Supporting Self-Management in Bipolar Disorder: Mixed-Methods Knowledge Translation Study

Designing a Library of Lived Experience for Mental Health: integrated realist synthesis and experience-based co-design study in UK mental health services

OBJECTIVE

Living Library events involve people being trained as living 'Books', who then discuss aspects of their personal experiences in direct conversation with attendees, referred to as 'Readers'. This study sought to generate a realist programme theory and a theory-informed implementation guide for a Library of Lived Experience for Mental Health (LoLEM).

DESIGN

Integrated realist synthesis and experience-based co-design.

SETTING

Ten online workshops with participants based in the North of England.

PARTICIPANTS

Thirty-one participants with a combination of personal experience of using mental health services, caring for someone with mental health difficulties and/or working in mental health support roles.

RESULTS

Database searches identified 30 published and grey literature evidence sources which were integrated with data from 10 online co-design workshops conducted over 12 months. The analysis generated a programme theory comprising five context-mechanism-outcome (CMO) configurations. Findings highlight how establishing psychological safety is foundational to productive Living Library events (CMO 1). For Readers, direct conversations humanise others' experiences (CMO 2) and provide the opportunity to flexibly explore new ways of living (CMO 3). Through participation in a Living Library, Books may experience personal empowerment (CMO 4), while the process of self-authoring and co-editing their story (CMO 5) can contribute to personal development. This programme theory informed the co-design of an implementation guide highlighting the importance of tailoring event design and participant support to the contexts in which LoLEM events are held.

CONCLUSIONS

The LoLEM has appeal across stakeholder groups and can be applied flexibly in a range of mental health-related settings. Implementation and evaluation are required to better understand the positive and negative impacts on Books and Readers.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42022312789.

Participatory Action Research Among People With Serious Mental Illness: A Scoping Review

Participatory action research (PAR) is a research approach that creates spaces for marginalized individuals and communities to be co-researchers to guide relevant social change. While working toward social transformation, all members of the PAR team often experience personal transformation. Engaging people with serious mental illness (PSMI) in PAR helps them to develop skills and build relationships with stakeholders in their communities. It supports positive changes that persist after the completion of the formal research project. With the increasing recognition of PAR's value in PSMI, it is helpful to consider the challenges and advantages of this approach to research with this population. This review aimed at determining how PAR has been conducted with PSMI and at summarizing strategies used to empower PSMI as co-researchers by engaging them in research. This scoping review followed five steps Arkesy and O'Malley (2005) outlined. We charted, collated, and summarized relevant information from 87 studies that met the inclusion criteria. We identified five strategies to empower PSMI through PAR. These are to build capacity, balance power distribution, create collaborative environments, promote peer support, and enhance their engagement as co-researchers. In conclusion, PAR is an efficient research approach to engage PSMI. Further, PSMI who engage in PAR may benefit from strategies for empowerment that meet their unique needs as co-researchers.

Designing a library of lived experience for mental health (LoLEM): protocol for integrating a realist synthesis and experience based codesign approach

INTRODUCTION

People with lived expertise in managing mental health challenges can be an important source of knowledge and support for other people facing similar challenges, and for carers to learn how best to help. However, opportunities for sharing lived expertise are limited. Living libraries support people with lived expertise to be 'living books', sharing their experiences in dialogue with 'readers' who can ask questions. Living libraries have been piloted worldwide in health-related contexts but without a clear model of how they work or rigorous evaluation of their impacts. We aim to develop a programme theory about how a living library could be used to improve mental health outcomes, using this theory to codesign an implementation guide that can be evaluated across different contexts.

METHODS AND ANALYSIS

We will use a novel integration of realist synthesis and experience-based codesign (EBCD) to produce a programme theory about how living libraries work and a theory and experience informed guide to establishing a library of lived experience for mental health (LoLEM). Two workstreams will run concurrently: (1) a realist synthesis of literature on living libraries, combined with stakeholder interviews, will produce several programme theories; theories will be developed collaboratively with an expert advisory group of stakeholders who have hosted or taken part in a living library and will form our initial analysis framework; a systematic search will identify literature about living libraries; data will be coded into our analysis framework, and we will use retroductive reasoning to explain living libraries' impacts across multiple contexts. Individual stakeholder interviews will help refine and test theories; (2) data from workstream 1 will inform 10 EBCD workshops with people with experience of managing mental health difficulties and health professionals to produce a LoLEM implementation guide; data from this process will also inform the theory in workstream 1.

