An online positive affect skills intervention reduces depression in adults with type 2 diabetes

A hybrid type II effectiveness-implementation trial of a positive emotion regulation intervention among people living with HIV engaged in Ryan White Medical Case Management: protocol and design for the ORCHID study

BACKGROUND

The Ryan White Medical Case Management System, which serves more than half of people living with HIV (PLWH) in the USA, is an opportune setting for identifying and addressing depression among PLWH. A growing body of research suggests that interventions that promote positive emotion may lessen symptoms of depression and improve physical and psychological well-being among people experiencing a variety of health-related stress, including living with HIV. Research on how best to integrate standardized mental health screening and referral to evidence-based interventions in Ryan White Medical Case Management settings has the potential to improve the health and wellbeing of PLWH.

METHODS

This mixed-methods study will enroll up to N = 300 Ryan White clients who screen positive for depressive symptoms in ORCHID (Optimizing Resilience and Coping with HIV through Internet Delivery), a web-based, self-guided positive emotion regulation intervention. The study will be conducted in 16 Ryan White Medical Case Management clinics in Chicago, IL. Following pre-implementation surveys and interviews with Medical Case Managers (MCMs) and Supervisors to develop an implementation facilitation strategy, we will conduct a hybrid type 2 implementation-effectiveness stepped wedge cluster randomized trial to iteratively improve the screening and referral process via interviews with MCMs in each wedge. We will test the effectiveness of ORCHID on depression and HIV care outcomes for PLWH enrolled in the program. RE-AIM is the implementation outcomes framework and the Consolidated Framework for Implementation Research is the implementation determinants framework.

DISCUSSION

Study findings have the potential to improve mental health and substance use screening of Ryan White clients, decrease depression and improve HIV care outcomes, and inform the implementation of other evidence-based interventions in the Ryan White Medical Case Management System.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05123144. Trial registered 6/24/2021.

Feasibility, acceptability, and efficacy of a positive emotion regulation intervention to promote resilience for healthcare workers during the COVID-19 pandemic: A randomized controlled trial

INTRODUCTION

Burnout poses a substantial, ongoing threat to healthcare worker (HCW) wellbeing and to the delivery of safe, quality healthcare. While systemic and organization-level changes in healthcare are critically important, HCWs also need individual-level skills to promote resilience. The objective of this trial is to test feasibility, acceptability, and efficacy of PARK, an online self-guided positive affect regulation intervention, in a sample of healthcare workers during the COVID-19 pandemic.

DESIGN AND METHODS

In the context of the unprecedented rise in burnout during the COVID-19 pandemic, we conducted a randomized waitlist-controlled trial of the Positive Affect Regulation sKills (PARK) program-a five-week, online, self-guided coping skills intervention nested within an ongoing cohort of HCWs. N = 554 healthcare workers were randomly assigned to receive the intervention immediately or to receive the intervention after approximately 12 weeks. Outcomes included change in burnout, emotional wellbeing (positive affect, meaning and purpose, depression, anxiety) and sleep over approximately 12 weeks. Analyses included mixed-effects linear regression models comparing change over time in outcomes between intervention and control conditions.

RESULTS

One third (n = 554) of the participants in the cohort of HCWs consented to participate and enrolled in PARK in April 2022. Compared to those who did not enroll, participants in the trial reported higher burnout, poorer emotional wellbeing, and poorer sleep at baseline (April, 2022; all ps < .05). Intent-to-treat analyses showed that participants randomly assigned to the intervention immediately (PARK-Now) improved significantly on anxiety (within-group change on PROMIS T-score = -0.63; p = .003) whereas those in the waitlist (PARK-Later) did not (within group T-score change 0.04, p = 0.90). The between-group difference in change, however, was not statistically significant (B = -0.67 p = 0.10). None of the other wellbeing outcomes changed significantly in the intervention group compared to the waitlist. Additional as-treated analyses indicated that those participants who completed all 5 of the weekly online lessons (N = 52; 9.4%) improved significantly more on the primary outcome of positive affect compared to those who enrolled in PARK but completed zero lessons (n = 237; 42.8%; B = 2.85; p = .0001).

CONCLUSIONS

Online self-guided coping skills interventions like PARK can be effective in targeted samples and future work will focus on adaptations to increase engagement and tailor PARK for HCWs who could most benefit.

Using Positive Psychology to Address Emotional Barriers to Physical Activity After Bariatric Surgery: Proof-of-Concept Trial of the Gaining Optimism After Weight Loss Surgery (GOALS) Project

Physical activity promotes health and longevity after metabolic/bariatric surgery (MBS), but most patients do not meet recommended levels. The Gaining Optimism After weight Loss Surgery (GOALS) Project was a positive psychological intervention designed to address common emotional barriers to physical activity in patients who have recently undergone MBS (e.g., low confidence around exercise, internalized weight bias, fear of injury) and use motivational interviewing and standard behavior change techniques (e.g., self-monitoring) to increase physical activity. This single-arm proof-of-concept trial was designed to refine the intervention, test feasibility and acceptability, and explore pre-post changes in behavioral and psychological outcomes. Participants were 12 adults 6-12 months post-MBS (M age of 46, 58% female, 67% non-Hispanic white). GOALS was a 10-week telephone counseling program that introduced new positive psychological skills and physical activity topics each week. Participants tracked physical activity with a Fitbit and set weekly goals. Results showed that the intervention was feasible (85% of sessions completed) and acceptable (average participant ratings of session ease and utility above 8.0 on a 0-10 scale). There were medium-to-large effect size improvements in physical activity and psychological well-being (e.g., depressive symptoms). The GOALS intervention will next be tested in a pilot randomized controlled trial with longer-term follow-up to assess its effect more robustly.

Developing Social Enhancements for a Web-Based, Positive Emotion Intervention for Alzheimer Disease Caregivers: Qualitative Focus Group and Interview Study

BACKGROUND

Alzheimer disease is a degenerative neurological condition that requires long-term care. The cost of these responsibilities is often borne by informal caregivers, who experience an elevated risk of negative physical and psychological outcomes. Previously, we designed a positive emotion regulation intervention that was shown to improve well-being among dementia caregivers when delivered through one-on-one videoconferencing lessons with a trained facilitator. However, the format required significant resources in terms of logistics and facilitator time. To broaden the reach of the intervention, we aimed to develop the Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF) program, an iteration of the intervention in a self-guided, web-based format with enhanced opportunities for social connection.

OBJECTIVE

The aim of this study was to gather feedback to inform the design of social features for the SAGE LEAF intervention. In the absence of a facilitator, our goal with the self-guided SAGE LEAF intervention was to integrate various social features (eg, discussion board, automated support, and profiles) to maximize engagement among participants.

METHODS

Qualitative data were collected from 26 individuals through (1) interviews with participants who completed a previous version of the intervention via videoconferencing with a facilitator, (2) focus groups with dementia caregivers who had not previously experienced the intervention, and (3) focus groups with Alzheimer disease clinical care providers. We conducted a qualitative thematic analysis to identify which social features would be the most helpful and how they could be implemented in a way that would be best received by caregivers.

RESULTS

Interview and focus group feedback indicated that participants generally liked the potential features suggested, including the discussion boards, multimedia content, and informational support. They had valuable suggestions for optimal implementation. For example, participants liked the idea of a buddy system where they would be matched up with another caregiver for the duration of the study. However, they expressed concern about differing expectations among caregivers and the possibility of matched caregivers not getting along. Participants also expressed interest in giving caregivers access to a podcast on the skills, which would allow them to review additional content when they wished.

CONCLUSIONS

Taken together, the discussions with caregivers and providers offered unique insights into the types of social features that may be integrated into the SAGE LEAF intervention, as well as implementation suggestions to improve the acceptability of the features among caregivers. These insights will allow us to design social features for the intervention that are optimally engaging and helpful for caregivers.

Randomized controlled trial of a positive emotion regulation intervention to reduce stress in family caregivers of individuals with Alzheimer's disease: protocol and design for the LEAF 2.0 study

BACKGROUND

Caring for a loved one with Alzheimer's disease can be stressful, resulting in poorer emotional and physical health among family caregivers. Although supportive resources for caregivers are available, distance, caregiver health, and the daily demands of caregiving are barriers to access. Based on research demonstrating the importance of positive emotions in coping with stress, our previous trial showed that dementia caregivers who participated in facilitated, web-based delivery of a positive emotion regulation intervention called LEAF (Life Enhancing Activities for Family caregivers) experienced increased positive emotion and decreased depression and anxiety. Building on this evidence, the LEAF 2.0 study aims to test whether web-based, self-guided delivery can confer similar benefits for caregivers of individuals with Alzheimer's disease.

METHODS

This paper presents the design and methods for LEAF 2.0, a 3-arm web-based randomized controlled trial (N = 500) in which family caregivers of patients with Alzheimer's disease (AD) are randomized to (1) the LEAF intervention facilitated remotely via the web (N = 200), (2) the LEAF intervention self-guided online (N = 200), or (3) an emotion reporting control (N = 100), which then crosses over to the intervention after approximately 6 months, half to the facilitated arm and half to the self-guided arm. We aim to (1) compare the effect of the facilitated and self-guided LEAF positive emotion interventions to an emotion reporting control condition on AD caregiver well-being (positive emotion, depression, anxiety, and perceived stress) and secondary outcomes (caregiving burden, caregiving self-efficacy, positive aspects of caregiving, quality of care, and AD patient quality of life); (2) assess whether effects are mediated by improvements in positive emotion or other aspects of caregiver well-being; and (3) test whether caregiver age or gender or the care recipient's dementia severity moderates the effects of the intervention.

