone support) time (≤30 min), the response rate on patient-reported outcomes (≥90%), adherence (≥75% respond to ≥75% of messages), and acceptability (≥75%). The secondary outcome of objective physical activity was assessed with accelerometers.

Results

Ten women and 30 men with cardiovascular diseases aged 63.5 (±9.8 SD) participated. The progression criteria for retention (90%), accelerometer data completeness (83%), coordinator time (9.9 min), adherence (83%), and acceptability (82%) were at acceptable levels, exceptions were progression criteria for recruitment (35%) being below acceptable levels for recruitment, and response rate on patient-reported outcomes (75%). High satisfaction (92.6%) with the intervention was found. All objectively measured physical activity levels remained unchanged from baseline to follow-up. No serious adverse events related to the intervention were reported.

Conclusion

Mobile health-supported maintenance of physical activity after cardiac rehabilitation completion was feasible, safe, and acceptable. Yet, changes to improve recruitment and response rate are needed before conducting a large-scale effect evaluation.

Socio-Cognitive Determinants of Lifestyle Behavior in the Context of Dementia Risk Reduction: A Population-Based Study in the Netherlands

Background

Unhealthy behavior increases the risk of dementia. Various socio-cognitive determinants influence whether individuals persist in or alter these unhealthy behaviors.

Objective

This study identifies relevant determinants of behavior associated to dementia risk.

Methods

4,104 Dutch individuals (40-79 years) completed a screening questionnaire exploring lifestyle behaviors associated with dementia risk. Subsequently, 3,065 respondents who engaged in one or more unhealthy behaviors completed a follow-up questionnaire investigating socio-cognitive determinants of these behaviors. Cross-tables were used to assess the accuracy of participants' perceptions regarding their behavior compared to recommendations. Confidence Interval-Based Estimation of Relevance (CIBER) was used to identify the most relevant determinants of behavior based on visual inspection and interpretation.

Results

Among the respondents, 91.3% reported at least one, while 65% reported two or more unhealthy lifestyle behaviors associated to dementia risk. Many of them were not aware they did not adhere to lifestyle recommendations. The most relevant determinants identified include attitudes (i.e., lacking a passion for cooking and finding pleasure in drinking alcohol or smoking), misperceptions on social comparisons (i.e., overestimating healthy diet intake and underestimating alcohol intake), and low perceived behavioral control (i.e., regarding changing physical inactivity, altering diet patterns, and smoking cessation).

Conclusions

Individual-level interventions that encourage lifestyle change should focus on enhancing accurate perceptions of behaviors compared to recommendations, while strengthening perceived control towards behavior change. Given the high prevalence of dementia risk factors, combining interventions at both individual and environmental levels are likely to be the most effective strategy to reduce dementia on a population scale.

Pregnancy Desirability and Motivational Readiness for Postpartum Contraceptive Use: Findings from Population-Based Surveys in Eight Sub-Saharan African Countries

This study examined the associations between pregnancy intention and motivational readiness for postpartum contraceptive use. Data for this cross-sectional analysis were derived from nationally representative surveys of the Performance Monitoring and Accountability 2020 (PMA2020) project conducted in eight sub-Saharan African countries. Participants included 9488 nonpregnant women of reproductive age (15-49 years) who had given birth in the last 2 years. Weighted multinomial logistic regression analyses were performed to estimate the odds ratios (OR) and their corresponding 95% confidence intervals (CIs) of the associations of motivational readiness for contraceptive adoption categorized as precontemplation, contemplation, and post-action with pregnancy intention. After adjusting for confounding factors, the findings revealed that women in Côte d'Ivoire and Nigeria who had mistimed pregnancies had significantly higher odds of being in the contemplation vs. precontemplation stage compared to those who had intended pregnancies. Similarly, women who had unwanted pregnancies in Ethiopia were also more likely to be in the contemplation stage. Furthermore, significant differences were observed for women in Burkina Faso, Côte d'Ivoire, and Nigeria regarding the association between mistimed pregnancies and being in the post-action stage. For women who had unwanted pregnancies, this association was significant only in Nigeria. Additionally, the odds of being in the contemplation stage, compared to the post-action stage, for women who had unwanted pregnancies were significantly higher in Ethiopia and Nigeria. These results indicate that recent unintended pregnancies in specific sub-Saharan African countries may motivate women to take action to prevent future unintended pregnancies. The findings underscore the importance of tailored and context-specific approaches in family-planning programs based on the stage of motivational readiness.

Randomized-controlled trial of a whole-family obesity prevention and treatment intervention designed for low-income Hispanic families: HeLP the healthy living program

BACKGROUND

Low-income Hispanic families face marked disparities in obesity, but interventions for obesity prevention and treatment have rarely been designed with this population as a focus. Hispanic culture is characterized by Familism, a value that prioritizes familial respect, cooperation, and togetherness. We describe the rationale and design of a trial of the Healthy Living Program (HeLP), a bilingual whole-family behavioral obesity prevention and treatment intervention designed around the value Familism and addressing food insecurity.

METHODS/DESIGN

This two-group randomized comparative effectiveness trial will compare the effects of HeLP versus a primary care counseling intervention (Recommended Treatment of Obesity in Primary Care, or RTOP) on decreasing body mass index (BMI; kg/m2) in Hispanic children 2-16 years of age with obesity and preventing BMI increase among siblings without obesity. 164 families per arm will be recruited from primary care practices. Families randomized to HeLP will participate in 12 two-hour sessions, followed by booster sessions. HeLP sessions include family meals and instruction in parenting skills, nutrition, culinary skills, fitness, and mindfulness delivered at community recreation centers by bilingual health educators and athletic trainers. Families randomized to RTOP will be offered individual visits in primary care every 3 months throughout the 18-month follow-up period. Secondary outcomes include changes to objectively measured child fitness, the home environment related to nutrition, physical activity, and media usage, food insecurity, child eating behaviors, quality of life, parent BMI and waist circumference, and implementation outcomes.

DISCUSSION

This protocol paper describes the rationale and planned methods for the comparative effectiveness trial.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT05041855 (6/13/2023).

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study

BACKGROUND

Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood.

OBJECTIVE

This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress.

