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Terhorst Y, Kaiser T, Brakemeier EL, Moshe I, Philippi P, Cuijpers P, Baumeister H, Sander LB. Heterogeneity of Treatment Effects in Internet- and Mobile-Based Interventions for Depression: A Systematic Review and Meta-Analysis. JAMA Netw Open 2024; 7:e2423241. [PMID: 39023887 PMCID: PMC11258589 DOI: 10.1001/jamanetworkopen.2024.23241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024] Open
Abstract
Importance While the effects of internet- and mobile-based interventions (IMIs) for depression have been extensively studied, no systematic evidence is available regarding the heterogeneity of treatment effects (HTEs), indicating to what extent patient-by-treatment interactions exist and personalized treatment models might be necessary. Objective To investigate the HTEs in IMIs for depression as well as their efficacy and effectiveness. Data Sources A systematic search in Embase, MEDLINE, Central, and PsycINFO for randomized clinical trials and supplementary reference searches was conducted on October 13, 2019, and updated March 25, 2022. The search string included various terms related to digital psychotherapy, depression, and randomized clinical trials. Study Selection Titles, abstracts, and full texts were reviewed by 2 independent researchers. Studies of all populations with at least 1 intervention group receiving an IMI for depression and at least 1 control group were eligible, if they assessed depression severity as a primary outcome and followed a randomized clinical trial (RCT) design. Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines. Risk of bias was evaluated using the Cochrane Risk of Bias Tool. HTE was investigated using logarithmic variance ratios (lnVR) and effect sizes using Hedges g. Three-level bayesian meta-regressions were conducted. Main Outcomes and Measures Heterogeneity of treatment effects was the primary outcome of this study; magnitudes of treatment effect sizes were the secondary outcome. Depression severity was measured by different self-report and clinician-rated scales in the included RCTs. Results The systematic review of 102 trials included 19 758 participants (mean [SD] age, 39.9 [10.58] years) with moderate depression severity (mean [SD] in Patient Health Questionnaire-9 score, 12.81 [2.93]). No evidence for HTE in IMIs was found (lnVR = -0.02; 95% credible interval [CrI], -0.07 to 0.03). However, HTE was higher in more severe depression levels (β̂ = 0.04; 95% CrI, 0.01 to 0.07). The effect size of IMI was medium (g = -0.56; 95% CrI, -0.46 to -0.66). An interaction effect between guidance and baseline severity was found (β̂ = -0.24, 95% CrI, -0.03 to -0.46). Conclusions and Relevance In this systematic review and meta-analysis of RCTs, no evidence for increased patient-by-treatment interaction in IMIs among patients with subthreshold to mild depression was found. Guidance did not increase effect sizes in this subgroup. However, the association of baseline severity with HTE and its interaction with guidance indicates a more sensitive, guided, digital precision approach would benefit individuals with more severe symptoms. Future research in this population is needed to explore personalization strategies and fully exploit the potential of IMI.
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Affiliation(s)
- Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
- Department of Psychology, Ludwig Maximilian University of Munich, Munich, Germany
| | - Tim Kaiser
- Methods and Evaluation/Quality Assurance, Freie Universität Berlin, Berlin, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, University Greifswald, Greifswald, Germany
| | - Isaac Moshe
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Paula Philippi
- Department of Clinical Child and Adolescent Psychology and Psychotherapy, Bergische Universität Wuppertal, Wuppertal, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro-, and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University Ulm, Ulm, Germany
| | - Lasse Bosse Sander
- Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Thielecke J, Kuper P, Lehr D, Schuurmans L, Harrer M, Ebert DD, Cuijpers P, Behrendt D, Brückner H, Horvath H, Riper H, Buntrock C. Who benefits from indirect prevention and treatment of depression using an online intervention for insomnia? Results from an individual-participant data meta-analysis. Psychol Med 2024:1-14. [PMID: 38469832 DOI: 10.1017/s0033291724000527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Major depressive disorder (MDD) is highly prevalent and burdensome for individuals and society. While there are psychological interventions able to prevent and treat MDD, uptake remains low. To overcome structural and attitudinal barriers, an indirect approach of using online insomnia interventions seems promising because insomnia is less stigmatized, predicts MDD onset, is often comorbid and can outlast MDD treatment. This individual-participant-data meta-analysis evaluated the potential of the online insomnia intervention GET.ON Recovery as an indirect treatment to reduce depressive symptom severity (DSS) and potential MDD onset across a range of participant characteristics. METHODS Efficacy on depressive symptom outcomes was evaluated using multilevel regression models controlling for baseline severity. To identify potential effect moderators, clinical, sociodemographic, and work-related variables were investigated using univariable moderation and random-forest methodology before developing a multivariable decision tree. RESULTS IPD were obtained from four of seven eligible studies (N = 561); concentrating on workers with high work-stress. DSS was significantly lower in the intervention group both at post-assessment (d = -0.71 [95% CI-0.92 to -0.51]) and at follow-up (d = -0.84 [95% CI -1.11 to -0.57]). In the subsample (n = 121) without potential MDD at baseline, there were no significant group differences in onset of potential MDD. Moderation analyses revealed that effects on DSS differed significantly across baseline severity groups with effect sizes between d = -0.48 and -0.87 (post) and d = - 0.66 to -0.99 (follow-up), while no other sociodemographic, clinical, or work-related characteristics were significant moderators. CONCLUSIONS An online insomnia intervention is a promising approach to effectively reduce DSS in a preventive and treatment setting.