DISCUSSION

If demonstrated to be effective, LEAF can be widely disseminated and ultimately have a significant impact on the stress experienced by AD caregivers and the well-being of people living with Alzheimer's disease.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03610698.

A web-based positive-affect intervention to reduce stress and improve well-being in women living with HIV - feasibility and acceptability of a single-arm, pilot study

Women living with HIV (WLWH) experience high rates of depression but are underrepresented in mental health research. Positive emotions are associated with beneficial health outcomes in WLWH and should be a targeted component of psychological interventions in this population. Positive psychological interventions aim to increase positive emotions through the use of simple exercises, such as keeping a gratitude journal. We conducted a single-arm feasibility/acceptability study of a five-week, self-guided, web-based positive affect skills intervention in a sample of WLWH (N = 23) who also participate in a longitudinal observational study, the Women's Interagency HIV Study. The intervention was feasible as measured by home practice and post-intervention assessment completion, and acceptable as measured by exit interview feedback regarding recommendation of the program to friends or others living with HIV. On average, participants completed home practice for about 8 out of 9 skills. The mean response for recommendation of the program to a friend was 9.26/10 (SD = 1.63) and the mean response for recommendation of the program to others living with HIV was 9.68/10 (SD = 0.82). Participant feedback will be used to adapt and enhance the delivery of this intervention. Further studies are needed to assess efficacy and impact on psychological outcomes.

Waitlist-controlled trial of an online intervention to address mental health among older people living with HIV

Background: Older people living with HIV (PLWH) often experience elevated levels of depression, anxiety, and loneliness.Methods: This waitlist-controlled trial examined the effectiveness of online audio mindfulness lessons in impacting these feelings among older PLWH.Results: Among 214 participants, the mean (SD) age was 60.4 (5.9) years, 89% were male, and 69% were white. After 25 days, the intervention group showed significant improvements versus the waitlist control group in symptoms of depression (20.3% improvement, p < .01) and symptoms of anxiety (22.4% improvement, p = .03), but not in loneliness as measured by a Daily Diary (12.9% improvement, p = .07) or the 3-Item Loneliness Scale (4.8% improvement, p = .27). Secondary analyses among participants with elevated baseline symptoms of depression showed a 26.3% improvement (p < .01), with a moderate effect size (Hedge's g = 0.69). Similarly, those with elevated baseline symptoms of anxiety showed a 25.6% improvement (p < .01), a moderate effect size (g = 0.54), while those with moderate or severely elevated loneliness showed an 18.9% improvement in daily loneliness (p < .01), a moderate effect size (g = 0.55).Conclusion: This waitlist-controlled trial is the first to show that a series of brief, online audio mindfulness lessons improves mental health outcomes among older PLWH. For many patients, this intervention may offer relief that is both accessible and affordable.

Positive Psychology Interventions for Improving Self-management Behaviors in Patients with Type 1 and Type 2 Diabetes: a Narrative Review of Current Evidence

PURPOSE OF REVIEW

Interests have been emerging in using positive psychology interventions (PPIs) to improve diabetes self-management (DSM) behaviors (e.g., blood glucose monitoring, physical activity). To explore the impact of those interventions on DSM behaviors, we summarized the evidence of PPIs on self-management behaviors among both type 1 diabetes (T1D) and type 2 diabetes (T2D) patients between 2012 and 2022.

RECENT FINDINGS

Among the eight studies identified, different study designs and types of PPIs were apparent. Typical PPIs (e.g., activities enhancing positive affect/gratitude/self-affirmation/optimism) were usually applied to T1D patients (N = 5); PPIs were usually combined with motivational interviewing for T2D patients (N = 3). Contrary to expectations, PPIs did not consistently demonstrate positive effects on self-management behaviors' change regardless of the types of diabetes patients, compared to the control groups. Improvements in diabetes patients' self-management behaviors from PPIs are still unclear. Future studies should more rigorously evaluate and identify the active ingredients of PPIs for behavioral changes among diabetes patients.

Effectiveness of Gratitude Therapy in Diabetes Management: A Qualitative Study

The present study involves a Qualitative research design. The study intends to assess the effectiveness of interventions on the diabetic participants. In the present study, four participants screened with high perceived stress, moderate depression, poor sense of gratitude, were selected. The study consisted of three successive phases such as baseline assessment, intervention, and follow-up. Pre-test and Post-test design were adopted. Qualitative data were expressed as percentages, and Schwartz and Blanchard's technique was administered. Participants have shown improvement in positive dimension scores and there is reduction in negative dimension scores. Blood glucose level readings are also marked before, during, and after the intervention. Participants are found to control their blood glucose level, but the change in the glucose level is not clinically significant.

Promoting Resilience After Stroke in Dyads (ReStoreD): A Supplemental Analysis

OBJECTIVE

To examine preliminary effects of ReStoreD (Resilience after Stroke in Dyads) on resilience in couples coping with stroke-related challenges.

DESIGN

Supplemental analysis of prospective pilot trial with pre-/post-assessments and 3-month follow-up.

SETTING

Community.

PARTICIPANTS

Thirty-four cohabitating stroke-care partner dyads (N=34); at least 3 months post-stroke.

INTERVENTIONS

8-week self-administered dyadic intervention (ReStoreD) consisting of activities completed individually and as a couple.

MAIN OUTCOME MEASURES

10-item Connor-Davidson Resilience Scale.

RESULTS

Care partner baseline resilience scores were significantly higher than persons with stroke scores. Repeated-measures analysis of variance suggest significant pre-post improvement in resilience for persons with stroke (mean difference [I - J]=-2.42, SE=.91, P=.04, 95% CI [-4.75, -0.08]) with a large effect size (η2=.34), which was maintained at 3-month follow-up. Care partners showed no significant change over time.

CONCLUSIONS

This study provides preliminary evidence that ReStoreD improves resilience in persons with stroke. More research is needed to address resilience in care partners. These findings represent a promising first step to address the mental health needs in this population.

Acceptability and Feasibility of a Socially Enhanced, Self-Guided, Positive Emotion Regulation Intervention for Caregivers of Individuals With Dementia: Pilot Intervention Study

BACKGROUND

The responsibilities of being a primary caregiver for a loved one with dementia can produce significant stress for the caregiver, leading to deleterious outcomes for the caregiver's physical and psychological health. Hence, researchers are developing eHealth interventions to provide support for caregivers. Members of our research team previously developed and tested a positive emotion regulation intervention that we delivered through videoconferencing, in which caregiver participants would meet one-on-one with a trained facilitator. Although proven effective, such delivery methods have limited scalability because they require significant resources in terms of cost and direct contact hours.

OBJECTIVE

This study aimed to conduct a pilot test of a socially enhanced, self-guided version of the positive emotion regulation intervention, Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF). Studies have shown that social presence or the perception of others in a virtual space is associated with enhanced learning and user satisfaction. Hence, the intervention leverages various social features (eg, discussion boards, podcasts, videos, user profiles, and social notifications) to foster a sense of social presence among participants and study team members.

METHODS

Usability, usefulness, feasibility, and acceptability data were collected from a pilot test in which participants (N=15) were given full access to the SAGE LEAF intervention over 6 weeks and completed preintervention and postintervention assessments (10/15, 67%). Preliminary outcome measures were also collected, with an understanding that no conclusions about efficacy could be made, because our pilot study did not have a control group and was not sufficiently powered.

RESULTS

The results suggest that SAGE LEAF is feasible, with participants viewing an average of 72% (SD 42%) of the total available intervention web pages. In addition, acceptability was found to be good, as demonstrated by participants' willingness to recommend the SAGE LEAF program to a friend or other caregiver. Applying Pearson correlational analyses, we found moderate, positive correlation between social presence scores and participants' willingness to recommend the program to others (r9=0.672; P=.03). We also found positive correlation between social presence scores and participants' perceptions about the overall usefulness of the intervention (r9=0.773; P=.009). This suggests that participants' sense of social presence may be important for the feasibility and acceptability of the program.

CONCLUSIONS

In this pilot study, the SAGE LEAF intervention demonstrates potential for broad dissemination for dementia caregivers. We aim to incorporate participant feedback about how the social features may be improved in future iterations to enhance usability and to further bolster a sense of social connection among participants and study staff members. Next steps include partnering with dementia clinics and other caregiver-serving organizations across the United States to conduct a randomized controlled trial to evaluate the effectiveness of the intervention.

Feasibility, Acceptability, and Preliminary Efficacy of a Positive Affect Skills Intervention for Adults With Fibromyalgia

Background and Objectives

To examine the feasibility, acceptability, and preliminary efficacy of a positive affect skills intervention for middle-aged and older adults with fibromyalgia syndrome (FMS).

Research Design and Methods

Ninety-five participants with FMS aged 50 and older (94% female) were randomized to 1 of 2 conditions: (a) Lessons in Affect Regulation to Keep Stress and Pain UndeR control (LARKSPUR; n = 49) or (b) emotion reporting/control (n = 46). LARKSPUR included 5 weeks of skill training that targeted 8 skills to help foster positive affect, including (a) noticing positive events, (b) savoring positive events, (c) identifying personal strengths, (d) behavioral activation to set and work toward attainable goals, (e) mindfulness, (f) positive reappraisal, (g) gratitude, and (h) acts of kindness. Outcome data were collected via online surveys at baseline, postintervention, and 1-month follow-up.

