Comparing usage of a web and app stress management intervention: An observational study

Internet-based enrollment of a myositis patient cohort-a national experience

INTRODUCTION

Recruitment for idiopathic inflammatory myopathies (IIM) research is a challenge due to the rarity of the disease and the scarcity of specialized myositis centers. Online recruitment may be a feasible alternative to reach rare disease patients. We evaluated various online recruitment methods in a large longitudinal IIM cohort.

METHODS

The "Myositis Patient Centered Tele-Research" (My Pacer) is a prospective 6-month observational study of IIM, recruited online and through traditional clinic visits. We utilized diverse recruitment methods, such as physician referrals, social media, websites, direct emails, and partnerships with patient-support organizations. Participants self-enrolled and completed pre-screening, e-consenting, and release of medical information via the study-specific app or website. We compared the effectiveness of various recruitment and enrollment methods and the characteristics of the population recruited.

RESULTS

A total of 841 participants completed the pre-screening; 408 completed e-consent and registration. From those, 353 (86.5%) were remotely recruited. Email (201; 49.26%) and social media (77; 18.87%) were important recruitment tools. Patient-support organizations were responsible for disseminating the study to 312 (75.46%) participants. The study app was used by 232 (65.72%) individuals for enrollment, with app users being slightly younger than website users (p = 0.001). Participants were mostly female 317 (77.76%), mean age of 54.84 years, White 328 (80.42%), Black 49 (12%), Asian 13 (3.26%), and non-Hispanic 378 (92.65%). Our study reached all U.S. regions and 45 (90%) U.S. states.

CONCLUSIONS

Social media and partnerships with patient-support organizations lead to a high rate of recruitment, with a wide reach, and a reasonably diverse population.

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement

INTRODUCTION

Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain.

METHODS AND ANALYSIS

A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews.

ETHICS APPROVAL AND DISSEMINATION

Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country.

TRIAL REGISTRATION NUMBER

ISRCTN18010240.

Biofeedback and Digitalized Motivational Interviewing to Increase Daily Physical Activity: Series of Factorial N-of-1 Randomized Controlled Trials Piloting the Precious App

BACKGROUND

Insufficient physical activity is a public health concern. New technologies may improve physical activity levels and enable the identification of its predictors with high accuracy. The Precious smartphone app was developed to investigate the effect of specific modular intervention elements on physical activity and examine theory-based predictors within individuals.

OBJECTIVE

This study pilot-tested a fully automated factorial N-of-1 randomized controlled trial (RCT) with the Precious app and examined whether digitalized motivational interviewing (dMI) and heart rate variability-based biofeedback features increased objectively recorded steps. The secondary aim was to assess whether daily self-efficacy and motivation predicted within-person variability in daily steps.

METHODS

In total, 15 adults recruited from newspaper advertisements participated in a 40-day factorial N-of-1 RCT. They installed 2 study apps on their phones: one to receive intervention elements and one to collect ecological momentary assessment (EMA) data on self-efficacy, motivation, perceived barriers, pain, and illness. Steps were tracked using Xiaomi Mi Band activity bracelets. The factorial design included seven 2-day biofeedback interventions with a Firstbeat Bodyguard 2 (Firstbeat Technologies Ltd) heart rate variability sensor, seven 2-day dMI interventions, a wash-out day after each intervention, and 11 control days. EMA questions were sent twice per day. The effects of self-efficacy, motivation, and the interventions on subsequent steps were analyzed using within-person dynamic regression models and aggregated data using longitudinal multilevel modeling (level 1: daily observations; level 2: participants). The analyses were adjusted for covariates (ie, within- and between-person perceived barriers, pain or illness, time trends, and recurring events).

RESULTS

All participants completed the study, and adherence to activity bracelets and EMA measurements was high. The implementation of the factorial design was successful, with the dMI features used, on average, 5.1 (SD 1.0) times of the 7 available interventions. Biofeedback interventions were used, on average, 5.7 (SD 1.4) times out of 7, although 3 participants used this feature a day later than suggested and 1 did not use it at all. Neither within- nor between-person analyses revealed significant intervention effects on step counts. Self-efficacy predicted steps in 27% (4/15) of the participants. Motivation predicted steps in 20% (3/15) of the participants. Aggregated data showed significant group-level effects of day-level self-efficacy (B=0.462; P<.001), motivation (B=0.390; P<.001), and pain or illness (B=-1524; P<.001) on daily steps.

CONCLUSIONS

The automated factorial N-of-1 trial with the Precious app was mostly feasible and acceptable, especially the automated delivery of the dMI components, whereas self-conducted biofeedback measurements were more difficult to time correctly. The findings suggest that changes in self-efficacy and motivation may have same-day effects on physical activity, but the effects vary across individuals. This study provides recommendations based on the lessons learned on the implementation of factorial N-of-1 RCTs.

Stress Management Apps: Systematic Search and Multidimensional Assessment of Quality and Characteristics

BACKGROUND

Chronic stress poses risks for physical and mental well-being. Stress management interventions have been shown to be effective, and stress management apps (SMAs) might help to transfer strategies into everyday life.