METHODS

A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis.

RESULTS

Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience.

CONCLUSIONS

The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention.

TRIAL REGISTRATION

Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2021.100369.

Young people's experience of the therapeutic alliance: A systematic review

OBJECTIVE

The aim of this systematic review was to synthesise qualitative evidence on young people's conceptualisation, utilisation and experiences of the therapeutic alliance in individual psychotherapy or counselling and its role in bringing about change.

METHOD

The thematic synthesis method was used to synthesise data. The methodological quality of included studies was assessed using the CASP checklist for qualitative research.

RESULTS

Four superordinate analytical themes were generated: (1) valuable therapist qualities, (2) conditions for the development and maintenance of the therapeutic alliance, (3) therapeutic processes and (4) barriers to the development of the therapeutic alliance. Findings indicate that young people appreciated the uniqueness of the therapeutic relationship that provided a sense of safety, choice and autonomy. Flexibility and accessibility were noted as important elements of therapeutic alliance building as they elicited a sense of agency. Young people emphasised the non-linear nature of therapy and prioritised process variables such as improvement in self-understanding, self-efficacy and self-worth.

CONCLUSION

The current systematic review is a comprehensive overview of qualitative studies of experiences of therapy from young people's perspectives. Important practical implications derived from this review as the role of autonomy in the change process and the formation and maintenance of the therapeutic relationship were outlined as important elements in youth therapy.

Breaking barriers to rehabilitation: the role of behavior change theories in overcoming the challenge of exercise-related behavior change

BACKGROUND

Promoting exercise-related behavior change in rehabilitation is a challenge. The lack of integration between rehabilitation program prescriptions, behavior change interventions, and behavioral change theories is profound. Using behavior change theories properly is crucial for better adherence and promoting positive outcomes. Therefore, it is essential to bring theories that support the understanding of exercise-related behavioral change to the attention of rehabilitation practitioners.

OBJECTIVE

This masterclass article aims to provide the theoretical background of theories and strategies for exercise behavior change within the physical therapy context based on acknowledged behavioral change theoretical models.

METHODS

This is a narrative review that examines six behavior theories; five of them well-established, and a new (and promising) theory that has exhibited the most favorable outcomes in rehabilitation settings. The development process for this masterclass included conversations between authors, reviewing behavior theories, summarizing and discussing the theories' concepts and strategies for physical therapy.

RESULTS

The included theories were self-determination theory, social-cognitive theory, the transtheoretical model, the theory of planned behavior, the health belief model, and the unifying theory of physical activity. Each theory offers a unique perspective on exercise behavior change within rehabilitation, exploring constructs such as motivation, self-efficacy, stages of change, behavioral intention, perceived threat, and the core elements of physical activity expression.

CONCLUSION

These theoretical models provide a foundation for understanding and developing strategies for promoting exercise behavior change in rehabilitation. Knowing and using these theories is important for respecting the patient's individuality.

Physical Activity Message Framing and Ethnicity Before and During COVID-19

People of Black ethnicities are well known to be disproportionately burdened by coronavirus and have poorer health outcomes. Public health messages encouraged physical activity during the pandemic as it is evidenced to positively affect the immune system, however people of Black ethnicities are often reported as failing to achieve the recommended daily amount. Health message framing during COVID-19 specifically in relation to ethnicity and physical activity motivation has yet to be investigated. Two studies examined message frame effect on physical activity motivation prior to and at the onset of the pandemic and how this differed by ethnicity. Gain framed messages were found to positively affect physical activity motivation pre-COVID-19 and during the pandemic fear framed messages were found to positively affect physical activity motivation. Neither of these effects differed by ethnicity. Implications for future physical activity health message framing are discussed.

Correlates of Rates and Treatment Readiness for Depressive Symptoms, Pain, and Fatigue in Hemodialysis Patients: Results from the TĀCcare Study

Key Points

Lower neighborhood walkability was associated with higher depressive symptoms and fatigue and younger age with depressive symptoms. Depressive symptoms, pain, and fatigue were frequently reported, often occurred together, and were often not all already treated. Patients with a higher symptom burden and men may be more likely to be ready to seek treatment for depressive symptoms, pain, or fatigue.

Background

Patients on hemodialysis (HD) often experience clinically significant levels of pain, fatigue, and depressive symptoms. We explored potential sociodemographic differences in symptom burden, current treatment, and readiness to seek treatment for these symptoms in patients screened for the TĀCcare trial.

Methods

In-center HD patients from Pennsylvania and New Mexico were screened for fatigue (≥5 on 0–10-point Likert scale), pain (Likert scale ≥4), depressive symptoms (≥10 Patient Health Questionnaire-9), and readiness to seek treatment (5–item Stages of Behavior Change questionnaire). Symptom burden and treatment status by sociodemographic factors were evaluated using chi square, Fisher exact tests, and logistic regression models.

Results

From March 2018 to December 2021, 506 of 896 (57%) patients screened met eligibility criteria and completed the symptom screening (mean age 60±13.9 years, 44% female, 17% Black, 25% American Indian, and 25% Hispanics). Of them, 77% screened positive for ≥1 symptom and 35% of those were receiving treatment for ≥1 of these symptoms. Pain, fatigue, and depressive symptom rates were 52%, 64%, and 24%, respectively. Age younger than 65 years was associated with a higher burden of depressive symptoms, pain, and reporting ≥1 symptom (P <0.05). The percentage of patients ready to seek treatment increased with symptom burden. More men reported readiness to seek treatment (85% versus 68% of women, P <0.001). Among those with symptoms and treatment readiness, income was inversely associated with pain (>$60,000/yr: odds ratio [OR]=0.16, confidence interval [CI]=0.03 to 0.76) and living in less walkable neighborhoods with more depressive symptoms (OR= 5.34, CI=1.19 to 24.05) and fatigue (OR= 5.29, CI=1.38 to 20.33).

Conclusions

Pain, fatigue, and depressive symptoms often occurred together, and younger age, less neighborhood walkability, and lower income were associated with a higher burden of symptoms in HD patients. Male patients were less likely to be receiving treatment for symptoms. These findings could inform priority HD patient symptom identification and treatment targets.