Results

Completion rates (88%) and satisfaction ratings (10-point scale) were high (LARKSPUR: M = 9.14, standard deviation (SD) = 1.49; control: M = 8.59, SD = 1.97). Improvements were greater in LARKSPUR participants compared with control participants on measures of positive affect (Cohen's d = 0.19 [0.15, 0.24]), negative affect (Cohen's d = -0.07 [-0.11, -0.02]), and pain catastrophizing (Cohen's d = -0.14 [-0.23, -0.05]). Improvements in positive affect (Cohen's d = 0.17 [0.13, 0.22]) and negative affect (Cohen's d = -0.11 [-0.15, -0.06]) were maintained at 1-month follow-up. Dose-response analyses indicated that intervention engagement significantly predicted pre-to-post and post-to-follow-up reductions in pain catastrophizing.

Discussion and Implications

The current preliminary findings add to existing literature and highlight the specific potential of internet-delivered positive affect skills programs for adults with FMS.

Clinical Trial Registration

NCT04869345.

Positive psychology interventions for family caregivers coping with cancer: Who will use them?

Background

Positive psychology-based (PPB) activities have been under-researched in cancer caregiving.

Objective

This study investigated caregiver: (1) attitudes toward using PPB activities while caregiving; and (2) characteristics associated with these attitudes.

Methods

Secondary analyses of a cross-sectional survey were conducted in a national caregiver sample of hematopoietic cell transplant (HCT) patients. Survey items assessed caregivers' likelihood of engaging in six PPB activities. Hierarchical regression was performed and potential predictors of PPB activity use (e.g., technology familiarity, coping style, caregiving duration) were examined.

Results

Most of the N = 948 respondents were White (78.9%), female (65.5%), married (86.7%), employed (78.4%), and college-educated (79.8%). Caregivers favorably disposed to positive activities were younger and female, provided care for 6-12 months and >40 h/week, and used coping styles involving religion and social support.

Conclusions

Our findings provide guidance for development and testing of PPB activities for cancer caregivers.

Positive Psychological Intervention Delivered Using Virtual Reality in Patients on Hemodialysis With Comorbid Depression: Protocol and Design for the Joviality Randomized Controlled Trial

BACKGROUND

Depression is highly prevalent in individuals on hemodialysis, but it is infrequently identified and remains undertreated. In this paper, we present details of the methodology of a randomized controlled trial (RCT) aimed at testing the feasibility and preliminary efficacy of a 5-week positive psychological intervention in individuals on hemodialysis with comorbid depression delivered using immersive virtual reality (VR) technology.

OBJECTIVE

We aim to describe the protocol and design of the Joviality trial whose main objectives are 2-fold: determine the feasibility of the Joviality VR software through metrics capturing rates of recruitment, refusal, retention, noncompliance, and adherence, as well as end-user feedback; and assess preliminary efficacy for outcomes measures of depressive symptoms, psychological well-being and distress, quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalizations.

METHODS

This 2-arm RCT is scheduled to enroll 84 individuals on hemodialysis with comorbid depression from multiple outpatient centers in Chicago, Illinois, United States. Enrollees will be randomized to the following groups: VR-based Joviality positive psychological intervention or sham VR (2D wildlife footage and nature-based settings with inert music presented using a head-mounted display). To be eligible, individuals must be on hemodialysis for at least 3 months, have Beck Depression Inventory-II scores of ≥11 (ie, indicative of mild-to-severe depressive symptoms), be aged ≥21 years, and be fluent in English or Spanish. The Joviality VR software was built using agile design principles and incorporates fully immersive content, digital avatars, and multiplex features of interactability. Targeted skills of the intervention include noticing positive events, positive reappraisal, gratitude, acts of kindness, and mindful or nonjudgmental awareness. The primary outcomes include metrics of feasibility and acceptability, along with preliminary efficacy focused on decreasing symptoms of depression. The secondary and tertiary outcomes include quality of life, treatment adherence, clinical biomarkers, and all-cause hospitalization rates. There are 4 assessment time points: baseline, immediately after the intervention, 3 months after the intervention, and 6 months after the intervention. We hypothesize that depressive symptoms and hemodialysis-related markers of disease will substantially improve in participants randomized to the VR-based Joviality positive psychology treatment arm compared with those in the attention control condition.

RESULTS

This RCT is funded by the National Institute of Diabetes and Digestive and Kidney Diseases and is scheduled to commence participant recruitment in June 2023.

CONCLUSIONS

This trial will be the first to test custom-built VR software to deliver a positive psychological intervention, chairside, in individuals on hemodialysis to reduce symptoms of depression. Within the context of an RCT using an active control arm, if proven effective, VR technology may become a potent tool to deliver mental health programming in clinical populations during their outpatient treatment sessions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05642364; https://clinicaltrials.gov/ct2/show/NCT05642364.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45100.

Psychological Support Strategies for Adults With Type 2 Diabetes in a Very Low-Carbohydrate Web-Based Program: Randomized Controlled Trial

BACKGROUND

A very low-carbohydrate (VLC) nutritional strategy may improve glycemic control and weight loss in adults with type 2 diabetes (T2D). However, the supplementary behavioral strategies that might be able to improve outcomes using this nutritional strategy are uncertain.

OBJECTIVE

This study aims to compare the impact of adding 3 different supplementary behavioral strategies to a web-based VLC diet intervention. To our knowledge, this is the first trial to randomize participants to different frequencies of dietary self-monitoring.

METHODS

The study included 112 overweight adults with T2D (hemoglobin A1c ≥6.5%) taking no antiglycemic medications or only metformin. They received a remotely delivered 12-month VLC diet intervention. Participants were randomly assigned through a full factorial 2×2×2 design to supplementary strategies: either daily or monthly dietary self-monitoring, either mindful eating training or not, and either positive affect skills training or not. Our research goal was to determine whether 3 different supplemental strategies had at least a medium effect size (Cohen d=0.5).

RESULTS

Overall, the VLC intervention led to statistically significant improvements in glycemic control (-0.70%, 95% CI -1.04% to -0.35%; P<.001), weight loss (-6.82%, 95% CI -8.57% to -5.08%; P<.001), and depressive symptom severity (Cohen d -0.67, 95% CI -0.92 to -0.41; P<.001). Furthermore, 30% (25/83) of the participants taking metformin at baseline reduced or discontinued their metformin. Only 1 Cohen d point estimate reached 0.5; daily (vs monthly) dietary self-monitoring had a worse impact on depressive symptoms severity (Cohen d=0.47, 95% CI -0.02 to 0.95; P=.06). None of the strategies had a statistically significant effect on outcomes. For changes in our primary outcome, hemoglobin A1c, the daily (vs monthly) dietary self-monitoring impact was 0.42% (95% CI -0.28% to 1.12%); for mindful eating, it was -0.47% (95% CI -1.15% to 0.22%); and for positive affect, it was 0.12% (95% CI -0.57% to 0.82%). Other results for daily (vs monthly) dietary self-monitoring were mixed, suggesting an increase in weight (0.98%) and depressive symptoms (Cohen d=0.47), less intervention satisfaction (Cohen d=-0.20), more sessions viewed (3.02), and greater dietary adherence (Cohen d=0.24). For mindful eating, the results suggested a benefit for dietary adherence (Cohen d=0.24) and intervention satisfaction (Cohen d=0.30). For positive affect, the results suggested a benefit for depressive symptoms (Cohen d=-0.32), the number of sessions viewed (3.68), dietary adherence (Cohen d=0.16), and intervention satisfaction (Cohen d=0.25).

CONCLUSIONS

Overall, our results support the use of a VLC diet intervention in adults with T2D. The addition of monthly (not daily) dietary self-monitoring, mindful eating, and positive affect skills training did not show a definitive benefit, but it is worth further testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03037528; https://clinicaltrials.gov/ct2/show/NCT03037528.

Technology-Supported Integrated Care Innovations to Support Diabetes and Mental Health Care: Scoping Review

BACKGROUND

For individuals living with diabetes and its psychosocial comorbidities (eg, depression, anxiety, and distress), there remains limited access to interprofessional, integrated care that includes mental health support, education, and follow-up. Health technology, broadly defined as the application of organized knowledge or skill as software, devices, and systems to solve health problems and improve quality of life, is emerging as a means of addressing these gaps. There is thus a need to understand how such technologies are being used to support, educate, and help individuals living with co-occurring diabetes and mental health distress or disorder.

OBJECTIVE

The purpose of this scoping review was to (1) describe the literature on technology-enabled integrated interventions for diabetes and mental health; (2) apply frameworks from the Mental Health Commission of Canada and World Health Organization to elucidate the components, type, processes, and users of technology-enabled integrated interventions for diabetes and mental health; and (3) map the level of integration of interventions for diabetes and mental health.

METHODS

We searched 6 databases from inception to February 2022 for English-language, peer-reviewed studies of any design or type that used technology to actively support both diabetes and any mental health distress or disorder in succession or concurrently among people with diabetes (type 1 diabetes, type 2 diabetes, and gestational diabetes). Reviewers screened citations and extracted data including study characteristics and details about the technology and integration used.