OBJECTIVE

This review aims to provide a comprehensive overview of the quality and characteristics of SMAs to give potential users or health professionals a guideline when searching for SMAs in common app stores.

METHODS

SMAs were identified with a systematic search in the European Google Play Store and Apple App Store. SMAs were screened and checked according to the inclusion criteria. General characteristics and quality were assessed by 2 independent raters using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality (range 1 to 5) on the following four dimensions: (1) engagement, (2) functionality, (3) esthetics, and (4) information. In addition, the theory-based stress management strategies, evidence base, long-term availability, and common characteristics of the 5 top-rated SMAs were assessed and derived.

RESULTS

Of 2044 identified apps, 121 SMAs were included. Frequently implemented strategies (also in the 5 top-rated SMAs) were psychoeducation, breathing, and mindfulness, as well as the use of monitoring and reminder functions. Of the 121 SMAs, 111 (91.7%) provided a privacy policy, but only 44 (36.4%) required an active confirmation of informed consent. Data sharing with third parties was disclosed in only 14.0% (17/121) of the SMAs. The average quality of the included apps was above the cutoff score of 3.5 (mean 3.59, SD 0.50). The MARS-G dimensions yielded values above this cutoff score (functionality: mean 4.14, SD 0.47; esthetics: mean 3.76, SD 0.73) and below this score (information: mean 3.42, SD 0.46; engagement: mean 3.05, SD 0.78). Most theory-based stress management strategies were regenerative stress management strategies. The evidence base for 9.1% (11/121) of the SMAs could be identified, indicating significant group differences in several variables (eg, stress or depressive symptoms) in favor of SMAs. Moreover, 38.0% (46/121) of the SMAs were no longer available after a 2-year period.

CONCLUSIONS

The moderate information quality, scarce evidence base, constraints in data privacy and security features, and high volatility of SMAs pose challenges for users, health professionals, and researchers. However, owing to the scalability of SMAs and the few but promising results regarding their effectiveness, they have a high potential to reach and help a broad audience. For a holistic stress management approach, SMAs could benefit from a broader repertoire of strategies, such as more instrumental and mental stress management strategies. The common characteristics of SMAs with top-rated quality can be used as guidance for potential users and health professionals, but owing to the high volatility of SMAs, enhanced evaluation frameworks are needed.

Web-Based Psychosocial Interventions for Disaster-Related Distress: What Has Been Trialed in the Past, and What Can We Learn From This?

OBJECTIVES

To summarize reports describing implementation and evaluation of Web-based psychosocial interventions for disaster-related distress with suggestions for future intervention and research, and to determine whether a systematic literature review on the topic is warranted.

METHODS

Systematic searches of Embase, PsycINFO, and MEDLINE were conducted. Duplicate entries were removed. Two rounds of inclusion/exclusion were conducted (abstract and full-text review). Relevant data were systematically charted by 2 reviewers.

RESULTS

The initial search identified 112 reports. Six reports, describing and evaluating 5 interventions, were included in a data analysis. Four of the 5 interventions were asynchronous and self-guided modular programs, with interactive components. The fifth was a short-term, online supportive group intervention. Studies utilized a variety of evaluation methods, and only 1 of 14 outcome measures used across the studies was utilized in more than 1 project.

CONCLUSIONS

Several Web-based psychosocial interventions have been developed to target disaster-related distress, but few programs have been formally evaluated. A systematic review of the topic would not be recommended at this time due to heterogeneity in reported studies. Further research on factors impacting participation, generalizability, and methods of program delivery with consistent outcome measures is needed.

The Efficacy of Digital Cognitive–Behavioral Interventions in Supporting the Psychological Adjustment and Sleep Quality of Pregnant Women with Sub-Clinical Symptoms: A Systematic Review and Meta-Analysis

The present meta-analysis investigated the overall and differential efficacy of digital cognitive–behavioral therapies (CBTs) vs. third-generation CBTs deployed to pregnant women in reducing sub-clinical depression, anxiety, and stress symptoms while fostering sleep quality and quality of life. A PRISMA-guided systematic search was used, including randomized controlled trials (RCTs) evaluating the above-mentioned interventions. Data were pooled using either the mean difference (MD) or standardized MD (SMD). Sub-group analyses were carried out when appropriate. The primary outcomes were depression, anxiety, and stress symptoms, as well as sleep quality and quality of life. The interventions’ acceptability was evaluated through the odds ratio (OR) of drop-out rates. Seven RCTs were included, comprising 1873 pregnant women. The results showed the interventions’ efficacy in terms of reducing depression symptoms (SMD = −0.36, CI = 0.61, −0.11, k = 9) at the endpoint, although it was not maintained at follow-up during the postpartum period. The interventions’ efficacy in terms of reducing anxiety symptoms (SMD = 1.96, CI = −2.72, −1.21, k = 3) at the endpoint was also significant, while having no effect on sleep quality. The interventions were well accepted (OR = 1.68; 95% CI = 0.84, 3.35; k = 7). Although no sound conclusions can be drawn concerning the joint or differential efficacy of the considered interventions, this study was useful in highlighting the need to develop evidence-based digital prevention programs for pregnant women with sub-clinical symptoms.