Essentials to Improve the Effectiveness of Healthy Aging Programming: Consideration of Social Determinants and Utilization of a Theoretical Model

Older adult health, while partially determined by genetics, is mostly determined by behavioral and lifestyle choices. Researchers and interventionists develop and administer behavioral health interventions with older adults, and interventions are advertised in any number of settings, for example, by providers in healthcare settings and by activity directors in senior centers or assisted living facilities. However, previous studies and metanalyses indicate that many interventions targeting older adults are unsuccessful in recruitment or in retention. While providers and activity directors may assume older adults are unwilling to participate in behavioral change, in reality, low participation may be caused by erroneous design and administration. The objective of this manuscript is to recommend to creators and implementers of behavioral interventions for older adults that they focus on two critical considerations: the contextual perspective pertaining to healthy aging as well as an appropriately employed theoretical model that most effectively informs program design and implementation. In this commentary, we discuss how Prochaska and DiClemente's Transtheoretical Model of Health Behavior Change may lead to more desirable outcomes as it considers that a person may be at any one of six stages of change, from pre-contemplation to maintenance. Currently, many behavioral interventions are targeted at individuals who are poised for action or in maintenance phases, ignoring those in earlier phases, resulting in limited overall success. Regarding viewing healthy aging in a contextual manner, determinants external to the individual may remain unnoted and unconsidered when designing or recruiting for a behavioral intervention. In conclusion, the integration of an intrapersonal health behavior model such as the Transtheoretical Model of Health Behavior Change, coupled with clearer considerations of the interplay of contextual factors operating in the lives of older adults, may allow for more effective design and implementation, as well as resulting in higher participation in behavioral interventions targeted toward older adults.

Body awareness and cognitive behavioral therapy for multisite musculoskeletal pain: patients` experiences with group rehabilitation

BACKGROUND

An extended group program called Mind and Body (MB), based on body awareness exercises and cognitive behavioral therapy (CBT), was offered to a subgroup of patients who had completed their traditional outpatient multidisciplinary rehabilitation and were motivated for further treatment.

PURPOSE

To explore how patients with multisite musculoskeletal pain experienced participation in the MB program with respect to usefulness, meaningfulness, behavioral changes, and transferability to daily life and work.

METHOD

The study is rooted in the phenomenological tradition. Individual, semi-structured interviews were performed with eight patients aged 29-56 years. The data were analyzed using systematic text condensation.

RESULTS

Two main themes emerged: 1) New knowledge provided increased body awareness, new ways of thinking, and acceptance of one's own situation. This theme reflected how new knowledge and MB coping strategies were useful in the process of changing problematic thoughts, increasing body awareness, and facilitating acceptance; and 2) Implementing new habits and strategies in daily life revealed how demanding it was to alter behavior, a process that unfolded over time.

CONCLUSION

A combination of body awareness exercises and cognitive coping strategies was described as helpful in further improving function and coping with pain and stress in daily life and work.

Approaching rehabilitation in patients with advanced glaucoma

Vision loss from advanced glaucoma is currently irreversible and impairs functional visual ability to effectively perform everyday tasks in a number of distinct functional domains. Vision rehabilitation strategies have been demonstrated to be effective in low vision populations and should be utilized in persons with advanced glaucoma to reduce disability and improve quality of life. Initial challenges to rehabilitation include an incomplete understanding of vision rehabilitation by the physician and patient, motivation to integrate rehabilitation into the plan of care, and availability of suitable providers to deliver this care. Physicians, working with well-trained vision rehabilitation providers can maximize function in important visual domains customized to the patient based on their needs, specific complaints, severity/pattern of visual damage, and comorbidities. Potential rehabilitative strategies to be considered for reading impairment include spectacle correction, visual assistive equipment, and sensory substitution, while potential strategies to facilitate driving in those deemed safe to do so include refractive correction, lens design, building confidence, restriction of driving to safer conditions, and avoiding situations where cognitive load is high. Mobility is frequently disrupted in advanced glaucoma, and can be addressed through careful distance refraction, behavior modification, home modification, mobility aids, walking assistance (i.e., sighted guide techniques), and smartphone/wearable technologies. Visual motor complaints are best addressed through optimization of lighting/contrast, sensory substitution, IADL training, and education. Special rehabilitative concerns may arise in children, where plans must be coordinated with schools, and working adults, where patients should be aware of their rights to accommodations to facilitate specific job tasks.

Reasons for recovery and readiness to change among adolescents and young adults engaging in self-injury

Background

Non-suicidal self-injury (NSSI) typically begins during adolescence and the process of treatment and recovery can be challenging. We examine NSSI through the lens of the Transtheoretical Model of Change, a framework that views the process of change as five stages, with differing degrees of readiness to change.

Methods

Thirty participants, both adolescents and young adults (14 to 35 years), were recruited from a tertiary care neuropsychiatric hospital. The participants were predominantly female and had self-injured at least once in the last year. They completed the Inventory of Statements about Self Injury, the University of Rhode Island Change Assessment and the Reasons to Stop Self-Injury Questionnaire.

Results

Seventy-three percent were in the contemplation stage with respect to their readiness to change, while the rest were in the pre-contemplation stage. Participants endorsed a range of vulnerability and resilience related reasons to stop injuring; reasons related to self-efficacy, the addictive nature of NSSI, self-efficacy and impact on interpersonal relationships were prominent levers for the recovery process. Preliminary trends indicated that participants in the contemplation stage endorsed reasons to stop self-injuring more strongly than those in pre-contemplation.

Conclusion

The findings carry implications for assessment, the amplification of reasons for recovery and individualized interventions to support the recovery process with individuals who engage in NSSI.

Effectiveness of a targeted primary preventive intervention in a high-risk group identified using an efficiency score from data envelopment analysis: a randomised controlled trial of local residents in Japan

OBJECTIVE

To determine whether a minimal intervention based on the data envelopment analysis (DEA)-identified efficiency score effectively prevents hypertension.

DESIGN

Randomised controlled trial.

SETTING

Takahata town (Yamagata, Japan).