RESULTS

We included 24 studies described in 38 publications. These studies were conducted in a range of settings and sites of care including both web-based and in-person settings. Studies were mostly website-based (n=13) and used technology for wellness and prevention (n=16) and intervention and treatment (n=15). The primary users of these technologies were clients and health care providers. All the included intervention studies (n=20) used technology for clinical integration, but only 7 studies also used the technology for professional integration.

CONCLUSIONS

The findings of this scoping review suggest that there is a growing body of literature on integrated care for diabetes and mental health enabled by technology. However, gaps still exist with how to best equip health care professionals with the knowledge and skills to offer integrated care. Future research is needed to continue to explore the purpose, level, and breadth of technology-enabled integration to facilitate an approach to overcome or address care fragmentation for diabetes and mental health and to understand how health technology can further drive the scale-up of innovative integrated interventions.

The impact of technology systems and level of support in digital mental health interventions: a secondary meta-analysis

BACKGROUND

The majority of people with a chronic disease (e.g., diabetes, hypertension, COPD) have more than one concurrent condition and are also at higher risk for developing comorbidities in mental health, including anxiety and depression. There is an urgent need for more relevant and accurate data on digital interventions in this area to prepare for an increase demand for mental health services. The aim of this study was to conduct a meta-analysis of the digital mental health interventions for people with comorbid physical and mental chronic diseases to compare the effect of technology systems and level of support.

METHODS

This secondary meta-analysis follows a rapid review of systematic reviews, a virtual workshop with knowledge users to identify research questions and a modified Delphi study to guide research methods: What types of digital health interventions (according to a recognized categorization) are the most effective for the management of concomitant mental health and chronic disease conditions in adults? We conducted a secondary analysis of the primary studies identified in the rapid review. Two reviewers independently screened the titles and abstracts and applied inclusion criteria: RCT design using a digital mental health intervention in a population of adults with another chronic condition, published after 2010 in French or English, and including an outcome measurement of anxiety or depression.

RESULTS

Seven hundred eight primary studies were extracted from the systematic reviews and 84 primary studies met the inclusion criteria Digital mental health interventions were significantly more effective than in-person care for both anxiety and depression outcomes. Online messaging was the most effective technology to improve anxiety and depression scores; however, all technology types were effective. Interventions partially supported by healthcare professionals were more effective than self-administered.

CONCLUSIONS

While our meta-analysis identifies digital intervention's characteristics are associated with better effectiveness, all technologies and levels of support could be used considering implementation context and population.

TRIAL REGISTRATION

The protocol for this review is registered in the National Collaborating Centre for Methods and Tools (NCCMT) COVID-19 Rapid Evidence Service (ID 75).

Positive Psychology Interventions in Medical Populations: Critical Issues in Intervention Development, Testing, and Implementation

Positive psychological well-being is prospectively associated with superior health outcomes. Positive psychology interventions have promise as a potentially feasible and effective means of increasing well-being and health in those with medical illness, and several initial studies have shown the potential of such programs in medical populations. At the same time, numerous key issues in the existing positive psychology literature must be addressed to ensure that these interventions are optimally effective. These include (1) assessing the nature and scope of PPWB as part of intervention development and application; (2) identifying and utilizing theoretical models that can clearly outline potential mechanisms by which positive psychology interventions may affect health outcomes; (3) determining consistent, realistic targets for positive psychology interventions; (4) developing consistent approaches to the promotion of positive psychological well-being; (5) emphasizing the inclusion of diverse samples in treatment development and testing; and (6) considering implementation and scalability from the start of intervention development to ensure effective real-world application. Attention to these six domains could greatly facilitate the generation of effective, replicable, and easily adopted positive psychology programs for medical populations with the potential to have an important impact on public health.

Positive Psychological Intervention Effects on Depression: Positive Emotion Does Not Mediate Intervention Impact in a Sample with Elevated Depressive Symptoms

Positive psychological interventions (PPIs), programs that specifically target positive emotions, cognitions, and behaviors, have been shown to reduce depression and improve other aspects of psychological well-being. However, potential pathways linking PPIs to better outcomes have been under-explored. In this paper, we report the results of a randomized trial of a self-guided online delivered PPI called MARIGOLD (Mobile Affect Regulation Intervention with the Goal of Lowering Depression). Participants with elevated depression were randomized to receive MARIGOLD (n = 539) or an emotion reporting control condition (n = 63). In addition to testing direct effects of the intervention on depressive symptoms, we explored whether positive or negative emotion-operationalized as past day, past week, reactivity, or flexibility-mediated the intervention impact on depression. Results demonstrated that participants in the MARIGOLD condition had reduced depressive symptoms compared to controls and, although the effect did not reach statistical significance, reductions in past day negative emotion appeared to mediate this effect. Contrary to hypotheses, the intervention did not increase positive emotion compared to the control condition. Discussion focuses on the need for future studies to continue investigating the mechanisms of action for PPIs with emphasis on theoretically-based measurement and operationalization of emotion and other potential mediators to maximize the ultimate impact of PPIs on psychological well-being. Clinical Trials registration #NCT02861755.

Positive Psychology Approaches to Interventions for Cancer Dyads: A Scoping Review

OBJECTIVE

Positive psychology approaches (PPAs) to interventions focus on developing positive cognitions, emotions, and behavior. Benefits of these interventions may be compounded when delivered to interdependent dyads. However, dyadic interventions involving PPAs are relatively new in the cancer context. This scoping review aimed to provide an overview of the available research evidence for use of dyadic PPA-based interventions in cancer and identify gaps in this literature.

METHODS

Following PRISMA guidelines, we conducted a scoping review of intervention studies that included PPAs delivered to both members of an adult dyad including a cancer patient and support person (e.g., family caregiver, intimate partner).

RESULTS

Forty-eight studies, including 39 primary analyses and 28 unique interventions, were included. Most often (53.8%), the support person in the dyad was broadly defined as a "caregiver"; the most frequent specifically-defined role was spouse (41.0%). PPAs (e.g., meaning making) were often paired with other intervention components (e.g., education). Outcomes were mostly individual well-being or dyadic coping/adjustment.

CONCLUSIONS

Wide variability exists in PPA type/function and their targeted outcomes. More work is needed to refine the definition/terminology and understand specific mechanisms of positive psychology approaches.

Enhancing Resilience in Family Caregivers Using an mHealth App

BACKGROUND

We previously developed a mobile health (mHealth) app (Roadmap) to promote the resilience of family caregivers during the acute phases of care in patients undergoing hematopoietic cell transplantation (HCT).

OBJECTIVE

This study explored users' perspectives on the uptake of Roadmap's multicomponent features and the app's utility in promoting resilience.

METHODS

Fifteen participants were randomized to the full version of the app that included resilience-building activities and the other 15 were randomized to the control version that included a limited view of the app (i.e., without any resilience-building activities). They were instructed to use the app for 120 days. Semistructured qualitative interviews were then conducted with users as part of an ongoing, larger Roadmap study (NCT04094844). During the interview, caregiver participants were asked about their overall experiences with the app, frequency of use, features used, facilitators of and barriers to use, and their perspectives on its utility in promoting resilience. Data were professionally transcribed, coded, and categorized through content analysis.

RESULTS

Interviews were conducted with 30 participants, which included 23 females and 7 males. The median age of the population was 58 years (range, 23-82). The four main themes that emerged included app use, ease of use, user experiences, and ability to foster resilience. The subthemes identified related to facilitators (convenience and not harmful), barriers (caregiver burden and being too overwhelmed during the acute phases of HCT care), resilience (optimism/positivity and self-care), and app design improvements (personalization and notifications/reminders).

CONCLUSION

The qualitative evaluation provided insights into which components were utilized and how one, or a combination of the multicomponent features, may be enhancing users' experiences. Lessons learned suggest that the Roadmap app contributed to promoting resilience during the acute phases of HCT care. Nonetheless, features that provided enhanced personalization may further improve longer-term engagement.

Lessons in Affect Regulation to Keep Stress and Pain UndeR control (LARKSPUR): Design of a randomized controlled trial to increase positive affect in middle-aged and older adults with fibromyalgia

BACKGROUND

Fibromyalgia syndrome (FMS) is a leading cause of functional limitations and disability for which there is no cure. Positive psychological interventions for improving health have received increasing attention, but evidence of the feasibility, acceptability, and impact of such interventions in adult populations with FMS is limited.

OBJECTIVES

To describe the rationale and design of a 5-week, online positive affect skills intervention, LARKSPUR: Lessons in Affect Regulation to Keep Stress and Pain UndeR control.

METHODS

FMS participants (N = 90) will be randomized to one of two conditions: (1) LARKSPUR or (2) emotion reporting/attention control. LARKSPUR is an online multicomponent intervention that targets eight skills to help foster positive affect: (1) noticing positive events, (2) savoring positive events, (3) identifying personal strengths, (4) behavioral activation to set and work toward attainable goals, (5) mindfulness, (6) positive reappraisal, (7) gratitude, and (8) acts of kindness. The primary outcomes include feasibility (i.e., recruitment, retention, adherence) and acceptability (i.e., helpfulness, usability, satisfaction). Secondary outcomes include pain intensity and pain interference.

SIGNIFICANCE

If feasibility and acceptability metrics are met and reductions in pain outcomes are achieved, we will undertake future efficacy and effectiveness trials of LARKSPUR among older adults with FMS.

TRIAL REGISTRATION

NCT04869345.