Pilot Testing in the Wild: Feasibility, Acceptability, Usage Patterns, and Efficacy of an Integrated Web and Smartphone Platform for Bipolar II Disorder

BACKGROUND

Bipolar II disorder (BD-II) is associated with significant burden, disability, and mortality; however, there continues to be a dearth of evidence-based psychological interventions for this condition. Technology-mediated interventions incorporating self-management have untapped potential to help meet this need as an adjunct to usual clinical care.

OBJECTIVE

The objective of this pilot study is to assess the feasibility, acceptability, and clinical utility of a novel intervention for BD-II (Tailored Recovery-oriented Intervention for Bipolar II Experiences; TRIBE), in which mindfulness-based psychological content is delivered via an integrated web and smartphone platform. The focus of the study is evaluation of the dynamic use patterns emerging from ecological momentary assessment and intervention to assist the real-world application of mindfulness skills learned from web-delivered modules.

METHODS

An open trial design using pretest and posttest assessments with nested qualitative evaluation was used. Individuals (aged 18-65 years) with a diagnosis of BD-II were recruited worldwide and invited to use a prototype of the TRIBE intervention over a 3-week period. Data were collected via web-based questionnaires and phone interviews at baseline and 3-week follow-up.

RESULTS

A total of 25 participants completed baseline and follow-up assessments. Adherence rates (daily app use) were 65.6% across the 3-week study, with up to 88% (22/25) of participants using the app synergistically alongside the web-based program. Despite technical challenges with the prototype intervention (from user, hardware, and software standpoints), acceptability was adequate, and most participants rated the intervention positively in terms of concept (companion app with website: 19/25, 76%), content (19/25, 76%), and credibility and utility in supporting their management of bipolar disorder (17/25, 68%). Evaluation using behavioral archetypes identified important use pathways and a provisional model to inform platform refinement. As hypothesized, depression scores significantly decreased after the intervention (Montgomery-Asberg Depression Rating Scale baseline mean 8.60, SD 6.86, vs follow-up mean 6.16, SD 5.11; t24=2.63; P=.01; Cohen d=0.53, 95% CI 0.52-4.36).

CONCLUSIONS

Our findings suggest that TRIBE is feasible and represents an appropriate and acceptable self-management program for patients with BD-II. Preliminary efficacy results are promising and support full development of TRIBE informed by the present behavioral archetype analysis. Modifications suggested by the pilot study include increasing the duration of the intervention and increasing technical support.

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.

From Bureaucracy to Citizen-Centricity

Organisations, including public service organisations, are increasingly adopting a digital transformation strategy, and deploying digital capabilities to enhance customer experience. However, digital initiatives in public services often focus more on the technology with relatively less regard to the citizen for whom the services are designed. To address this lacuna, this study contextualises the digital transformation of public services by focusing on the citizen. This study is based on data collected in the conduct of two projects involving public services within an EU member state. Based on the analysis of the citizen-journey in availing of public services, five common pain-points are identified – information inconsistencies, intricate website navigation, bureaucratic jargon, disconnected multichannel touchpoints, and a lack of real-time online support. To alleviate the pain-points, we offer five insights based on academic insights and international benchmarking.

Understanding Engagement Strategies in Digital Interventions for Mental Health Promotion: Scoping Review

BACKGROUND

Digital interventions offer a solution to address the high demand for mental health promotion, especially when facing physical contact restrictions or lacking accessibility. Engagement with digital interventions is critical for their effectiveness; however, retaining users' engagement throughout the intervention is challenging. It remains unclear what strategies facilitate engagement with digital interventions that target mental health promotion.

OBJECTIVE

Our aim is to conduct a scoping review to investigate user engagement strategies and methods to evaluate engagement with digital interventions that target mental health promotion in adults.

METHODS

This scoping review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews. The search was conducted in 7 electronic databases from inception to April 2020. The inclusion criteria for studies were as follows: adult (aged ≥18 years) users of digital interventions for mental health promotion from the general population; any digital intervention for mental health promotion; and user engagement strategies described in the intervention design. We extracted the following data items: study characteristics, digital intervention (type and engagement strategy), evaluation of engagement strategy (method and result specifying whether the strategy was effective at facilitating engagement), and features of engagement (extent of use and subjective experience of users).

RESULTS

A total of 2766 studies were identified, of which 16 (0.58%) met the inclusion criteria. The 16 studies included randomized controlled trials (6/16, 37%), studies analyzing process data (5/16, 31%), observational studies (3/16, 19%), and qualitative studies (2/16, 13%). The digital interventions for mental health promotion were either web based (12/16, 75%) or mobile app based (4/16, 25%). The engagement strategies included personalized feedback about intervention content or users' mental health status; guidance regarding content and progress through e-coaching; social forums, and interactivity with peers; content gamification; reminders; and flexibility and ease of use. These engagement strategies were deemed effective based on qualitative user feedback or responses on questionnaires or tools (4/16, 25%), usability data (5/16, 31%), or both (7/16, 44%). Most studies identified personalized support in the form of e-coaching, peer support through a social platform, personalized feedback, or joint videoconference sessions as an engaging feature.