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Affiliation(s)
- Janika Thielecke
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
- Unit Healthy Living & Work, TNO (The Netherlands Organization for Applied Scientific Research), Leiden, Netherlands
| | - Paula Kuper
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Dirk Lehr
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Lea Schuurmans
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Mathias Harrer
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
- GET.ON Institute for Online Health Trainings GmbH, Berlin, Germany
| | - David D Ebert
- Department of Sports and Health Sciences, Technical University of Munich, Munich, Germany
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, Netherlands
- Amsterdam Public Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Dörte Behrendt
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Hanna Brückner
- Department of Health Psychology and Applied Biological Psychology, Institute for Sustainability, Education & Psychology, Leuphana University Luneburg, Luneburg, Germany
| | - Hanne Horvath
- GET.ON Institute for Online Health Trainings GmbH, Berlin, Germany
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, VU University, Amsterdam, Netherlands
- Amsterdam Public Health, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Department of Psychiatry, VU University Medical Center, Amsterdam, Netherlands
| | - Claudia Buntrock
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Beck C, Peynenburg V, Patterson T, Titov N, Dear B, Hadjistavropoulos H. Acceptability and effectiveness study of therapist-assisted internet-delivered cognitive behaviour therapy for agriculture producers. Internet Interv 2024; 35:100709. [PMID: 38298471 PMCID: PMC10828050 DOI: 10.1016/j.invent.2024.100709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 02/02/2024] Open
Abstract
Agriculture producers are less likely to seek or to receive mental health services compared to the general population. Additional research is needed to identify effective and accessible mental health interventions for this underserved population. This study used a mixed-methods approach and open trial design to examine the acceptability and effectiveness of therapist-assisted internet-delivered cognitive behaviour therapy (ICBT) supplemented with an additional agricultural resource for clients from agricultural backgrounds receiving ICBT in routine care. Clients (n = 34) participated in an online, five-lesson course that provided psychoeducation and strategies for dealing with symptoms of anxiety and depression, with weekly therapist assistance. Clients also received a tailored resource (developed with input from those with an agricultural background) providing culturally specific information and case stories pertinent to agricultural communities. Intent-to-treat analyses showed that the ICBT program was effective in reducing anxiety and depression symptoms among the agricultural population. Large within-group pre-to-post-treatment Cohen's effect sizes of d = 1.14, 95 % CI [0.41, 1.86] and d = 1.15, 95 % CI [0.42, 1.87] were found for depression and anxiety, respectively and comparable to the same program offered to the general population. Clients also experienced reductions in perceived stress and significant improvements in resiliency from pre- to post-treatment. Semi-structured interviews conducted at post-treatment with the agricultural clients (n = 31) on their experiences with ICBT identified four main themes: perceived strengths of ICBT and the tailored resource, suggestions to improve service delivery for agriculture producers, clients experienced internal and external challenges to participating in ICBT, and the positive impact of the course reached beyond the client. Very high satisfaction rates were found. These results provide support for the acceptability and effectiveness of ICBT with a tailored resource offered in routine care among agriculture producers.