The Undoing Effect of Positive Emotions: A Meta-Analytic Review

The undoing hypothesis proposes that positive emotions serve to undo sympathetic arousal related to negative emotions and stress. However, a recent qualitative review challenged the undoing effect by presenting conflicting results. To address this issue quantitatively, we conducted a meta-analytic review of 16 studies ( N = 1,220; 72 effect sizes) measuring sympathetic recovery during elicited positive emotions and neutral conditions. Findings indicated that in most cases, positive emotions did not speed sympathetic recovery compared to neutral conditions. However, when a composite index of cardiovascular reactivity was used, undoing effects were evident. Our findings suggest the need for further work on the functions of positive emotions.

Finding Sunshine on a Cloudy Day: A Positive Affect Intervention for Co-Occurring Methamphetamine Use and HIV

Among sexual minority men (i.e., gay, bisexual, and other men who have sex with men) living with HIV, those who use methamphetamine experience profound health disparities. Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS) is an evidence-based, 5-session, individually delivered positive affect intervention adapted for sexual minority men living with HIV who use methamphetamine. ARTEMIS was designed to amplify the benefits of evidence-based substance use interventions such as contingency management (CM) with this high-priority population. Delivering ARTEMIS during CM has been shown to assist participants in reducing stimulant use, increasing positive affect, and achieving durable reductions in HIV viral load. We describe the theoretical underpinnings of the ARTEMIS intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications in research and clinical settings.

The efficacy and mechanism of positive psychological intervention on well-being for colostomy patients: a randomized controlled trial

AIMS

The positive psychology intervention (PPI) is an effective therapy designed to motivate individuals' positive quality and power, to help them survive in an adverse situation, and to establish a high-quality personal and social life. This study aims to evaluate the efficacy and mechanism of PPI on the psychological capital, psychological distress, and life satisfaction among colostomy patients.

METHODS

Patients (n = 120) with permanent stomas were recruited and randomly assigned into two groups. Patients in the experimental group (n = 60) received standard care and PPI, whereas patients in the control group (n = 60) only received standard care. The psychological capital, psychological distress, and life satisfaction were measured and compared between two groups before the intervention, the immediate post-intervention, and follow-up.

RESULTS

All 120 patients completed the study. The hope, optimism, resilience, psychological distress, and life satisfaction score of the experimental group were significantly higher than those of the control group at T1 and T2 (P < 0.05). Self-efficacy score of the experimental group had no significant difference at the two time points after the intervention than the control group (P > 0.05). Changes in hope and resilience which belong to psychological capital mediated the intervention's efficacy on changes in PPI on life satisfaction (β = 0.265, P = 0.005; β = 0.686, P = 0.002).

CONCLUSIONS

PPI could effectively improve psychological capital, psychological distress, and life satisfaction among patients with stomas. Besides, our findings add novel support that increased hope and resilience are the active ingredients that promote intervention change.

A phone and text message intervention to improve physical activity in midlife: initial feasibility testing

Background

Physical activity during midlife (ages 45-64) plays a major role in the prevention of chronic and serious medical conditions. Unfortunately, many midlife adults struggle to be physically active in the setting of low levels of psychological well-being and the management of multiple confluent sources of stress. Effective, scalable, midlife-specific interventions are needed to promote physical activity and prevent the development of chronic medical conditions.

Objectives

In an initial proof-of-concept trial, we assessed the feasibility and acceptability of a new, midlife-adapted, phone- and text message-based intervention using positive psychology (PP) skill-building and motivational interviewing (MI) techniques. We secondarily analyzed post-intervention changes in accelerometer-measured physical activity and self-reported outcomes.

Methods

The PP-MI intervention included six weekly phone sessions with a study trainer, with completion of PP activities and physical activity goals between calls, and in the subsequent six weeks briefer phone check-ins were conducted. Text messages over the 12-week intervention period were utilized to support participants and identify barriers to goal completion. Feasibility (session completion rates) and acceptability (participant ratings of intervention ease and utility) were assessed via descriptive statistics, and pre-post improvements in psychological, functional, and physical activity outcomes at 12 weeks were examined via mixed effects regression models.

Results

Twelve midlife adults with low baseline physical activity enrolled in the single-arm trial. Overall, 76.8% of all possible sessions were completed by participants, and mean ratings of weekly phone sessions were 8.9/10 (SD 1.6), exceeding our a priori thresholds for feasibility and acceptability. Participants demonstrated generally medium to large effect size magnitude improvements in accelerometer-measured physical activity, psychological outcomes, and function.

Conclusions

A novel, midlife-specific phone- and text-based PP-MI intervention was feasible and had promising effects on physical activity and other clinically relevant outcomes, supporting next-step testing of this program via a randomized controlled trial.

Intimate Relationships and Stroke: Piloting a Dyadic Intervention to Improve Depression

Stroke affects not only the survivor but also their romantic partner. Post-stroke depression is common in both partners and can have significant negative consequences, yet few effective interventions are available. The purpose of this study was to pilot test a novel 8-week remotely administered dyadic intervention (ReStoreD) designed to help couples better cope with stroke-related changes and reduce depressive symptoms. Thirty-four cohabitating survivor–partner dyads at least 3 months post-stroke and reporting some changes in mood were enrolled. Depressive symptoms were assessed pre- and post-intervention and at 3-month follow-up. Repeated measures analysis of variance was used to assess the effects of ReStoreD over time on depressive symptoms in stroke survivors and their partners. Twenty-six dyads completed the study. Although statistical significance was not reached, there was a large effect size for improvements in depressive symptoms for stroke survivors. There was no significant improvement for partners, and the effect size was minimal. Those with more significant depressive symptoms at baseline were more likely to benefit from the intervention. This pilot study established proof-of-concept by demonstrating that depressive symptoms can be lessened in stroke survivors and partners with more severe depressive symptoms. Future research will establish the efficacy of the intervention in a fully powered study.

Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial

BACKGROUND

As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life.

OBJECTIVE

The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes.

METHODS

A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre- and post-psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data.

RESULTS

In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received.

CONCLUSIONS

Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life.

Applying theoretical models of positive emotion to improve pediatric asthma: A positive psychology approach

Positive emotion, encompassing feelings such as joy and happiness, has been shown to predict a multitude of health outcomes. However, the role of positive emotion in pediatric asthma is not understood. No work to date has examined how positive emotion may offer benefits to children and adolescents with asthma. Based on theory and models of positive emotion and health, we hypothesize that positive emotion may improve asthma outcomes through mediators such as health behaviors and health-relevant physiological functioning. Moreover, boosting positive emotion during times of stress may be particularly relevant in mitigating asthma symptoms. In the present commentary, we elaborate on the hypothesized mechanisms behind such associations grounded within positive emotion theoretical frameworks. Additionally, we summarize the methodologically rigorous work of positive emotion interventions in other clinical settings to propose that positive emotion could be a useful tool in the management of pediatric asthma.

Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial

Background

Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another.

Objective

The aim of our study is to test whether 3 enhancements—facilitator contact (FC), an online discussion board, and virtual badges (VB)—alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence.

Methods

Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions—the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed.

Results

A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline.

Conclusions

The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence.

Trial Registration

ClinicalTrials.gov NCT02861755; http://clinicaltrials.gov/ct2/show/NCT02861755

Effectiveness of a brief positive skills intervention to improve psychological adjustment in patients with end-stage kidney disease newly initiated on haemodialysis: protocol for a randomised controlled trial (HED-Start)

INTRODUCTION

Initiation onto haemodialysis is a critical transition that entails multiple psychosocial and behavioural demands that can compound mental health burden. Interventions guided by self-management and cognitive-behavioural therapy to improve distress have been variably effective yet are resource-intensive or delivered reactively. Interventions with a focus on positive affect for patients with end-stage kidney disease are lacking. This study will seek (1) to develop a positive life skills intervention (HED-Start) combining evidence and stakeholder/user involvement and (2) evaluate the effectiveness of HED-Start to facilitate positive life skills acquisition and improve symptoms of distress and adjustment in incident haemodialysis patients.

METHODS AND ANALYSIS

This is a single/assessor-blinded randomised controlled trial (RCT) to compare HED-Start to usual care. In designing HED-Start, semistructured interviews, a codesign workshop and an internal pilot will be undertaken, followed by a two-arm parallel RCT to evaluate the effectiveness of HED-Start. A total of 148 incident HD patients will be randomised using a 1:2 ratio into usual care versus HED-Start to be delivered in groups by trained facilitators between January 2021 and September 2022. Anxiety and depression will be the primary outcomes; secondary outcomes will be positive and negative affect, quality of life, illness perceptions, self-efficacy, self-management skills, benefit finding and resilience. Assessments will be taken at 2 weeks prerandomisation (baseline) and 3 months postrandomisation (2 weeks post-HED-Start completion). Primary analyses will use an intention-to-treat approach and compare changes in outcomes from baseline to follow-up relative to the control group using mixed-effect models.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nanyang Technological University Institutional Review Board (IRB-2019-01-010). Written informed consent will be obtained before any research activities. Trial results will be disseminated via publications in peer-reviewed journals and conference presentations and will inform revision(s) in renal health services to support the transition of new patients to haemodialysis.

TRIAL REGISTRATION NUMBER

NCT04774770.