PARTICIPANTS

Residents aged 40-74 years belonged to the information provision group for specific health guidance. Participants with a blood pressure ≥140/90 mm Hg, those taking antihypertensive medication, or those with a history of cardiac diseases were excluded. Participants were consecutively assigned based on their health check-up visit at a single centre from September 2019 to November 2020 and were followed up at the check-up in the following year, until 3 December 2021.

INTERVENTION

A targeted approach using minimal intervention. Target was identified using DEA and 50% of participants with higher risk were targeted. The intervention was notifying the results of their risk of hypertension according to the efficiency score obtained by the DEA.

PRIMARY OUTCOME MEASURES

A reduction in the proportion of participants who developed hypertension (≥140/90 mm Hg or taking antihypertensive medication).

RESULTS

A total of 495 eligible participants were randomised, and follow-up data were available for 218 and 227 participants in the intervention and control groups, respectively. The risk difference for the primary outcome was 0.2% (95% CI -7.3 to 6.9) with 38/218 (17.4%) and 40/227 (17.6%) events in the intervention and control group, respectively (Pearson's χ² test, p=0.880). The adjusted OR of the effect of the intervention was 0.95 (95% CI 0.56 to 1.61, p=0.843), and that of the efficiency score (10-rank increase) was 0.81 (95% CI 0.74 to 0.89, p<0.0001).

CONCLUSIONS

Minimal intervention to a high-risk population stratified by DEA was not effective in reducing the onset of hypertension in 1 year. The efficiency score could predict the risk of hypertension.

TRIAL REGISTRATION NUMBER

UMIN000037883.

[Prevention and health promotion in dementia: motivation for change within preventive interventions-Empirical results]

BACKGROUND

Aging healthily and prevention of diseases are statutory and a national health target. There is convincing evidence that describes the modifiable risk factors, which are principally suitable for preventive measures.

OBJECTIVE

Definition of terms, presentation of the roots of prevention in laws, strategies and guidelines. Presentation of the risk factors for dementia, outline of effective preventive measures and their promising components.

MATERIAL AND METHODS

Prevention is systematically described. The available evidence on risk factors, health behavior and preventive measures is analyzed. A multimodal intervention is presented and the influence of motivation on a change in behavior is outlined, exemplified by physical activity.

RESULTS AND DISCUSSION

Aging healthily is a national health target and prevention of disease is rooted and defined in both the legislation and guidelines. The current evidence on modifiable risk factors for dementia originates from 12 factors. These include behavior-associated factors, such as inactivity, diabetes and smoking. The efficacy of preventive measures can be described by their effectiveness, the utilization when available and the principal availability for all people for whom they are indicated. Changing a health behavior is complex and dependent among other things on the motivation to want to change a behavior. Currently, multimodal prevention programs appear to be very promising for the prevention of cognitive disorders and dementia.

Developing a prototype for relationship therapy psychoanalysis: an empirical study with the Psychotherapy Process Q-set

Psychotherapy Process Q-set (PQS) prototype characteristic of psychoanalytic relationship therapy does not yet exist. Experts in psychoanalysis of relationship therapy [from the Italian Society of Psychoanalysis of the Relationship (SIPRe)] used the 100-Item PQS questionnaire to rate an ideal SIPRe therapy. Agreement between rates was high (Cronbach's alpha=0.84). The prototype for SIPRe therapy showed a significant correlation to the psychoanalytic prototype (r=0.68, p<0.000) and to the short expressive-supportive therapy (r=0.69, p<0.000) prototype. Correlations with Cognitive Behavioural Therapy (r=0.28, p<0.005) and Interpersonal Therapy (r=0.22, p<0.031), prototypes were significant, but weaker. The correlation between the two SIPRe samples (junior and expert therapists) was highly significant (Spearman's rho=0.936; p<000).

Effects of a feedback intervention on antibiotic prescription control in primary care institutions based on a Health Information System: a cluster randomized cross-over controlled trial

OBJECTIVES

Overuse and misuse of antibiotics are major factors in the development of antibiotic resistance in primary care institutions of rural China. In this study, the effectiveness of a Health Information System-based, automatic, and confidential antibiotic feedback intervention was evaluated.

METHODS

A randomized, cross-over, cluster-controlled trial was conducted in primary care institutions. All institutions were randomly divided into two groups and given either a three-month intervention followed by a three-month period without any intervention or vice versa. The intervention consisted of three feedback measures: a real-time pop-up warning message of inappropriate antibiotic prescriptions on the prescribing physician's computer screen, a 10-day antibiotic prescription summary, and distribution of educational manuals. The primary outcome was the 10-day inappropriate antibiotic prescription rate.

RESULTS

There were no significant differences in inappropriate antibiotic prescription rates (69.1% vs. 72.0%) between two groups at baseline (P = 0.072). After three months (cross-over point), inappropriate antibiotic prescription rates decreased significantly faster in group A (12.3%, P < 0.001) compared to group B (4.4%, P < 0.001). At the end point, the inappropriate antibiotic prescription rates decreased in group B (15.1%, P < 0.001) while the rates increased in group A (7.2%, P < 0.001). The characteristics of physicians did not significantly affect the rate of antibiotic or inappropriate antibiotic prescription rates.

CONCLUSION

A Health Information System-based, real-time pop-up warnings, a 10-day prescription summary, and the distribution of educational manuals, can effectively reduce the rates of antibiotic and inappropriate antibiotic prescriptions.

Habits and Routines of Adults in Early Recovery From Substance Use Disorder: Clinical and Research Implications From a Mixed Methodology Exploratory Study

The purpose of this exploratory, non-experimental mixed methods study was to analyze the habits and routines of adults in early recovery (>3 months) from substance use disorder (SUD). Participants (N = 14) were recruited from an intensive outpatient treatment (IOP) program for substance use disorders. Data collection consisted of a demographic survey, a researcher developed Daily Occupational Questionnaire (DOQ), and follow-up semi-structured interviews with 5 randomly selected participants. Quantitative results indicate rest as the most frequently engaged in activity on the most busy (31.0%) and least busy day (36.6%). There was no significant difference, t(13) = 0.117, P = .909, between newly established activities on the most busy and least busy day. Qualitative themes included 1. The most difficult time of day is often related to patterns of unused time. 2. When there is a lack of structure or unoccupied time, they return to their previously established positive supports. 3. There is a need for consistency and structure for developing anticipated/perceived routines. Implications for all healthcare and clinical providers working with this population, as well as research suggestions, are outlined.