CONCLUSIONS

Personalized support during the intervention, access to social support, and personalized feedback seem to promote engagement with digital interventions for mental health promotion. These findings need to be interpreted with caution because the included studies were heterogeneous, had small sample sizes, and typically did not address engagement as the primary outcome. Despite the importance of user engagement for the effectiveness of digital interventions, this field has not yet received much attention. Further research is needed on the effectiveness of different strategies required to facilitate user engagement in digital interventions for mental health promotion.

Internet-Based Lifestyle Intervention to Prevent Type 2 Diabetes Through Healthy Habits: Design and 6-Month Usage Results of Randomized Controlled Trial

Background

Type 2 diabetes can be prevented through lifestyle changes, but sustainable and scalable lifestyle interventions are still lacking. Habit-based approaches offer an opportunity to induce long-term behavior changes.

Objective

The purposes of this study were to describe an internet-based lifestyle intervention for people at risk for type 2 diabetes targeted to support formation of healthy habits and explore its user engagement during the first 6 months of a randomized controlled trial (RCT).

Methods

The app provides an online store that offers more than 400 simple and contextualized habit-forming behavioral suggestions triggered by daily life activities. Users can browse, inspect, and select them; report their performances; and reflect on their own activities. Users can also get reminders, information on other users’ activities, and information on the prevention of type 2 diabetes. An unblended parallel RCT was carried out to evaluate the effectiveness of the app in comparison with routine care. User engagement is reported for the first 6 months of the trial based on the use log data of the participants, who were 18- to 70-year-old community-dwelling adults at an increased risk of type 2 diabetes.

Results

Of 3271 participants recruited online, 2909 were eligible to participate in the RCT. Participants were randomized using a computerized randomization system to the control group (n=971), internet-based intervention (digital, n=967), and internet-based intervention with face-to-face group coaching (F2F+digital, n=971). Mean age of control group participants was 55.0 years, digital group 55.2 years, and F2F+digital 55.2 years. The majority of participants were female, 81.1% (787/971) in the control group, 78.3% (757/967) in the digital group, and 80.7% (784/971) in the F2F+digital group. Of the participants allocated to the digital and F2F+digital groups, 99.53% (1929/1938) logged in to the app at least once, 98.55% (1901/1938) selected at least one habit, and 95.13% (1835/1938) reported at least one habit performance. The app was mostly used on a weekly basis. During the first 6 months, the number of active users on a weekly level varied from 93.05% (1795/1929) on week 1 to 51.79% (999/1929) on week 26. The daily use activity was not as high. The digital and F2F+digital groups used the app on a median of 23.0 and 24.5 days and for 79.4 and 85.1 minutes total duration, respectively. A total of 1,089,555 habit performances were reported during the first 6 months. There were no significant differences in the use metrics between the groups with regard to cumulative use metrics.

Conclusions

Results demonstrate that internet-based lifestyle interventions can be delivered to large groups including community-dwelling middle-aged and older adults, many with limited experience in digital app use, without additional user training. This intermediate analysis of use behavior showed relatively good engagement, with the percentage of active weekly users remaining over 50% at 6 months. However, we do not yet know if the weekly engagement was enough to change the lifestyles of the participants.

Trial Registration

ClinicalTrials.gov NCT03156478; https://clinicaltrials.gov/ct2/show/NCT03156478

A Pilot Study of a Sleep Intervention Delivered through Group Prenatal Care to Overweight and Obese Women

OBJECTIVES

We sought to investigate the feasibility of a behavioral sleep intervention for insomnia, delivered through group prenatal care and the relationship of this intervention to improvements in insomnia symptoms and sleep quality.

PARTICIPANTS

Women receiving prenatal care and reporting a pre-pregnancy BMI of ≥25 kg/m² and sleep duration of <6.5 h per night.

METHODS

Participants were randomized to group prenatal care or group prenatal care with a behavioral sleep intervention, adapted from cognitive behavioral therapy for insomnia (CBT-I) online program Go! to Sleep®. In the second trimester (T1), late third trimester (T2) and 6-8 weeks postpartum (T3) study assessments were completed including the Insomnia Severity Index, Pittsburgh Sleep Quality Index, fasting glucose and insulin and weight and height. Data were analyzed using independent samples t-tests, chi-square tests, correlations, and two-way repeated measures ANOVA where appropriate. P < .05 was set as the level of significance.

RESULTS

From May 2014 to April 2015, 311 women were evaluated for inclusion and 53 women were randomized to participate (27 intervention; 26 control), 15% were lost to follow up. The intervention group had lower third trimester and postpartum levels of moderate to severe insomnia (T2 50.0% vs 85.0% (p = .018) and T3 13.6% vs 52.4% (p-.008)) and mean insomnia severity scores (T2 (14.7 (±6.6) vs 19.3 (± 6.0) p = .02) and T3 (9.7 (±5.4) vs 15.1(±7.2) p = .01)) when compared to the control group.

CONCLUSION

A randomized controlled trial of a behavioral sleep intervention for insomnia delivered through group prenatal care led to improvements in insomnia symptoms.