The best possible self-intervention as a viable public health tool for the prevention of type 2 diabetes: A reflexive thematic analysis of public experience and engagement

Background

Public health initiatives seek to modify lifestyle behaviours associated with risk (e.g., diet, exercise, and smoking), but underpinning psychological and affective processes must also be considered to maximize success.

Objective

This study aimed to qualitatively assess how participants engaged with and utilized the best possible self (BPS)‐intervention specifically as a type 2 diabetes (T2D) prevention tool.

Design and Methods

Fourteen participants engaged with a tailored BPS intervention. Reflexive thematic analysis analysed accounts of participant's experiences and feasibility of use.

Results

All participants submitted evidence of engagement with the intervention. The analysis considered two main themes: Holistic Health and Control. The analysis highlighted several nuanced ways in which individuals conceptualized their health, set goals, and received affective benefits, offering insights into how people personalized a simple intervention to meet their health needs.

Conclusions

To our knowledge, this is the first study to tailor the BPS intervention as a public health application for the prevention of T2D. The intervention enabled users to identify their best possible selves in a way that encouraged T2D preventive behaviours. We propose that our tailored BPS intervention could be a flexible and brief tool to assist public health efforts in encouraging change to aid T2D prevention.

Public Contribution

The format, language and application of the BPS intervention were adapted in response to a public consultation group that developed a version specifically for application in this study.

Positive Emotion Skills Intervention to Address Burnout in Critical Care Nurses

Critical care nurses experience high levels of workplace stress, which can lead to burnout. Many medical centers have begun offering wellness programs to address burnout in their nursing staff; however, most of these programs focus on reducing negative states such as stress, depression, and anxiety. A growing body of evidence highlights the unique, independent role of positive emotion in promoting adaptive coping in the face of stress. This article describes a novel approach for preventing burnout in critical care nurses: an intervention that explicitly aims to increase positive emotion by teaching individuals empirically supported skills. This positive emotion skills intervention has been used successfully in other populations and can be tailored for critical care nurses. Also discussed are recommendations for addressing burnout in intensive care unit nurses at both the individual and organizational levels.

A systematic review and meta-analysis of psychological interventions to improve mental wellbeing

Our current understanding of the efficacy of psychological interventions in improving mental states of wellbeing is incomplete. This study aimed to overcome limitations of previous reviews by examining the efficacy of distinct types of psychological interventions, irrespective of their theoretical underpinning, and the impact of various moderators, in a unified systematic review and meta-analysis. Four-hundred-and-nineteen randomized controlled trials from clinical and non-clinical populations (n = 53,288) were identified for inclusion. Mindfulness-based and multi-component positive psychological interventions demonstrated the greatest efficacy in both clinical and non-clinical populations. Meta-analyses also found that singular positive psychological interventions, cognitive and behavioural therapy-based, acceptance and commitment therapy-based, and reminiscence interventions were impactful. Effect sizes were moderate at best, but differed according to target population and moderator, most notably intervention intensity. The evidence quality was generally low to moderate. While the evidence requires further advancement, the review provides insight into how psychological interventions can be designed to improve mental wellbeing.

Psychological Health, Well-Being, and the Mind-Heart-Body Connection: A Scientific Statement From the American Heart Association

As clinicians delivering health care, we are very good at treating disease but often not as good at treating the person. The focus of our attention has been on the specific physical condition rather than the patient as a whole. Less attention has been given to psychological health and how that can contribute to physical health and disease. However, there is now an increasing appreciation of how psychological health can contribute not only in a negative way to cardiovascular disease (CVD) but also in a positive way to better cardiovascular health and reduced cardiovascular risk. This American Heart Association scientific statement was commissioned to evaluate, synthesize, and summarize for the health care community knowledge to date on the relationship between psychological health and cardiovascular health and disease and to suggest simple steps to screen for, and ultimately improve, the psychological health of patients with and at risk for CVD. Based on current study data, the following statements can be made: There are good data showing clear associations between psychological health and CVD and risk; there is increasing evidence that psychological health may be causally linked to biological processes and behaviors that contribute to and cause CVD; the preponderance of data suggest that interventions to improve psychological health can have a beneficial impact on cardiovascular health; simple screening measures can be used by health care providers for patients with or at risk for CVD to assess psychological health status; and consideration of psychological health is advisable in the evaluation and management of patients with or at risk for CVD.

Mindfulness-based Virtual Reality Intervention in Hemodialysis Patients: A Pilot Study on End-user Perceptions and Safety

Background

Virtual reality (VR) is an evolving technology that is becoming a common treatment for pain management and psychologic phobias. Although nonimmersive devices (e.g., the Nintendo Wii) have been previously tested with patients on hemodialysis, no studies to date have used fully immersive VR as a tool for intervention delivery. This pilot trial tests the initial safety, acceptability, and utility of VR during maintenance hemodialysis treatment sessions-particularly, whether VR triggers motion sickness that mimics or negatively effects treatment-related symptoms (e.g., nausea).

Methods

Patients on hemodialysis (n=20) were enrolled in a phase 1 single-arm proof-of-concept trial. While undergoing hemodialysis, participants were exposed to our new Joviality VR program. This 25-minute program delivers mindfulness training and guided meditation using the Oculus Rift head-mounted display. Participants experienced the program on two separate occasions. Before and immediately after exposure, participants recorded motion-related symptoms and related discomfort on the Simulator Sickness Questionnaire. Utility measures included the end-user's ability to be fully immersed in the virtual space, interact with virtual objects, find hardware user friendly, and easily navigate the Joviality program with the System Usability Scale.

Results

Mean age was 55.3 (±13.1) years; 80% male; 60% Black; and mean dialysis vintage was 3.56 (±3.75) years. At the first session, there were significant decreases in treatment and/or motion-related symptoms after VR exposure (22.6 versus 11.2; P=0.03); scores >20 indicate problematic immersion. Hemodialysis end-users reported high levels of immersion in the VR environment and rated the software easy to operate, with average System Usability Scale scores of 82.8 out of 100.

Conclusions

Patients on hemodialysis routinely suffer from fatigue, nausea, lightheadedness, and headaches that often manifest during their dialysis sessions. Our Joviality VR program decreased symptom severity without adverse effects. VR programs may be a safe platform to improve the experience of patients on dialysis.

Harnessing mobile health technology to support long-term chronic illness management: exploring family caregiver support needs in the outpatient setting

OBJECTIVE

Family caregiving is an important public health issue, particularly with the aging population. In recent years, mobile health (mHealth) technology has emerged as a potential low-cost, scalable platform to address caregiver support needs, and thereby alleviate the burden on caregivers. This study sought to examine the support needs of family caregivers in their lived experiences of outpatient care to inform the development of a future mHealth intervention.

MATERAILS AND METHODS

We conducted 20 semi-structured interviews in 2 outpatient hematopoietic cell transplant (HCT) clinics at a large academic medical center in the Midwestern United States. A thematic analysis was performed to define emerging themes.

RESULTS

Qualitative data analysis identified 5 primary themes that HCT caregivers faced: (I) lifestyle restrictions due to the patient's immunocompromised state; (II) Unmet needs due to limitations in the current resources, including unfamiliar medical tasks without necessary trainings; and (III) caregivers' adaptive strategies, including reformation of social relationships with family and friends. Based on these findings, we suggest 3 design considerations to guide the development of a future mHealth intervention.

CONCLUSIONS

The findings herein captured the family caregiver's lived experiences during outpatient care. There was broad agreement that caregiving was challenging and stressful. Thus, effective and scalable interventions to support caregivers are needed. This study provided data to guide the content and design of a future mHealth intervention in the outpatient setting.

Promoting Health and Well-Being Through Mobile Health Technology (Roadmap 2.0) in Family Caregivers and Patients Undergoing Hematopoietic Stem Cell Transplantation: Protocol for the Development of a Mobile Randomized Controlled Trial

Background

Cancer patients who undergo allogeneic hematopoietic stem cell transplantation are among the most medically fragile patient populations with extreme demands for caregivers. Indeed, with earlier hospital discharges, the demands placed on caregivers continue to intensify. Moreover, an increased number of allogeneic hematopoietic stem cell transplantations are being performed worldwide, and this expensive procedure has significant economic consequences. Thus, the health and well-being of family caregivers have attracted widespread attention. Mobile health technology has been shown to deliver flexible, and time- and cost-sparing interventions to support family caregivers across the care trajectory.

Objective

This protocol aims to leverage technology to deliver a novel caregiver-facing mobile health intervention named Roadmap 2.0. We will evaluate the effectiveness of Roadmap 2.0 in family caregivers of patients undergoing hematopoietic stem cell transplantation.

Methods

The Roadmap 2.0 intervention will consist of a mobile randomized trial comparing a positive psychology intervention arm with a control arm in family caregiver-patient dyads. The primary outcome will be caregiver health-related quality of life, as assessed by the PROMIS Global Health scale at day 120 post-transplant. Secondary outcomes will include other PROMIS caregiver- and patient-reported outcomes, including companionship, self-efficacy for managing symptoms, self-efficacy for managing daily activities, positive affect and well-being, sleep disturbance, depression, and anxiety. Semistructured qualitative interviews will be conducted among participants at the completion of the study. We will also measure objective physiological markers (eg, sleep, activity, heart rate) through wearable wrist sensors and health care utilization data through electronic health records.