Assessing owners' readiness to change their behaviour to address their companion animal's obesity

BACKGROUND

Owner behaviour change in relation to management is critical for successful pet weight loss. The stages of change (SOC) can be used to conceptualise the process of intentional behaviour change. Clients may be more likely to make successful changes when practitioners use communication techniques appropriate for a client's current stage. The objective of this cross-sectional study was to assess pet owners' SOC in relation to managing the weight of their overweight or obese pet.

METHODS

An online questionnaire targeting dog and cat owners was distributed via snowball sampling. A total of 532 questionnaires were included in the analysis. Of these, 153 participants (28.8%) self-identified their pet's body condition score (BCS) as greater than 5 (on a nine-point scale). An adapted University of Rhode Island Change Assessment scale was completed by 119 of these participants (77.8%) to assess their readiness to change related to managing their overweight or obese pet.

RESULTS

Most participants were scored in the precontemplation (52.1%) and contemplation (42%) stages, where readiness to change is low. Owner assessments likely resulted in underestimation of pets' BCS.

CONCLUSION

The results offer preliminary insight into the SOC of owners who identify their pets as overweight or obese. Developing tools to assess and understand owners' readiness to change may be useful in informing veterinary professionals' communication approaches when engaging in weight management conversations.

Developments in respiratory self-management interventions over the last two decades

This paper describes developments in the fields of asthma and COPD self-management interventions (SMIs) over the last two decades and discusses future directions. Evidence around SMIs has exponentially grown. Efficacy on group level is convincing and both asthma and COPD SMIs are currently recommended by respiratory guidelines. Core components of asthma SMIs are defined as education, action plans, and regular review, with some discussion about self-monitoring. Exacerbation action plans are defined as an integral part of COPD management. Patient's adherence to SMI's is however inadequate and significantly reducing the intervention's impact. Adherence could be improved by tailoring of SMIs to patients' needs, health beliefs, and capabilities; the use of shared decision making; and optimising the communication between patients and health care providers. Due to the COVID-19 pandemic, digital health innovations have rapidly been introduced and expanded. Digital technology use may increase efficiency, flexibility, and efficacy of SMIs. Furthermore, artificial intelligence can be used to e.g., predict exacerbations in action plans. Research around digital health innovations to ensure evidence-based practice is of utmost importance. Current implementation of respiratory SMIs is not satisfactory. Implementation research should be used to generate further insights, with cost-effectiveness, policy (makers), and funding being significant determinants.

Self-Determination Theory and Preventive Medication Adherence: Motivational Considerations to Support Historically Marginalized Adolescents With Asthma

INTRODUCTION

Using self-determination theory, we explored relationships between autonomous motivation (AM) and perceived competence (PC) with previously validated measures of motivation and adolescent-reported asthma medication adherence.

METHOD

Data were from adolescents (n = 260) enrolled in the School-Based Asthma Care for Teens study and taking preventive medication at baseline. Eligible adolescents (aged 12-16 years) had physician-diagnosed persistent asthma or poor control.

RESULTS

Adolescents taking daily preventive medicine reported higher AM and PC for adherence, whereas adolescents likely to miss ≥1 dose in the next 2 weeks had lower AM and PC. Adolescents taking medicines as prescribed, with plans to continue, and those feeling able to follow provider care plans, had higher AM and PC. Findings remained significant in regressions with control variables.

DISCUSSION

Many factors interfere with adolescent medication-taking. Clinicians' efforts to build AM and PC with patients and caregivers may be key to promoting adherence in this group.

Social Environments and Physical Activity Among Active Black Women

PURPOSE

To explore the social context of physical activity (PA) among active Black women, we examine the patterns of PA engagement and the benefits of social support in PA maintenance.

DESIGN

A cross-sectional study design and descriptive phenomenological approach were used to examine social support and lived experiences of active Black women.

SETTING

The study setting was an online survey of active Black women, ages 21 to 71 years who were recruited from across the United States.

PARTICIPANTS

This secondary data analysis was conducted among a sample of 187 active Black women who maintained PA for ≥6 months. The mean age was 41 ± 12.3 years, 83.4% completed some college, 37.7% were married, and 30.0% had children.

MEASURES

Participants self-reported 'with whom' they engaged in PA and provided qualitative responses about their strategies for PA maintenance. Descriptive statistics were used to examine between-group differences among demographic characteristics and PA variables by category of PA engagement using SAS 9.4. Descriptive phenomenology was used to explore social support themes across and within categories of PA engagement.

RESULTS

On average, the active Black women in this study reported engaging in 57.0 ± 18.9 minutes of moderate intensity leisure-time PA per session. Most engaged in PA alone (n = 87), with a group (n = 72), or with another individual (n = 28). Social context themes within categories included: alone - self-management, groups - motivation and accountability, family - values health, and friends - shared interests in PA. Subthemes across social context categories included: who? - people, what and how? - types of social support, and where? - place of social support.

CONCLUSIONS

Our findings suggest that some Black women may need added social support from others beyond family and friends, while other Black women may prefer additional self-management skills. Nonetheless, this study provides data for developing hypotheses about the mechanisms by which social context may facilitate PA maintenance among Black women. Therefore, intervention studies targeting PA maintenance among Black women should include an in-depth query of social support needs.

Meeting Young Adults' Social Support Needs across the Health Behavior Change Journey: Implications for Digital Mental Health Tools

In pursuit of mental wellness, many find that behavioral change is necessary. This process can often be difficult but is facilitated by strong social support. This paper explores the role of social support across behavioral change journeys among young adults, a group at high risk for mental health challenges, but with the lowest rates of mental health treatment utilization. Given that digital mental health tools are effective for treating mental health conditions, they hold particular promise for bridging the treatment gap among young adults, many of whom, are not interested in - or cannot access - traditional mental healthcare. We recruited a sample of young adults with depression who were seeking information about their symptoms online to participate in an Asynchronous Remote Community (ARC) elicitation workshop. Participants detailed the changing nature of social interactions across their behavior change journeys. They noted that both directed and undirected support are necessary early in behavioral change and certain needs such as informational support are particularly pronounced, while healthy coping partnerships and accountability are more important later in the change process. We discuss the conceptual and design implications of our findings for the next generation of digital mental health tools.