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Affiliation(s)
- C.D. Beck
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - V. Peynenburg
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - T. Patterson
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
| | - N. Titov
- eCentre Clinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - B.F. Dear
- eCentre Clinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - H.D. Hadjistavropoulos
- Department of Psychology, University of Regina, 3737 Wascana Parkway, Regina, SK S4S 0A2, Canada
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Thielecke J, Buntrock C, Freund J, Braun L, Ebert DD, Berking M, Baumeister H, Titzler I. How to promote usage of telehealth interventions for farmers' mental health? A qualitative study on supporting and hindering aspects for acceptance and satisfaction with a personalized telephone coaching for depression prevention. Internet Interv 2023; 34:100671. [PMID: 37772161 PMCID: PMC10523267 DOI: 10.1016/j.invent.2023.100671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/08/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023] Open
Abstract
Low-threshold and remotely delivered preventive interventions, like telephone coaching, are warranted for farmers who experience multiple risk factors for depression, live in underserved areas, and show low help-seeking behavior. Factors facilitating uptake and actual use of effective remote interventions are important to reduce depression disease burden. This study aimed at identifying factors that potentially can influence acceptance of and satisfaction with a telephone coaching in this occupational group.Semi-structured interviews were based on the 'Unified Theory of Acceptance and Use of Technology', the 'Evaluation', and 'Discrepancy' models for satisfaction. Interviews were conducted with 20 of 66 invited participants of a 6-months telephone coaching during an effectiveness or implementation study. Audio-recorded interviews were transcribed and analyzed (deductive-inductive qualitative content analysis). Independent coding by two persons resulted in good agreement (Κ = 0.80). Participants validated results via questionnaire.Overall, 32 supporting (SF) and 14 hindering factors (HF) for acceptance and satisfaction were identified and organized into five dimensions: Coaching result (SF = 9, HF = 3), coach (SF = 9, HF = 1), organization (SF = 5, HF = 2), the telephone as communication medium (SF = 4, HF = 5) and participant characteristics (SF = 5, HF = 3). Most named SFs were 'Flexible appointment arrangement' (n = 19/95 %) and 'low effort' (n = 17/85 %), while most reported HFs were 'lack of visual cues' (n = 12/60 %) and 'social/professional involvement restricts change process' (n = 10/50 %).The perceived changes initiated by coaching, a low effort through telephone conduct, and the indicated personalization were identified as important influencing factors on acceptance and satisfaction based on interviewees' statements. Both may be further enhanced by offering choice and advice for delivery formats (e.g., video-calls) and training of coaches in farm-related issues. Study registration German Clinical Trial Registrations: DRKS00017078 and DRKS00015655.
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Affiliation(s)
- Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Claudia Buntrock
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Lina Braun
- Department of Clinical Psychology and Psychotherapy, Ulm University, Ulm, Germany
| | - David D. Ebert
- Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Ulm University, Ulm, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Hornstein S, Zantvoort K, Lueken U, Funk B, Hilbert K. Personalization strategies in digital mental health interventions: a systematic review and conceptual framework for depressive symptoms. Front Digit Health 2023; 5:1170002. [PMID: 37283721 PMCID: PMC10239832 DOI: 10.3389/fdgth.2023.1170002] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction Personalization is a much-discussed approach to improve adherence and outcomes for Digital Mental Health interventions (DMHIs). Yet, major questions remain open, such as (1) what personalization is, (2) how prevalent it is in practice, and (3) what benefits it truly has. Methods We address this gap by performing a systematic literature review identifying all empirical studies on DMHIs targeting depressive symptoms in adults from 2015 to September 2022. The search in Pubmed, SCOPUS and Psycinfo led to the inclusion of 138 articles, describing 94 distinct DMHIs provided to an overall sample of approximately 24,300 individuals. Results Our investigation results in the conceptualization of personalization as purposefully designed variation between individuals in an intervention's therapeutic elements or its structure. We propose to further differentiate personalization by what is personalized (i.e., intervention content, content order, level of guidance or communication) and the underlying mechanism [i.e., user choice, provider choice, decision rules, and machine-learning (ML) based approaches]. Applying this concept, we identified personalization in 66% of the interventions for depressive symptoms, with personalized intervention content (32% of interventions) and communication with the user (30%) being particularly popular. Personalization via decision rules (48%) and user choice (36%) were the most used mechanisms, while the utilization of ML was rare (3%). Two-thirds of personalized interventions only tailored one dimension of the intervention. Discussion We conclude that future interventions could provide even more personalized experiences and especially benefit from using ML models. Finally, empirical evidence for personalization was scarce and inconclusive, making further evidence for the benefits of personalization highly needed. Systematic Review Registration Identifier: CRD42022357408.