Results

We plan to enroll 166 family caregiver-patient dyads for the full data analysis. The study has received Institutional Review Board approval as well as Code Review and Information Assurance approval from our health information technology services. Owing to the COVID-19 pandemic, the study has been briefly put on hold. However, recruitment began in August 2020. We have converted all recruitment, enrollment, and onboarding processes to be conducted remotely through video telehealth. Consent will be obtained electronically through the Roadmap 2.0 app.

Conclusions

This mobile randomized trial will determine if positive psychology-based activities delivered through mobile health technology can improve caregiver health-related quality of life over a 16-week study period. This study will provide additional data on the effects of wearable wrist sensors on caregiver and patient self-report outcomes.

Trial Registration

ClinicalTrials.gov NCT04094844; https://www.clinicaltrials.gov/ct2/show/NCT04094844

International Registered Report Identifier (IRRID)

PRR1-10.2196/19288

Exploring the feasibility and impact of positive psychology-motivational interviewing interventions to promote positive affect and physical activity in type 2 diabetes: design and methods from the BEHOLD-8 and BEHOLD-16 clinical trials

BACKGROUND

Physical activity among those with type 2 diabetes (T2D) is independently associated with superior medical outcomes, but existing behavioral interventions have not led to widespread increases in activity in this population. A remotely delivered intervention that targets well-being constructs associated with greater activity and assists in the creation of specific physical activity goals has the potential to improve activity and outcomes in T2D.

OBJECTIVE

To outline the rationale and methods of two studies designed to assess the impact and optimal duration of a combined positive psychology-motivational interviewing (PP-MI) intervention for inactive persons with T2D.

METHODS

We conducted trials studying 8-week (BEHOLD-8;) and 16-week (BEHOLD-16;) phone-delivered interventions, compared to attention-matched control conditions. In a two-step randomization design, participants were allocated randomly first to study (BEHOLD-8 or BEHOLD-16), then to study condition within study. The primary aims in both trials were feasibility (rates of session completion) and acceptability (participant session ratings), with additional aims examining intervention effects on accelerometer-measured physical activity, psychological measures, and health-related metrics (e.g. vital signs). Main analyses, currently being conducted, will utilize mixed effects models between study conditions, and secondary analyses will utilize the same models to compare the 8- and 16-week PP-MI interventions on feasibility and impact.

RESULTS

Enrollment and data collection have been completed for both trials (BEHOLD-8: N = 60; BEHOLD-16: N = 70), and data analysis is ongoing to assess feasibility and acceptability within study, as well as the relative feasibility and acceptability of the PP-MI interventions across the two studies. We will also explore impact on clinical outcomes between groups.

CONCLUSIONS

This design will address how intervention content (i.e. PP elements vs. no PP elements) and intervention duration (8 weeks vs. 16 weeks) affect feasibility, acceptability, and impact, allowing intervention optimization before a next-step larger clinical trial.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03150199; NCT03001999.

Measuring Positive Emotion Outcomes in Positive Psychology Interventions: A Literature Review

Accumulating evidence for the unique social, behavioral, and physical health benefits of positive emotion and related well-being constructs has led to the development and testing of positive psychological interventions (PPIs) to increase emotional well-being and enhance health promotion and disease prevention. PPIs are specifically aimed at improving emotional well-being and consist of practices such as gratitude, savoring, and acts of kindness. The purpose of this narrative review was to examine the literature on PPIs with a particular focus on positive emotion outcomes. We evaluated the evidence on the effects of PPIs on positive emotion specifically, and discussed the range of evidence regarding the relative responsiveness of emotion measures to PPIs in order to gain a better understanding of the specific emotional pathways through which PPIs influence psychological and physical well-being. We conclude with recommendations for best evaluating effects of PPIs on positive emotion outcomes.

A Web-Based Positive Psychological Intervention to Improve Blood Pressure Control in Spanish-Speaking Hispanic/Latino Adults With Uncontrolled Hypertension: Protocol and Design for the ¡Alégrate! Randomized Controlled Trial

BACKGROUND

Growing evidence links psychological well-being and resilience with superior cardiac health, but there remains a critical scientific gap about whether (or how) interventions that aim to cultivate psychological well-being reduce cardiac risk. Hispanic/Latino people in the United States have high cardiovascular disease risk and poorly controlled blood pressure (BP) compared with their peers of European ancestry, and they represent a population in need of new and innovative therapeutic approaches. As such, a focused intervention to boost psychological well-being holds promise as a novel therapeutic target for hypertension in Hispanic/Latino adults; to date, however, no research has explored whether a causal link is evident.

OBJECTIVE

The aim of this paper is to detail the protocol for the ¡Alégrate! (Be Happy!) intervention, a Phase II randomized controlled trial testing initial efficacy in improving BP of a web-based positive psychological intervention designed to boost psychological well-being in Spanish-speaking Hispanic/Latino people with hypertension.

METHODS

A total of 70 Hispanic/Latino people aged ≥18 years, fluent in Spanish, and with elevated BP (≥140/90 mm Hg) will be recruited in person from a single Federally Qualified Health Center in Chicago. Enrollees will be randomly assigned to 1 of 2 trial arms: (1) web-based positive psychological intervention or (2) an active control condition (eg, 3 times weekly emotion reporting). Our 5-week Spanish-language ¡Alégrate! intervention is web-based and delivers curricular content via didactic instruction, journaling, and assigned at-home practice-all accessed via our website using investigator-purchased tablet computers, with a unique username and password assigned to each enrollee. Targeted skills include noting daily positive events, positive reappraisal of stressful events, effective expression of gratitude, performing acts of kindness, and regular practice of mindfulness and meditation. The primary outcome is improvement in BP, both sitting values and 24-hour ambulatory readings, as measured at baseline and 5 and 12 weeks from baseline. Secondary outcomes include psychological well-being, engagement in healthy behaviors, and circulating levels of inflammatory markers. The outcomes of interest are collected by trained research staff through in-person interviews using the REDCap software.

RESULTS

Activities of the ¡Alégrate! intervention were funded in August 2017, and data collection is ongoing. We expect to submit trial results for peer-reviewed publications in 2021, soon after recruitment has been concluded and statistical analyses are finalized.

CONCLUSIONS

Findings will provide evidence on whether interventions to boost psychological well-being and resilience have downstream effects on BP control and cardiovascular health, particularly as they are deployed in the Spanish language with cultural tailoring and via a web-based platform. If effective, we will have an easily disseminatable application that can positively impact well-being profiles and BP control in Hispanic/Latino people, with the possibility of addressing health disparities of this US racial/ethnic minority group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03892057; https://clinicaltrials.gov/ct2/show/NCT03892057.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17721.

Immediate and Long-Term Effects of an 8-Week Digital Mental Health Intervention on Adults With Poorly Managed Type 2 Diabetes: Protocol for a Randomized Controlled Trial

Background

Diabetes is a leading cause of years of life lost and accounts for approximately one-fourth of health care dollars spent in the United States. Many of these costs are related to poor medication adherence and lack of self-care behaviors and are thus preventable. Depression, which is more prevalent among people with diabetes than in the general population, predicts poorer management of one’s diabetes, whereas positive affect predicts engaging in more positive health behaviors. Consequently, interventions that improve depression and positive affect may also improve diabetes-related outcomes among people with diabetes. Although preliminary research on the impact of such interventions among people with diabetes is promising, these studies focused primarily on in-person interventions, have had small samples, and lack long-term follow-up.

Objective

This study aims to examine the short- and long-term effects of a digital therapeutic platform focused on mental health among adults with poorly managed type 2 diabetes and elevated levels of depression.

Methods

This is a randomized controlled trial in which adults with a type 2 diabetes diagnosis, elevated hemoglobin A_1c (HbA_1c) levels (≧7), and moderate to severe depressive symptoms will be randomly assigned to a positive emotion regulation skills intervention group or a sham digital intervention with only psychoeducational content. The study will take place over 14 months, including the 8-week intervention (or control) delivered via a digital therapeutic platform (Happify Health) and follow-up assessments at 3, 6, and 12 months postintervention. Throughout the intervention and for 1 week at each postintervention follow-up, participants will complete daily assessments of diabetes-related distress, diabetes regimen adherence, and mood. Our primary outcome, HbA_1c, will be self-reported every 3 months throughout the study. Secondary and exploratory outcomes will be assessed at baseline; at 8 weeks; and at 3, 6, and 12 months postintervention.

Results

Recruitment is expected to begin in June 2020. Participants will begin the study as they are recruited and will finish in waves. The final wave of data collection from the 8-week intervention is expected for winter 2020, with the completion of the 12-month follow-up in winter 2021.

Conclusions

Although previous research suggests that in-person psychological interventions have promising effects on both psychological and physical outcomes among adults with diabetes, digital interventions can be advantageous because they are easily scalable and reduce many barriers that prevent people from seeking treatment. This trial will provide important information about the effects of a digital mental health intervention among adults with type 2 diabetes, assessing both short- and long-term effects of this intervention on HbA1c, depressive symptoms, and other diabetes-specific outcomes. If successful, this may introduce a scalable intervention that would help reduce some of the preventable costs associated with diabetes.

Trial Registration

ClinicalTrials.gov NCT04068805; https://clinicaltrials.gov/ct2/show/NCT04068805.

International Registered Report Identifier (IRRID)

PRR1-10.2196/18578

MyStrengths, a Strengths-Focused Mobile Health Tool: Participatory Design and Development

BACKGROUND

People living with chronic illnesses are an increasingly large group. Research indicates that care and self-management should not only focus on the illness and problem-oriented aspects of these individuals' lives but also support them in recognizing and leveraging their personal strengths in daily life.