Online Psychosis Screening: Characterizing an Underexamined Population to Improve Access and Equity

OBJECTIVE

Online resources represent an important avenue to identify and support individuals who may be experiencing symptoms of psychosis but have yet to engage in care. Understanding the experiences and needs of this group is critical to inform outreach for early psychosis and improve outcomes by addressing barriers to early treatment.

METHODS

The authors conducted a retrospective, explorative, cross-sectional analysis by using data collected by Mental Health America as part of their online psychosis screening and support program. Data included scores from the Prodromal Questionnaire-Brief, basic demographic information, and respondents' plans for next steps.

RESULTS

Of 120,937 respondents, most (82.1%) reported distressing psychosis-like experiences at levels sufficient to merit a referral to specialty care for additional evaluation. However, only 17.1% planned to seek treatment as a next step, with most (53.6%) wanting instead more information. Higher distress was only weakly associated with the plan to seek treatment. In the multivariable analysis, respondents who were younger; lesbian, gay, bisexual, transgender, or queer; or Native American or who had lower income reported the greatest symptom-related distress. Younger and higher-income respondents were less likely to plan to seek treatment next. Across race-ethnicity, African Americans were most likely to plan to seek treatment.

CONCLUSIONS

Most respondents reported that psychosis-like experiences caused significant distress, but they did not plan to seek treatment next. Addressing this treatment gap requires careful consideration regarding what services individuals want, how services should be presented, and what barriers may limit help seeking. These steps are critical to improve access to early intervention for individuals with psychosis spectrum disorders.

Empowerment for behaviour change through social connections: a qualitative exploration of women's preferences in preconception health promotion in the state of Victoria, Australia

BACKGROUND

Health behaviours in the preconception period have the potential to impact on fertility and pregnancy outcomes, and the health of all women regardless of pregnancy intention. Public awareness of this is low and interventions that promote behaviour change have not been integrated into real-world settings. Aims were to explore women's understandings of health and health behaviours and what supports are important to promote behaviour change in the preconception period.

METHODS

This qualitative study is the first phase of a broader co-design project set in the state of Victoria, Australia. Over 3 months, a series of in-depth interviews were conducted with female participants who were intending to become pregnant in the next 2 years (n = 6) and participants who were not intending to become pregnant in the next 2 years (n = 6). Community advisors (n = 8) aged 18-45 years provided feedback throughout the process. Coding of transcripts from interviews and meetings was undertaken by two researchers before a deductive process identified themes mapped to the COM-B framework.

RESULTS

Nine themes and eight sub-themes were identified. Participants had a holistic view of health with nutrition, physical activity and sleep being most valued. Social connections were considered as being important for overall health and wellbeing and for promoting health behaviours. The only difference between groups was that pregnancy was an additional motivator for women who were planning to become pregnant in the next 2 years. A range of health information is available from health professionals and other sources. Unlimited access to information was empowering but sometimes overwhelming. Being listened to and shared experiences were aspects of social connections that validated participants and guided them in their decision-making.

CONCLUSIONS

Women valued their health and had a holistic view that includes physical, mental and social dimensions. Women viewed social connections with others as an opportunity to be listened to and to gain support that empowers behaviour change. Future interventions to promote behaviour change in preconception women should consider the importance all women placed on social connections and leverage off existing resources to connect women.

Effects of multidimensional life management on healthy behavior in polycystic ovary syndrome patients: A randomized controlled trial

Objective

To confirm the effects of a transtheoretical model (TTM) based on multidimensional life management on healthy behavior in patients with polycystic ovary syndrome (PCOS).

Methods

In total, eighty eligible patients were recruited from March 2021 to June 2021 and randomly assigned to either the intervention (n = 40) or control (n = 40) groups. Outcome measures include health-promoting behavior, self-efficacy, anthropometrics, and the number of unplanned outpatient admissions. Data were collected at baseline, 3, and 6 months after the intervention. The chi-square test, rank-sum test, t-test, and repeated measurement analysis of variance (ANOVA) were used to analyze the data.

Results

In total, sixty-six participants completed the study: 35 participants in the intervention group and 31 participants in the control group. After 6 months of intervention, the healthy behavior level of patients with PCOS increased from moderate [health-promoting lifestyle profile (HPLP)-II score of 105.37 ± 12.57] to good (156.94 ± 19.36) in the intervention group; and there was no change observed in the control group. In addition, the total self-efficacy score (p < 0.001), PCOS-related unplanned outpatient admissions (p = 0.008), waist circumference (WC) (p = 0.016), and body mass index (BMI) (p = 0.011) were found to have a significant difference in the intervention group at 6 months. Meanwhile, repeated measures analysis of variance showed a significantly greater improvement in health-promoting behavior and self-efficacy over time in the intervention group than in the control group (p < 0.001).

Conclusion

The transtheoretical model based on multidimensional life management positively affected healthy behavior, self-efficacy, the number of unplanned outpatient admissions, and anthropometrics in patients with PCOS.

Clinical Trial Registration

www.chictr.org.cn, ChiCTR2000034572.

Utilizing Internet Search Volume to Monitor Stages of Change in Vaccine Hesitancy During the COVID-19 Outbreaks

Real-time vaccine hesitancy surveillance is needed to better understand changes in vaccination behaviors. We aim to understand the association between coronavirus disease 2019 (COVID-19) outbreaks and population vaccine hesitancy and to monitor the dynamic changes in vaccination behaviors. We used the autoregressive integrated moving average model to examine the association between daily internet search volume for vaccines and two waves of COVID-19 local outbreaks in Taiwan from 19 March to 25 May, 2021. During the small-scale outbreak, the search volume increased significantly for 7 out of 22 days with an average increase of 17.3% ± 10.7% from the expected search volume. During the large-scale outbreak, the search volume increased significantly for 14 out of 14 days, with an average increase of 58.4% ± 14.7%. There was a high correlation between the search volume and the number of domestic cases (r = 0.71, P < 0.001). Google Trends serves as a timely indicator to monitor the extent of population vaccine willingness.