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Affiliation(s)
- Silvan Hornstein
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kirsten Zantvoort
- Institute of Information Systems, Leuphana University, Lueneburg, Germany
| | - Ulrike Lueken
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Burkhardt Funk
- Institute of Information Systems, Leuphana University, Lueneburg, Germany
| | - Kevin Hilbert
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany
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Freund J, Ebert DD, Thielecke J, Braun L, Baumeister H, Berking M, Titzler I. Using the Consolidated Framework for Implementation Research to evaluate a nationwide depression prevention project (ImplementIT) from the perspective of health care workers and implementers: Results on the implementation of digital interventions for farmers. Front Digit Health 2023; 4:1083143. [PMID: 36761450 PMCID: PMC9907445 DOI: 10.3389/fdgth.2022.1083143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/28/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Depression has a significant impact on individuals and society, which is why preventive measures are important. Farmers represent an occupational group exposed to many risk factors for depression. The potential of guided, tailored internet-based interventions and a personalized telephone coaching is evaluated in a German project of the Social Insurance for Agriculture, Forestry and Horticulture (SVLFG). While user outcomes are promising, not much is known about actual routine care use and implementation of the two digital health interventions. This study evaluates the implementation from the perspective of social insurance employees to understand determinants influencing the uptake and implementation of digital interventions to prevent depression in farmers. Methods The data collection and analysis are based on the Consolidated Framework for Implementation Research (CFIR). Health care workers (n = 86) and implementers (n = 7) completed online surveys and/or participated in focus groups. The surveys consisted of validated questionnaires used in implementation research, adapted items from the CFIR guide or from other CFIR studies. In addition, we used reporting data to map implementation based on selected CFIR constructs. Results Within the five CFIR dimensions, many facilitating factors emerged in relation to intervention characteristics (e.g., relative advantage compared to existing services, evidence and quality) and the inner setting of the SVLFG (e.g., tension for change, compatibility with values and existing working processes). In addition, barriers to implementation were identified in relation to the outer setting (patient needs and resources), inner setting (e.g., available resources, access to knowledge and information) and characteristics of individuals (e.g., self-efficacy). With regard to the implementation process, facilitating factors (formal implementation leaders) as well as hindering factors (reflecting and evaluating) were identified. Discussion The findings shed light on the implementation of two digital prevention services in an agricultural setting. While both offerings seem to be widely accepted by health care workers, the results also point to revealed barriers and contribute to recommendations for further service implementation. For instance, special attention should be given to "patient needs and resources" by raising awareness of mental health issues among the target population as well as barriers regarding the inner setting. Clinical Trial Registration German Clinical Trial Registration: [DRKS00017078]. Registered on 18.04.2019.