ETHICS AND DISSEMINATION

Ethical approval was granted by Coventry and Warwick National Health Service Research Ethics Committee on 29 December 2021 (reference number 305975). The programme theory and implementation guide will be published as open access and shared widely through a knowledge exchange event, a study website, mental health provider and peer support networks, peer reviewed journals and a funders report.

PROSPERO REGISTRATION DETAILS

CRD42022312789.

The Effects of Online Self-management Interventions for Patients With Mood Disorders: Protocol for a Systematic Review and Meta-analysis

BACKGROUND

Self-management has become important as a complementary approach to the recovery of patients with mood disorders, and the need for a remote intervention program has been revealed in relation to the COVID-19 pandemic.

OBJECTIVE

The aim of this review is to systematically review the studies for evidence on the effects of online self-management interventions based on cognitive behavioral therapy or psychoeducation for patients with mood disorders and to verify the statistical significance of the effectiveness of the interventions.

METHODS

A comprehensive literature search will be conducted using a search strategy in nine electronic bibliographic databases and will include all randomized controlled trial studies conducted up through December 2021. In addition, unpublished dissertations will be reviewed to minimize publication bias and to include a wider range of research. All steps in selecting the final studies to be included in the review will be performed independently by two researchers, and any discrepancies will be resolved through discussion.

RESULTS

Institutional review board approval was not required because this study was not conducted on people. Systematic literature searches, data extraction, narrative synthesis, meta-analysis, and final writing of the systematic review and meta-analysis are expected to be completed by 2023.

CONCLUSIONS

This systematic review will provide a rationale for the development of web-based or online self-management interventions for the recovery of patients with mood disorders and will be used as a clinically meaningful reference in terms of mental health management.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45528.

Development and evaluation of a website with patients experiences of multiple sclerosis: a mixed methods study

BACKGROUND

A variety of management options (e.g., disease-modifying therapy, lifestyle interventions, rehabilitation) are available for persons with relapsing-remitting multiple sclerosis (MS). Besides coping with the diagnosis, persons with MS have to make complex decisions, e.g., regarding disease-modifying therapies. In addition to factual information, reports of patient experiences may support other patients in their decision-making. Therefore, we developed a website presenting patient experiences illustrated by video, audio and text files. This study aimed to test the acceptability and usability of a website with patient experiences with MS.

METHODS

A mixed-methods approach was applied. A total of 69 participants visited the German "Patient Experiences with MS (PExMS)" website and among them, 50 persons with MS and 6 experts completed an online survey. In total, 18 participants took part in telephone interviews or focus groups. Data from the survey were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis.

RESULTS

Both quantitative and qualitative responses suggest that the PExMS website was viewed positively by patients and experts. 94% of persons with MS agreed that the information was comprehensible and reliable. 54% felt encouraged to share their health problems with others after having studied the website. 74% claimed to use the website if they had to make a decision regarding their health. Qualitative responses deduced from the website fell into 5 key themes: (1) web design, appearance, and functionality, (2) content, (3) usability, (4) satisfaction, and (5) loyalty. The search for persons of similar age and with comparable experiences was a major driving force to navigate the website. The material on the website was perceived as diverse, covering both positive and negative experiences in daily living with MS. All participants greatly appreciated having access to other people's experiences online and judged the material on the website as particularly helpful in decision-making for disease-modifying therapies.

CONCLUSIONS

The findings suggest that the PExMS website might have the potential to be a useful source of audio-visual information for persons with MS. Given the lack of websites available to patients with experiential information, health care professionals may be encouraged to routinely inform patients about this website at regular appointments.