Engagement with a Web-Based Health Promotion Intervention among Vocational School Students: A Secondary User and Usage Analysis

Engagement with web-based interventions is both generally low and typically declining. Visits and revisits remain a challenge. Based on log data of a web-based cluster randomized controlled trial conducted in vocational schools, the present secondary analysis aimed to identify influencing factors on initially logging in to a health promotion platform among young adults and to examine the engagement over the course of an eight-week intervention. Data of 336 students (62.2% female, age span 18–25) from two intervention arms (web-based intervention and web-based intervention with an additional initial face-to-face contact) was included. Binary logistic regression and log-data visualization were performed. An additional initial face-to-face contact (odds ratio (OR) = 2.971, p = 0.005), female sex (OR = 2.237, p = 0.046) and the health-related skill “dealing with health information” (OR = 2.179, p = 0.030) significantly increased the likelihood of initially logging in. Other variables showed no influence. 16.6% of all potential users logged in at least once, of which 57.4% revisited the platform. Most logins were tracked at the beginning of the intervention and repeated engagement was low. To increase the engagement with web-based interventions, health-related skills should be fostered. In addition, a strategy could be to interlink comparable interventions in vocational schools more regularly with everyday teaching through multi-component interventions.

A self-report measure of engagement with digital behavior change interventions (DBCIs): development and psychometric evaluation of the "DBCI Engagement Scale"

Engagement with digital behavior change interventions (DBCIs) is a potentially important mediator of effectiveness; however, we lack validated measures of engagement. This study describes (a) the development of a self-report scale that captures the purported behavioral and experiential facets of engagement and (b) the evaluation of its validity in a real-world setting. A deductive approach to item generation was taken. The sample consisted of adults in the UK who drink excessively, downloaded the freely available Drink Less app with the intention to reduce alcohol consumption, and completed the scale immediately after their first login. Five types of validity (i.e., construct, criterion, predictive, incremental, divergent) were examined using exploratory factor analysis, correlational analyses, and through regressing the number of subsequent logins in the next 14 days onto total scale scores. Cronbach's α was calculated to assess internal reliability. A 10-item scale assessing amount and depth of use, interest, enjoyment, and attention was generated. Of 5,460 eligible users, only 203 (3.7%) users completed the scale. Seven items were retained, and the scale was found to be unifactorial and internally reliable (α = 0.77). Divergent and criterion validity were not established. Total scale scores were not significantly associated with the number of subsequent logins (B = 0.02; 95% CI = -0.01 to 0.05; p = .14). Behavioral and experiential indicators of engagement with DBCIs may constitute a single dimension, but low response rates to engagement surveys embedded in DBCIs may make their use impracticable in real-world settings.

Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and Feasibility Testing of the Precious App

Background

Most adults do not engage in sufficient physical activity to maintain good health. Smartphone apps are increasingly used to support physical activity but typically focus on tracking behaviors with no support for the complex process of behavior change. Tracking features do not engage all users, and apps could better reach their targets by engaging users in reflecting their reasons, capabilities, and opportunities to change. Motivational interviewing supports this active engagement in self-reflection and self-regulation by fostering psychological needs proposed by the self-determination theory (ie, autonomy, competence, and relatedness). However, it is unknown whether digitalized motivational interviewing in a smartphone app engages users in this process.

Objective

This study aimed to describe the theory- and evidence-based development of the Precious app and to examine how digitalized motivational interviewing using a smartphone app engages users in the behavior change process. Specifically, we aimed to determine if use of the Precious app elicits change talk in participants and how they perceive autonomy support in the app.

Methods

A multidisciplinary team built the Precious app to support engagement in the behavior change process. The Precious app targets reflective processes with motivational interviewing and spontaneous processes with gamified tools, and builds on the principles of self-determination theory and control theory by using 7 relational techniques and 12 behavior change techniques. The feasibility of the app was tested among 12 adults, who were asked to interact with the prototype and think aloud. Semistructured interviews allowed participants to extend their statements. Participants’ interactions with the app were video recorded, transcribed, and analyzed with deductive thematic analysis to identify the theoretical themes related to autonomy support and change talk.

Results

Participants valued the autonomy supportive features in the Precious app (eg, freedom to pursue personally relevant goals and receive tailored feedback). We identified the following five themes based on the theory-based theme autonomy support: valuing the chance to choose, concern about lack of autonomy, expecting controlling features, autonomous goals, and autonomy supportive feedback. The motivational interviewing features actively engaged participants in reflecting their outcome goals and reasons for activity, producing several types of change talk and very little sustain talk. The types of change talk identified were desire, need, reasons, ability, commitment, and taking steps toward change.

Conclusions

The Precious app takes a unique approach to engage users in the behavior change process by targeting both reflective and spontaneous processes. It allows motivational interviewing in a mobile form, supports psychological needs with relational techniques, and targets intrinsic motivation with gamified elements. The motivational interviewing approach shows promise, but the impact of its interactive features and tailored feedback needs to be studied over time. The Precious app is undergoing testing in a series of n-of-1 randomized controlled trials.