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Affiliation(s)
- Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany,TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany,Correspondence: Johanna Freund
| | | | - Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany,TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | - Lina Braun
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Braun L, Freund J, Thielecke J, Baumeister H, Ebert DD, Titzler I. Barriers to and Facilitators of Engaging With and Adhering to Guided Internet-Based Interventions for Depression Prevention and Reduction of Pain-Related Disability in Green Professions: Mixed Methods Study. JMIR Ment Health 2022; 9:e39122. [PMID: 36350684 PMCID: PMC9685507 DOI: 10.2196/39122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Internet-based interventions (IBIs) are effective for the prevention and treatment of mental disorders and are valuable additions for improving routine care. However, the uptake of and adherence to IBIs are often limited. To increase the actual use of IBIs, it is important to identify factors for engaging with and adhering to IBIs. OBJECTIVE We qualitatively evaluated barriers and facilitators regarding a portfolio of guided IBIs in green professions (farmers, gardeners, and foresters). METHODS Interview participants were selected from 2 randomized controlled trials for either the prevention of depression (Prevention of Depression in Agriculturists [PROD-A]) or the reduction of pain interference (Preventive Acceptance and Commitment Therapy for Chronic Pain in Agriculturists [PACT-A]) in green professions. The intervention group in PROD-A (N=180) participated in an IBI program, receiving access to 1 of 6 symptom-tailored IBIs. The intervention group in PACT-A (N=44) received access to an IBI for chronic pain. Overall, 41 semistructured qualitative interviews were conducted and transcribed verbatim. Barriers and facilitators were identified via inductive qualitative content analysis, with 2 independent coders reaching almost perfect intercoder reliability (Cohen κ=0.92). A quantitative follow-up survey (30/41, 73%) was conducted to validate the results. Subgroup analyses were performed based on intervention characteristics. RESULTS We identified 42 barriers and 26 facilitators, which we assigned to 4 superordinate categories related to the intervention (20 barriers; 17 facilitators), work (4 barriers; 1 facilitator), individual (13 barriers; 8 facilitators), and technical (5 barriers; 0 facilitators) aspects. Key barriers (identified by at least 50% of the interviewees) were time-consuming work life (29/40, 73%) and time-consuming private life (23/40, 58%). Similarly, the most frequently identified facilitators included presence of motivation, curiosity, interest and perseverance (30/40, 75%), flexible time management at work (25/40, 63%), and support from family and friends (20/40, 50%). Although agreement with barriers in the quantitative follow-up survey was rather low (mean 24%, SD 11%), agreement with facilitators was substantially higher (mean 80%, SD 13%). Differences in agreement rates were found particularly between intervention completers and noncompleters. Completers agreed significantly more often that perceived IBI success; being motivated, curious, interested, and perseverant; and having a persisting level of psychological strain have been facilitating. Noncompleters agreed more often with experiencing the e-coach contact as insufficient and technical problems as hindering for intervention completion. CONCLUSIONS Based on these results, strategies such as customization of modules for more flexible and adaptive use; video chat options with the e-coach; options to facilitate social support by family, friends, or other participants; or using prompts to facilitate training completion can be derived. These approaches could be evaluated in further quantitative research designs in terms of their potential to enhance intervention use in this occupational group. TRIAL REGISTRATION German Clinical Trials Register DRKS00014000, https://tinyurl.com/3bukfr48; German Clinical Trials Register DRKS0001461, https://tinyurl.com/ebsn4sns.
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Affiliation(s)
- Lina Braun
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, Ulm, Germany
| | - Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Sport and Health Sciences, Professorship for Psychology and Digital Mental Health Care, Technical University Munich, Munich, Germany
| | - Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Department of Sport and Health Sciences, Professorship for Psychology and Digital Mental Health Care, Technical University Munich, Munich, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, Ulm, Germany
| | - David Daniel Ebert
- Department of Sport and Health Sciences, Professorship for Psychology and Digital Mental Health Care, Technical University Munich, Munich, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Braun L, Terhorst Y, Titzler I, Freund J, Thielecke J, Ebert DD, Baumeister H. Lessons Learned from an Attempted Pragmatic Randomized Controlled Trial for Improvement of Chronic Pain-Associated Disability in Green Professions: Long-Term Effectiveness of a Guided Online-Based Acceptance and Commitment Therapy (PACT-A). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13858. [PMID: 36360738 PMCID: PMC9655679 DOI: 10.3390/ijerph192113858] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/10/2022] [Accepted: 10/19/2022] [Indexed: 06/16/2023]
Abstract
Musculoskeletal symptoms are increased in farmers, whereas the prevalence of chronified pain is unknown. Online interventions based on acceptance and commitment therapy (ACT) have shown encouraging results in the general population, representing a promising approach for reducing pain interference in green professions (i.e., farmers, foresters, gardeners). We conducted a pragmatic RCT comparing a guided ACT-based online intervention to enhanced treatment-as-usual in entrepreneurs, contributing spouses, family members and pensioners in green professions with chronic pain (CPG: ≥grade II, ≥6 months). Recruitment was terminated prematurely after 2.5 years at N = 89 (of planned N = 286). Assessments were conducted at 9 weeks (T1), 6 months (T2) and 12 months (T3) post-randomization. The primary outcome was pain interference (T1). The secondary outcomes encompassed pain-, health- and intervention-related variables. No treatment effect for reduction of pain interference was found at T1 (β = -0.16, 95%CI: -0.64-0.32, p = 0.256). Improvements in cognitive fusion, pain acceptance, anxiety, perceived stress and quality of life were found only at T3. Intervention satisfaction as well as therapeutic and technological alliances were moderate, and uptake and adherence were low. Results are restricted by low statistical power due to recruitment issues, high study attrition and low intervention adherence, standing in contrast to previous studies. Further research is warranted regarding the use of ACT-based online interventions for chronic pain in this occupational group. Trial registration: German Clinical Trial Registration: DRKS00014619. Registered: 16 April 2018.