Stage-of-change Assessment Predicts Short-term Treatment Engagement for Opioid Use Disorder Patients Initiated on Buprenorphine

Introduction

The emergency department (ED) is an effective setting for initiating medication for opioid use disorder (MOUD); however, predicting who will remain in treatment remains a central challenge. We hypothesize that baseline stage-of-change (SOC) assessment is associated with short-term treatment retention outcomes.

Methods

This is a longitudinal cohort study of all patients enrolled in an ED MOUD program over 12 months. Eligible and willing patients were treated with buprenorphine at baseline and had addiction medicine specialist follow-up arranged. Treatment retention at 30 and 90 days was determined by review of the Prescription Drug Monitoring Program. We used uni- and multivariate logistic regression to evaluate associations between patient variables and treatment retention at 30 and 90 days.

Results

From June 2018–May 2019, 279 patients were enrolled in the ED MOUD program. Of those patients 151 (54.1%) and 120 (43.0%) remained engaged in MOUD treatment at 30 and 90 days, respectively. The odds of treatment adherence at 30 days were significantly higher for those with advanced SOC (preparation/action/maintenance) compared to those presenting with limited SOC (pre-contemplation/contemplation) (60.0% vs 40.8%; odds ratio 2.18; 95% confidence interval 1.15 to 4.1; P <0.05). At 30 days, multivariate logistic regression determined that advanced SOC, age >40, having medical insurance, and being employed were significant predictors of continued treatment adherence. At 90 days, advanced SOC, non-White race, age > 40, and having insurance were all significantly associated with higher likelihood of treatment engagement.

Conclusion

Greater stage-of-change was significantly associated with MOUD treatment retention at 30 and 90 days post index ED visit.

The Healthy Eater’s Idea and Related Behavior of a Healthy Diet—A Case Study with Kombucha Drinkers

Consumers’ demand for ‘healthy’ food is growing at a fast pace. Beverages are one of the fastest-growing segments in the healthy food market. Kombucha is a product with a rapid market growth and is considered a ‘healthy beverage’. Kombucha drinkers (n = 296) in the contiguous United States (U.S.) were targeted to investigate differences in the various consumer segments regarding the healthy eater’s behavior, namely—(1) healthy diet stage-of-change attitudes, (2) healthy eating criteria, and (3) label information usage. An online survey questionnaire was used as a data collection tool. The data were analyzed via chi-square tests and multiple correspondence analysis (MCA). The majority of kombucha consumers were health-conscious and kombucha fitted into their view of a healthy diet. The female, older, western U.S. residents, and higher-educated consumers were more likely to take action and maintain a healthier diet. Healthy eaters’ idea of a healthy diet was very similar to that of the general population. Kombucha consumers focused mainly on sugar/calories and natural/organic ingredients. Additional investigations to expand the understanding of the healthy eater’s behavior with actual kombucha samples are needed in the future.

"It's messing with my physical health. It's messing with my sex life": Women's perspectives about, and impact of, pelvic health issues whilst awaiting specialist care

Introduction and hypothesis

Pelvic health conditions are a common health complaint among women worldwide, and conservative management is recognised as first-line treatment. There is often a time lag between referral from general practitioners to specialist consultation and conservative therapy. Therefore, the aim of this research was to explore perspectives from women with pelvic health conditions while they wait for specialist input, specifically about their understanding of their condition and its impact.

Methods

This research was underpinned by a qualitative descriptive methodology. Individual semi-structured interviews were conducted with women with pelvic health conditions who were waiting for specialist gynaecology consultation.

Results

A total of 11 women shared their perspectives about, and their understanding of, their condition and its impact. Thematic analysis of the interview data identified a variety of experiences and perspectives of women waiting to see the gynaecologist. These perspectives were categorised into four different themes: drivers to seek help, understanding the condition, experience/feeling being on the waiting list and expectations from the gynaecology team.

Conclusion

This study identified the main drivers for seeking help were worsening and/or persistent symptoms. Participants were able to articulate their symptoms, identify possible causes and describe various treatment options, and amenable to alternate treatment options. This research sheds light on the devastating impact of pelvic health conditions on women, which may be amplified while waiting to seek specialist input. There appears to be a need for health services to better support these women during this time of waiting.

What are they doing? A national survey of help-seeking and relationship-repair behavior of individuals who are thinking about divorce

Guided by the Stages of Change (SOC) model, we explored relationship-repair behaviors among those thinking about divorce, employing a recent national longitudinal survey of married individuals (N = 745). Person-centered analyses explored whether there were distinct typologies of relationship-repair behaviors. We found four distinct classes: Intense Seekers (6%), who engaged at high levels of all kinds of repair behaviors, including professional services; Moderate-fading Seekers (14%), who engaged in moderate levels of various repair behaviors, including professional services, but did not sustain that behavior over a year; and Minimal-private Seekers (42%) and Private-sustained Seekers (38%), who eschewed professional services and engaged in low-to-moderate personal and private repair behaviors. We discuss possible applications of the SOC model to the divorce decision-making process and conclude with implications for practice, including the need to allocate greater attention to personal and self-help interventions that match the way most people try to repair their relationships.

Digital interventions to enhance readiness for psychological therapy: A scoping review (Preprint)

Background

Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy.

Objective

This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature.

Methods

A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment.

Results

A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures.

Conclusions

Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.

Cognitive and emotional factors associated with the desire to cease non-suicidal self-injury

Background

Due to cognitive and emotional differences between individuals who have and have not stopped self‐injuring, we explored these in the context of desire to stop.

Method

Australian university students (n = 374) completed cognitive and emotional measures. Comparisons were made between those who had self‐injured in the past 12 months and those who had not, and between individuals who reported wanting to stop self‐injuring and those who did not.

Results

Approximately 20% of participants did not want to stop self‐injuring. Cognitive emotional factors (psychological distress, self‐efficacy to resist, difficulties regulating emotion, interpersonal functions, and outcome expectancies) differentiated individuals who had and had not stopped, but could not explain differences in desire to stop.