Determinant Factors of Public Acceptance of Stress Management Apps: Survey Study

BACKGROUND

Chronic stress is a major public health concern. Mobile health (mHealth) apps can help promote coping skills in daily life and prevent stress-related issues. However, little is known about the determinant factors of public acceptance of stress management in relation to preferences for psychological services.

OBJECTIVE

The aim of this survey study was to (1) assess determinant factors of public acceptance (behavioral use intention) of stress management apps based on an adapted and extended version of the Unified Theory of Acceptance and Use of Technology (UTAUT) model and (2) explore preferences for mHealth apps compared with other mental health services.

METHODS

Using convenience sampling, participants completed a multiscale 54-item Web-based survey. Based on significant correlations with acceptance, hierarchical stepwise regression analysis was performed within three blocks: (1) background and stress-related control variables, (2) beliefs and attitudes toward using mHealth, and (3) the core UTAUT determinants. The preference for mHealth apps in comparison with nine other mental health services (operationalized as readiness to use) was analyzed using paired t tests.

RESULTS

Of 141 participants, nearly half (69/141, 48.9%) indicated prior mHealth use. Acceptance of stress coping apps was moderate (mean 3.10, SD 1.03, range 1-5). Hierarchical stepwise regression including four of 11 variables (R²=.62; P=.01, f²=1.63) identified positive attitudes toward using mHealth for stress coping (beta=0.69, P<.001, 46% R² increase above block 1, f²=0.85), skepticism/perceived risks (beta=-0.14, P=.01, f²=0.16), and stress symptoms (beta=0.12, P=.03, f²=0.14) as significant predictors of acceptance. UTAUT determinants added no predictive contribution beyond attitudes (all P>.05, R² increase of 1%), whereas post hoc analysis showed significant R² increases of attitudes and skepticism/perceived risks beyond UTAUT determinants (all P<.001, R² increase of 13%). The readiness to use apps was equivalent to or significantly higher than most service types, but lower than information websites.

CONCLUSIONS

Attitudes may be at least as predictive for the acceptance of stress management apps as for more elaborated outcome beliefs. Efforts aimed at improving the public adoption of mHealth could put more emphasis on the pleasant aspects of app use, address misconceptions, offer stress screening tools on health websites, and increase options to try high-quality apps.

The peril of self-reported adherence in digital interventions: A brief example

Adherence is an important predictor of intervention outcomes, but not all measures of adherence are created equally. Here, we analyzed whether there was a discrepancy between self-report adherence and objective adherence in a digital mindfulness meditation randomised, controlled trial. A sample of 174 young adult undergraduate university students trialled either an app-based or email-based mindfulness meditation program (or an app-based attention control). Participants' adherence (number of sessions completed) and mental health was self-reported. Objective adherence data were provided by the owners of the digital mindfulness programs. We found evidence of inflated self-reported adherence to the app-based intervention and argue that the inflation was not explained by social desirability biases because participants were aware we would have access to object data and no remuneration was tied to adherence. We also comment on the different conclusions we would have drawn about the effectiveness of the digital interventions on mental health, had we used the self-reported adherence data rather than the objective adherence data. We use this example to suggest that it may be perilous to rely on self-reported measures of adherence when assessing the effectiveness of digital interventions.

Adherence Reporting in Randomized Controlled Trials Examining Manualized Multisession Online Interventions: Systematic Review of Practices and Proposal for Reporting Standards

Background

Adherence reflects the extent to which individuals experience or engage with the content of online interventions and poses a major challenge. Neglecting to examine and report adherence and its relation to outcomes can compromise the interpretation of research findings.

Objective

The aim of this systematic review is to analyze how adherence is accounted for in publications and to propose standards for measuring and reporting adherence to online interventions.

Methods

We performed a systematic review of randomized controlled trials on online interventions for the prevention and treatment of common mental disorders (depression, anxiety disorders, substance related disorders, and eating disorders) published between January 2006 and May 2018 and indexed in Medline and Web of Science. We included primary publications on manualized online treatments (more than 1 session and successive access to content) and examined how adherence was reported in these publications.

Results

We identified 216 publications that met our inclusion criteria. Adherence was addressed in 85% of full-text manuscripts, but only in 31% of abstracts. A median of three usage metrics were reported; the most frequently reported usage metric (61%) was intervention completion. Manuscripts published in specialized electronic health journals more frequently included information on the relation of adherence and outcomes.

Conclusions

We found substantial variety in the reporting of adherence and the usage metrics used to operationalize adherence. This limits the comparability of results and impedes the integration of findings from different studies. Based on our findings, we propose reporting standards for future publications on online interventions.

Guided Digital Cognitive Behavioral Program for Anxiety in Primary Care: Propensity-Matched Controlled Trial

BACKGROUND

Cognitive behavioral therapy (CBT) is the gold standard treatment for adult anxiety disorders but is often not readily available in a scalable manner in many clinical settings.

OBJECTIVE

This study examines the feasibility, acceptability, and effectiveness of a coach-facilitated digital cognitive behavioral program for anxious adults in primary care.