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Affiliation(s)
- Lina Braun
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, 89081 Ulm, Germany
| | - Yannik Terhorst
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, 89081 Ulm, Germany
- Department of Research Methods, Institute of Psychology and Education, University of Ulm, 89081 Ulm, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander University of Erlangen-Nürnberg, 91052 Erlangen, Germany
| | - Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander University of Erlangen-Nürnberg, 91052 Erlangen, Germany
- Faculty TUM Department of Sport and Health Sciences, TU Munich, 80992 Munich, Germany
| | - Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander University of Erlangen-Nürnberg, 91052 Erlangen, Germany
- Faculty TUM Department of Sport and Health Sciences, TU Munich, 80992 Munich, Germany
| | - David Daniel Ebert
- Faculty TUM Department of Sport and Health Sciences, TU Munich, 80992 Munich, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, University of Ulm, 89081 Ulm, Germany
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Freund J, Buntrock C, Braun L, Thielecke J, Baumeister H, Berking M, Ebert DD, Titzler I. Digital prevention of depression for farmers? A qualitative study on participants' experiences regarding determinants of acceptance and satisfaction with a tailored guided internet intervention program. Internet Interv 2022; 29:100566. [PMID: 36039069 PMCID: PMC9418375 DOI: 10.1016/j.invent.2022.100566] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 07/23/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Farmers, forest workers and gardeners have a higher risk of developing depression compared to other occupational populations. As part of the German pilot project "With us in balance", the potential of six guided internet- and mobile-based interventions (IMIs) to prevent depression among their insurants is examined. The IMI program is tailored to various risk factors of depression, individual symptoms, and needs. Although IMIs have been shown to be effective in reducing depressive symptoms, there is little qualitative research about the acceptance of digital preventive IMIs. The aim of this qualitative study is to gain insights into participants' experiences with the guided IMIs by focusing on determinants for acceptance and satisfaction. Methods Semi-structured interviews were conducted with 22/171 (13 %) intervention group (IG) participants of a randomized controlled trial. The interview guide was developed based on theoretical models of user acceptance (Unified Theory of Acceptance and Use of Technology) and patient satisfaction (evaluation model, discrepancy theory). The interviews were evaluated independently by two coders performing a deductive-inductive content analysis and attaining a substantial level of agreement (K = 0.73). Results The qualitative analysis revealed 71 determinants for acceptance and satisfaction across ten dimensions: performance expectancy, organisation, e-coach, usability, training content and structure, training usage, training outcome, financing, social influence, and behavioural intention. The most frequently identified drivers for the IMI use include "location independence", "positive relationship to the e-coach" (each n = 19, 86 %), "personal e-coach guidance", "expertise of the e-coach", "target group specific adaptation" (each n = 18, 82 %), "flexibility", "high willingness for renewed participation" (each n = 17, 77 %), "fast and easy availability", "training of health enhancing attitudes and behaviours" and "content with figurative expressions" (each n = 16, 73 %). Discussion The qualitative findings predominantly suggest the acceptance of and satisfaction with the IMI program for the prevention of depression in famers and related lines of work. Many identified positive drivers are related to the e-coach guidance, which emphasizes its importance in the preventive setting from the perspective of the participants. Nevertheless, some negative aspects have been identified which help to understand potential weaknesses of the IMI program. Participants indicated different needs in terms of IMI content and usage, which points towards the potential benefit of individualisation. The possibility of being able to use IMIs anonymously, flexibly and independently of location might be highly relevant for this specific target group.
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Affiliation(s)
- Johanna Freund
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- Faculty TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | - Claudia Buntrock
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
- Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Lina Braun
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Janika Thielecke
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- Faculty TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | - Harald Baumeister
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm University, Ulm, Germany
| | - Matthias Berking
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - David Daniel Ebert
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
- Faculty TUM Department of Sport and Health Sciences, TU Munich, Munich, Germany
| | - Ingrid Titzler
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
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