Conclusion

Factors associated with desire to stop are not the same as factors underlying behavioural cessation. Motivational approaches to changes in self‐injurious behaviour would be beneficial for clinicians and their clients.

Intervention for promoting intake of fruits and vegetables in Brazilians: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nutritional intervention to promote fruit and vegetable (FV) intake.

DESIGN

A randomised controlled community trial was conducted to evaluate the effectiveness of a 7-month nutritional intervention and to promote FV intake, separately and together. All participants attended physical exercise sessions. The intervention was based on the transtheoretical model and Paulo Freire's pedagogy. The interventions included group educational sessions, motivational cards and informational materials. The primary outcome was a change in FV intake (g/d), and secondary outcomes included stages of change, self-efficacy, decisional balance and knowledge on FV. All data were collected face-to-face; and FV intake was assessed using a validated brief questionnaire.

SETTING

Health promotion services of Brazilian Primary Health Care.

PARTICIPANTS

3414 users of Brazilian Primary Health Care (1931 in the control group and 1483 in the intervention group (IG)).

RESULTS

At baseline, the average daily FV intake was 370·4 g/d (95 % CI 364·2, 376·6). The increase in FV intake (23·4 g/d; 95 % CI 6·7, 40·0) and fruit intake (+17·3 g/d; 95 % CI 5·1, 29·4; P = 0·01) was greater in the IG among participants in the lowest baseline intake. Participants in the IG also showed progression in the stages of change (P < 0·001), increased self-efficacy (P < 0·001) and improved knowledge of FV crops (P < 0·001).

CONCLUSIONS

The nutritional intervention was effective in increasing FV intake and fruits intake among individuals with a lower intake at baseline and in maintaining FV intake among those who reported consuming FV as recommended (400 g/d).

Prenatal Provider Breastfeeding Toolkit: Results of a Pilot to Increase Women's Prenatal Breastfeeding Support, Intentions, and Outcomes

BACKGROUND

Breastfeeding rates for United States women with lower incomes fall below the government's Healthy People 2020 Goals. Breastfeeding recommendations combined with support from providers and peer counselors help women decide to begin and sustain breastfeeding, but peer counselor uptake is low.

RESEARCH AIM

To evaluate changes in referrals to Women, Infants, and Children's Supplemental Nutrition Program peer counselors, reported prenatal provider education and support, and breastfeeding outcomes (intention, initiation, 1-month duration of any and exclusive breastfeeding) after a prenatal breastfeeding promotion intervention.

METHOD

In this pre-post intervention study (2015-2016; upstate New York), providers implemented a Toolkit to discuss infant feeding recommendations and initiate peer counselor referral. We surveyed women pre- and post-implementation (after delivery; 1 month postpartum) about prenatal breastfeeding intentions, provider support, and breastfeeding outcomes. Analyses controlled for secular trends.

RESULTS

Pre-intervention (n = 71) and post-intervention (n = 70) participants were 49% Black, 61% publicly insured, and 16% uninsured. More post-intervention participants had > 1 Toolkit use (76%), peer counselor program referrals (60.0% post vs. 36.6% pre, p < .01), reported any breastfeeding intention (89% vs. 72%, p = .013), and intended to breastfeed for > 1 year (31% vs. 14%, p = .014). Post-intervention breastfeeding initiation and exclusivity were higher, but not significantly different. Post-intervention participants reported better prenatal breastfeeding support.

CONCLUSIONS

Implementing a prenatal Breastfeeding Toolkit, including facilitating peer counselor referral, was associated with increases in provider counseling, participants' breastfeeding intentions, and uptake of peer counselors. Replicating this approach may reinforce efforts to support breastfeeding in similar practices serving women with lower incomes.

“It’s About Going From Good to Great”: Expert Approaches to Conducting a First Sport Psychology Session

The aim of this study was to investigate expert practitioners’ approaches to conducting a first sport psychology session with individual clients as there is sparse empirical literature on this topic. Nine expert Certified Mental Performance Consultants completed a semistructured interview where they discussed experiences conducting a first meeting with an athlete. Primary objectives included establishing the relationship, setting guidelines and expectations, understanding the client’s background, identifying presenting concerns, and formulating the treatment plan and building skills. Building rapport was an aspect used to establish the relationship while discussing confidentiality was utilized to set guidelines. Important strategies employed to increase the perceived benefits to services included conveying the consulting approach and philosophy. Lessons learned centered around doing too much and not appreciating individual differences of clients. Findings show expert consultants aim to achieve similar broad objectives in the first session and provide a basis for best practices in this area.

Microdosing psychedelics: Subjective benefits and challenges, substance testing behavior, and the relevance of intention

BACKGROUND

Microdosing psychedelics is the practice of taking small, sub-hallucinogenic doses of lysergic acid diethylamide or psilocybin-containing mushrooms. Despite its surging popularity, little is known about the specific intentions to start microdosing and the effects of this practice.

AIMS

First, we aimed to replicate previous findings regarding the subjective benefits and challenges reported for microdosing. Second, we assessed whether people who microdose test their substances before consumption. Third, we examined whether having an approach-intention to microdosing was predictive of more reported benefits.

METHODS

The Global Drug Survey runs the world's largest online drug survey. Participants who reported last year use of lysergic acid diethylamide or psilocybin in the Global Drug Survey 2019 were offered the opportunity to answer a sub-section on microdosing.

RESULTS

Data from 6753 people who reported microdosing at least once in the last 12 months were used for analyses. Our results suggest a partial replication of previously reported benefits and challenges among the present sample often reporting enhanced mood, creativity, focus and sociability. Counter to our prediction, the most common challenge participants associated with microdosing was 'None'. As predicted, most participants reported not testing their substances. Counter to our hypothesis, approach-intention - microdosing to approach a desired goal - predicted less rather than more benefits. We discuss alternate frameworks that may better capture the reasons people microdose.

CONCLUSION

Our results suggest the perceived benefits associated with microdosing greatly outweigh the challenges. Microdosing may have utility for a variety of uses while having minimal side effects. Double-blind, placebo-controlled experiments are required to substantiate these reports.