METHODS

In an open trial, patients who screened positive for anxiety (General Anxiety Disorder-7 [GAD7] score ≥5) were offered the digital cognitive behavioral program (active group, n=593). Primary outcomes included anxiety, quality of life (QoL), and ambulatory medical use over 6 months. Intent-to-treat (ITT) and modified intent-to-treat (mITT) analyses were completed. Subsequently, we compared the outcomes of participants with those of a matched control group receiving primary care as usual (CAU; n=316).

RESULTS

More than half of the patients downloaded the cognitive behavioral mobile app program and about 60% of these were considered engaged, which was defined as completion of ≥3 techniques. The active group demonstrated medium size effects on reducing anxiety symptoms (effect size d=0.44; P<.001) and improving mental health QoL (d=0.49; P<.001) and showed significantly improved physical health QoL (d=0.39; P=.002) and a decreased likelihood of high utilization of outpatient medical care (odds ratio=0.49; P<.001). The active group did not significantly outperform the CAU group in anxiety reduction or QoL improvement (d=0.20; P=.07). However, intent-to-treat analysis showed that the active group had a significantly lower likelihood of high utilization of outpatient medical care than the enhanced CAU group (P<.0001; odds ratio=0.09).

CONCLUSIONS

A coach-facilitated digital cognitive behavioral program prescribed in primary care is feasible and acceptable. Primary care patients prescribed a digital cognitive behavioral program for anxiety experienced significant improvements in anxiety symptoms, QoL, and reduced medical utilization. This effect was observed even among patients with chronic medical conditions and behavioral health comorbidities. Although the primary outcomes in the active group did not improve significantly more than the CAU group, health care utilization declined, and some secondary outcomes improved in participants who engaged in the program compared to the CAU group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03186872; https://clinicaltrials.gov/ct2/show/NCT03186872.

A Framework for Analyzing and Measuring Usage and Engagement Data (AMUsED) in Digital Interventions: Viewpoint

Trials of digital interventions can yield extensive, in-depth usage data, yet usage analyses tend to focus on broad descriptive summaries of how an intervention has been used by the whole sample. This paper proposes a novel framework to guide systematic, fine-grained usage analyses that better enables understanding of how an intervention works, when, and for whom. The framework comprises three stages to assist in the following: (1) familiarization with the intervention and its relationship to the captured data, (2) identification of meaningful measures of usage and specifying research questions to guide systematic analyses of usage data, and (3) preparation of datasheets and consideration of available analytical methods with which to examine the data. The framework can be applied to inform data capture during the development of a digital intervention and/or in the analysis of data after the completion of an evaluation trial. We will demonstrate how the framework shaped preparation and aided efficient data capture for a digital intervention to lower transmission of cold and flu viruses in the home, as well as how it informed a systematic, in-depth analysis of usage data collected from a separate digital intervention designed to promote self-management of colds and flu. The Analyzing and Measuring Usage and Engagement Data (AMUsED) framework guides systematic and efficient in-depth usage analyses that will support standardized reporting with transparent and replicable findings. These detailed findings may also enable examination of what constitutes effective engagement with particular interventions.

Exploring Users' Experiences of the Uptake and Adoption of Physical Activity Apps: Longitudinal Qualitative Study

Background

Although smartphone apps might support physical activity (PA), engagement with them tends to be low.

Objective

This study aimed to examine potential users’ needs and preferences regarding their engagement with PA apps during a first exposure to a never-used PA app and after 2 weeks’ usage.

Methods

A longitudinal, one-arm qualitative study was conducted with potential PA app users. At baseline, participants (N=20) were asked to explore 1 of 3 randomly allocated PA apps while thinking aloud. Semistructured interview techniques allowed participants to elaborate on their statements. After 2 weeks, follow-up interviews explored participants’ (n=17) lived experiences of real-world app use. Verbal reports from both time points were analyzed using inductive thematic analysis.

Results

Features that promote a fair and simple user experience, support users’ self-regulation skills, and address users’ exercise motives were considered important for engagement both during a first exposure and after a 2-week use of PA apps. Features that support users’ need for relatedness as well as those that facilitate users to implement their intentions were expected to be important for engagement mainly during a first exposure to PA apps. Proactive and tailored features that integrate behavioral, psychological, and contextual information to provide adaptive exercise plans and just-in-time support were considered relevant to sustain engagement over time.

Conclusions

App features that address users’ exercise motives, promote self-regulation, and fulfill users’ need for relatedness might promote engagement with PA apps. Tailored and proactive features were expected to promote sustained engagement.

A Library of Analytic Indicators to Evaluate Effective Engagement with Consumer mHealth Apps for Chronic Conditions: Scoping Review

Background

There is mixed evidence to support current ambitions for mobile health (mHealth) apps to improve chronic health and well-being. One proposed explanation for this variable effect is that users do not engage with apps as intended. The application of analytics, defined as the use of data to generate new insights, is an emerging approach to study and interpret engagement with mHealth interventions.

Objective

This study aimed to consolidate how analytic indicators of engagement have previously been applied across clinical and technological contexts, to inform how they might be optimally applied in future evaluations.