OBJECTIVE

This paper presents the design and developmental process of MyStrengths, a mobile health (mHealth) app designed to help its users (people with chronic conditions) both find and make use of their personal strengths in their daily lives. Through 4 consecutive phases, this paper presents participant- and researcher-driven activities, discussions regarding design, and development of both the MyStrengths app and its content.

METHODS

During the 4 phases, we used a range of methods and activities, including (1) an idea-generating workshop aimed at creating ideas for strengths-supporting features with different stakeholders, including patients, caregivers, relatives, and designers (N=35); (2) research seminars with an international group of experts (N=6), in which the concept, theoretical background, and design ideas for the app were discussed; (3) a series of co-design workshops with people in the user group (N=22) aiming to create ideas for how to, in an engaging manner, design the app; and (4) in 4 developmental iterations, the app was evaluated by people in the user group (N=13). Content and strengths exercises were worked on and honed by the research team, the expert groups, and our internal editorial team during the entire developmental process.

RESULTS

The first phase found a wide range of stakeholder requirements to, and ideas for, strengths-focused mHealth apps. From reviewing literature during the second phase, we found a dearth of research on personal strengths with respect to people living with chronic illnesses. Activities during the third phase creatively provided numerous ideas and suggestions for engaging and gameful ways to develop and design the MyStrengths app. The final phase saw the output from all the earlier phases come together. Through multiple increasingly complete iterations of user evaluations testing and developing, the final prototype of the MyStrengths app was created.

CONCLUSIONS

Although research supports the use of strengths-focused mHealth tools to support people living with chronic illnesses, there is little guidance as to how these tools and their content should be designed. Through all activities, we found great support among participating users for strengths-focused apps, and we can consider such apps to be both appropriate and valuable. This paper illustrates how combining a range of user-, researcher-, literature-, and designer-based methods can contribute to creating mHealth tools to support people with chronic illnesses to find and use more of their own personal strengths.

Does Using Social Network Sites Reduce Depression and Promote Happiness?

Positive interventions based on theories in positive psychology have proven effective in contributing to well-being. Although college students frequently use social networking sites, few studies have investigated the use of these sites to facilitate positive interventions. For this research, two positive interventions, photo diaries and the expression of gratitude, were developed and implemented in Facebook using a randomized controlled trial. 136 college students were recruited and randomly assigned them to one of two experimental groups or a control group. Results indicated that photo diary reduced depression during the posttest stage, and these effects continued during the follow up stage. Concerning happiness, the photo diary presented no significant effects in the posttest but did present significant effects in the follow up. Expression of gratitude showed no significant effects on happiness in the posttest but did show significant effects in the follow up. The results of the study demonstrate that social networking sites can be used to implement positive interventions.

A Web-Based, Positive Emotion Skills Intervention for Enhancing Posttreatment Psychological Well-Being in Young Adult Cancer Survivors (EMPOWER): Protocol for a Single-Arm Feasibility Trial

BACKGROUND

Adolescent and young adult cancer survivors (AYAs) experience clinically significant distress and have limited access to supportive care services. Interventions to enhance psychological well-being have improved positive affect and reduced depression in clinical and healthy populations but have not been routinely tested in AYAs.

OBJECTIVE

The aim of this protocol is to (1) test the feasibility and acceptability of a Web-based positive emotion skills intervention for posttreatment AYAs called Enhancing Management of Psychological Outcomes With Emotion Regulation (EMPOWER) and (2) examine proof of concept for reducing psychological distress and enhancing psychological well-being.

METHODS

The intervention development and testing are taking place in 3 phases. In phase 1, we adapted the content of an existing, Web-based positive emotion intervention so that it would be suitable for AYAs. EMPOWER targets 8 skills (noticing positive events, capitalizing, gratitude, mindfulness, positive reappraisal, goal setting, personal strengths, and acts of kindness) and is delivered remotely as a 5-week, Web-based intervention. Phase 2 consisted of a pilot test of EMPOWER in a single-arm trial to evaluate feasibility, acceptability, retention, and adherence and to collect data on psychosocial outcomes for proof of concept. In phase 3, we are refining study procedures and conducting a second pilot test.

RESULTS

The project was part of a career development award. Pilot work began in June 2015, and data collection was completed in March 2019. The analysis is ongoing, and results will be submitted for publication by May 2020.

CONCLUSIONS

If this intervention proves feasible and acceptable, EMPOWER will be primed for a subsequent large, multisite randomized controlled trial. As a scalable intervention, it will be ideally suited for AYA survivors who would otherwise not have access to supportive care interventions to help manage posttreatment distress and enhance well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02832154, https://clinicaltrials.gov/ct2/show/NCT02832154.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17078.

Happiness and Inflammatory Responses to Acute Stress in People With Type 2 Diabetes

Background

Positive psychological characteristics in people with type 2 diabetes (T2D) are associated with better health and longevity, and one plausible physiological mechanism involves lower markers of inflammation. Positive affect is related to lower basal inflammatory markers and smaller inflammatory responses to acute stress, but this association in people with T2D remains to be examined.

Purpose

To examine the relationship between happiness and inflammatory markers at baseline and in response to acute stress in people with T2D.

Methods

One hundred forty people with T2D took part in laboratory-based stress testing. We aggregated daily happiness ratings over 7 days before stress testing. During the laboratory session, participants underwent two mental stress tasks—the mirror tracing and the Stroop task. Blood was sampled at baseline and post-stress (up to 75 min post-stress) to detect plasma interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1Ra), and monocyte chemoattractant protein-1 (MCP-1). Associations between happiness and inflammatory markers and responses were analyzed using multivariable linear regressions.

Results

Greater daily happiness significantly predicted lower baseline and post-stress IL-6 concentrations, and lower baseline MCP-1, after adjusting for covariates. The association between happiness and reduced basal IL-6 maintained after further controlling for daily sadness. We did not find significant associations between daily happiness and inflammatory responses to acute stress. No associations were detected for IL-1Ra.

Conclusions

Happier individuals with T2D have lower inflammatory markers before and after acute stress, albeit independent of stress responsivity. Findings could provide a protective physiological pathway linking daily happiness with better health in people with T2D.

Development of a National Caregiver Health Survey for Hematopoietic Stem Cell Transplant: Qualitative Study of Cognitive Interviews and Verbal Probing

Background

Roadmap 1.0 is a mobile health app that was previously developed for caregivers of patients who have undergone hematopoietic stem cell transplantation (HSCT). Formative research targeted toward its end users (caregivers) can help inform app design and development, allowing additional components to be incorporated into the app, which can then be tested in a future randomized controlled trial.

Objective

This study aimed to create a methodologically rigorous national survey that would help inform the development of Roadmap 2.0.

Methods

We conducted a prospective, qualitative research study that took place between November 18, 2018, and February 7, 2019, in a blood and marrow transplant unit within a large academic medical institution in the midwestern part of the United States. Cognitive interviews, including think-aloud and verbal probing techniques, were conducted in 10 adult caregivers (≥18 years) of patients who had undergone HSCT.

Results

Most participants were female (9/10, 90%), white (9/10, 90%), married (9/10, 90%), employed at least part time (6/10, 60%), caregivers of adult patients (7/10, 70%), and had some college education (9/10, 90%) and an annual household income of $60,000 or higher (6/10, 60%). All but one interview was audio-recorded, with permission. Overall, participants were engaged in the cognitive interview process of the draft survey, which included 7 topics. The interviews highlighted areas wherein survey items could be further refined, such as offering more response choices (eg, “NA”) or clarifying the type of transplant (eg, autologous or allogeneic) or context of transplant care (eg, pre-HSCT, during HSCT, post-HSCT, inpatient, and outpatient). Apart from these findings, the items in demographics, caregiving experiences, technology, positive activities, and mood were generally interpreted as intended. On the basis of the transcript data and field notes by the interviewer, items within self-efficacy (Caregiver Self-Efficacy Scale) and coping (Brief Coping Orientation to Problems Experienced inventory) questionnaires generated more confusion among interviewer and participants, reflecting difficulties in interpreting the meaning of some survey items.

Conclusions

This study incorporated the four cognitive aspects of survey methodology that describe the question-answering process—(1) comprehension, (2) information retrieval, (3) judgment and decision making, and (4) responding—by using the think-aloud and probing techniques in cognitive interviews. We conclude that this methodologically rigorous process informed revisions and improved our final questionnaire design.

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.49188

Pilot Test of an Appreciative Inquiry Intervention in Hypertension Self-management

We implemented an Appreciative Inquiry (AI) intervention to assist people with hypertension improve diet, physical activity, and blood pressure. In a two-group randomized controlled trial conducted over 12 weeks, 50 participants were recruited at an urban outpatient health care clinic. The intervention used participants' high peak positive experiences to promote behavior change, during two face-to-face individual sessions and three coaching telephone calls. Data were analyzed using test of differences between groups and analysis of covariance controlling for confounding variables. The intervention group had significantly higher levels of ideal self, positive emotions, and self-efficacy for chronic disease management than the control group. No significant group differences in physical activity, diet, or blood pressure. Findings provide empirical evidence about the underlying processes by which AI may promote health behavior change. Future research should examine the effectiveness of this AI intervention in a larger sample of patients and over a longer intervention period.