Methods

We conducted a scoping review to catalog the range of analytic indicators being used in evaluations of consumer mHealth apps for chronic conditions. We categorized studies according to app structure and application of engagement data and calculated descriptive data for each category. Chi-square and Fisher exact tests of independence were applied to calculate differences between coded variables.

Results

A total of 41 studies met our inclusion criteria. The average mHealth evaluation included for review was a two-group pretest-posttest randomized controlled trial of a hybrid-structured app for mental health self-management, had 103 participants, lasted 5 months, did not provide access to health care provider services, measured 3 analytic indicators of engagement, segmented users based on engagement data, applied engagement data for descriptive analyses, and did not report on attrition. Across the reviewed studies, engagement was measured using the following 7 analytic indicators: the number of measures recorded (76%, 31/41), the frequency of interactions logged (73%, 30/41), the number of features accessed (49%, 20/41), the number of log-ins or sessions logged (46%, 19/41), the number of modules or lessons started or completed (29%, 12/41), time spent engaging with the app (27%, 11/41), and the number or content of pages accessed (17%, 7/41). Engagement with unstructured apps was mostly measured by the number of features accessed (8/10, P=.04), and engagement with hybrid apps was mostly measured by the number of measures recorded (21/24, P=.03). A total of 24 studies presented, described, or summarized the data generated from applying analytic indicators to measure engagement. The remaining 17 studies used or planned to use these data to infer a relationship between engagement patterns and intended outcomes.

Conclusions

Although researchers measured on average 3 indicators in a single study, the majority reported findings descriptively and did not further investigate how engagement with an app contributed to its impact on health and well-being. Researchers are gaining nuanced insights into engagement but are not yet characterizing effective engagement for improved outcomes. Raising the standard of mHealth app efficacy through measuring analytic indicators of engagement may enable greater confidence in the causal impact of apps on improved chronic health and well-being.

What Would Digital Early Intervention for Bipolar Disorder Look Like? Theoretical and Translational Considerations for Future Therapies

There are growing calls for the development of early intervention/preventive interventions for young people identified to be at risk of bipolar disorder (BD), and digital delivery appears to be a strong candidate delivery method. To date, no such interventions exist, and the aim of this perspective paper is to advance the literature by reviewing theoretical issues related to early intervention in BD and introducing a framework for design of feasible, acceptable, and effective online psychosocial interventions for this population. It is concluded that, by adopting an appropriate transdiagnostic and humanistic framework, and recognizing emerging tenets of digital psychotherapy development, testable online interventions for young people at risk of BD are within reach.

Predictors of Engagement, Response to Follow Up, and Extent of Alcohol Reduction in Users of a Smartphone App (Drink Less): Secondary Analysis of a Factorial Randomized Controlled Trial

BACKGROUND

Digital interventions for alcohol can help achieve reductions in hazardous and harmful alcohol consumption. The Drink Less app was developed using evidence and theory, and a factorial randomized controlled trial (RCT) suggested that 4 of its intervention modules may assist with drinking reduction. However, low engagement is an important barrier to effectiveness, and low response to follow up is a challenge for intervention evaluation. Research is needed to understand what factors influence users' level of engagement, response to follow up, and extent of alcohol reduction.

OBJECTIVE

This study aimed to investigate associations between user characteristics, engagement, response to follow up, and extent of alcohol reduction in an app-based intervention, Drink Less.

METHODS

This study involved a secondary data analysis of a factorial RCT of the Drink Less app. Participants (N=672) were aged 18 years or older, lived in the United Kingdom, and had an Alcohol Use Disorders Identification Test score >7 (indicative of excessive drinking). Sociodemographic and drinking characteristics were assessed at baseline. Engagement was assessed in the first month of use (number of sessions, time on app, number of days used, and percentage of available screens viewed). Response to follow up and extent of alcohol reduction (change in past week consumption) were measured after 1 month. Associations were assessed using unadjusted and adjusted linear or logistic regression models.

RESULTS

Age (all unstandardized regression coefficients [B] >.02, all P<.001) and post-16 educational qualifications (all B>.18, all P<.03) were positively associated with all engagement outcomes. Age (odds ratio [OR] 1.04, P<.001), educational qualifications (OR 2.11, P<.001), and female gender (OR 1.58, P=.02) were positively associated with response to follow up. Engagement outcomes predicted response to follow up (all OR>1.02, all P<.001) but not the extent of alcohol reduction (all -.14.07). Baseline drinking characteristics were the only variables associated with the extent of alcohol reduction among those followed up (all B>.49, all P<.001).

CONCLUSIONS

Users of the alcohol reduction app, Drink Less, who were older and had post-16 educational qualifications engaged more and were more likely to respond at 1-month follow up. Higher baseline alcohol consumption predicted a greater extent of alcohol reduction among those followed up but did not predict engagement or response to follow up. Engagement was associated with response to follow up but was not associated with the extent of alcohol reduction, which suggests that the Drink Less app does not have a dose-response effect.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number ISRCTN40104069; http://www.isrctn.com/ISRCTN40104069 (Archived by WebCite at http://www.webcitation.org/746HqygIV).