Use of smartphone apps in bipolar disorder: An international web-based survey of feature preferences and privacy concerns

BACKGROUND

Smartphone apps have potential for delivering interventions and supporting self-management in bipolar disorder (BD), however clinical trials of mental health apps have high dropout rates and low sustained use in real-world contexts. To support the development of app-based interventions, we explored use of and attitudes towards apps amongst people with BD, specifically concerns about privacy and preferences for various app features.

METHODS

An international web-based survey was used to investigate concerns about privacy and the perceived importance of various app features among people with BD. Quantitative findings were summarised using descriptive statistics. Qualitative content analysis was used to investigate free-text responses.

RESULTS

A total of 919 people completed the survey; 97.5% reported using smartphone apps in general. Concerns regarding data security were prevalent. Commonly prioritised mHealth features included content quality/accuracy, ease and flexibility of use, cost, and data security. The ability to share data with others, rewards for use, inter-app connectivity, and peer support were endorsed as important by fewer than half of respondents. Qualitative findings suggested that sustained app use could be supported by novel and positive content, customisation, meaningful use of data, interactivity, and perceived real-world benefits.

CONCLUSIONS

The findings of the present study offer important design considerations for the development and evaluation of future app-based interventions for BD. Importantly, some features that have previously been suggested as clinically beneficial or likely to support engagement were perceived ambivalently, emphasising the need for in-depth consultation with potential end users during app development.

A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process

BACKGROUND

Bipolar disorder is a severe mental illness characterized by recurrent episodes of depressed, elevated, and mixed mood states. The addition of psychotherapy to pharmacological management can decrease symptoms, lower relapse rates, and improve quality of life; however, access to psychotherapy is limited. Mental health technologies such as smartphone apps are being studied as a means to increase access to and enhance the effectiveness of adjunctive psychotherapies for bipolar disorder. Individuals with bipolar disorder find this intervention format acceptable, but our understanding of how people utilize and integrate these tools into their behavior change and maintenance processes remains limited.

OBJECTIVE

The objective of this study was to explore how individuals with bipolar disorder perceive and utilize a smartphone intervention for health behavior change and maintenance.

METHODS

Individuals with bipolar disorder were recruited via flyers placed at university-affiliated and private outpatient mental health practices to participate in a pilot study of LiveWell, a smartphone-based self-management intervention. At the end of the study, all participants completed in-depth qualitative exit interviews. The behavior change framework developed to organize the intervention design was used to deductively code behavioral targets and determinants involved in target engagement. Inductive coding was used to identify themes not captured by this framework.

RESULTS

In terms of behavioral targets, participants emphasized the importance of managing mood episode-related signs and symptoms. They also discussed the importance of maintaining regular routines, sleep duration, and medication adherence. Participants emphasized that receiving support from a coach as well as seeking and receiving assistance from family, friends, and providers were important for managing behavioral targets and staying well. In terms of determinants, participants stressed the important role of monitoring for their behavior change and maintenance efforts. Monitoring facilitated self-awareness and reflection, which was considered valuable for staying well. Some participants also felt that the intervention facilitated learning information necessary for managing bipolar disorder but others felt that the information provided was too basic.

CONCLUSIONS

In addition to addressing acceptability, satisfaction, and engagement, a person-based design of mental health technologies can be used to understand how people experience the impact of these technologies on their behavior change and maintenance efforts. This understanding may then be used to guide ongoing intervention development. The participants' perceptions aligned with the intervention's primary behavioral targets and use of a monitoring tool as a core intervention feature. Participant feedback further indicates that developing additional content and tools to address building and engaging social support may be an important avenue for improving LiveWell. A comprehensive behavior change framework to understand participant perceptions of their behavior change and maintenance efforts may help facilitate ongoing intervention development.

Non-use of telemedicine: A scoping review

Many telemedicine interventions fail to be implemented in medical care with non-use and discontinued use by patients being among the major reasons. The aim of this scoping review was to provide an overview of barriers associated with non-use and discontinued use of telemedicine. An electronic search was conducted in Pubmed in October 2019 and updated in November 2020, followed by a hand search in the beginning of 2021. All potential articles were screened by two independent reviewers based on predefined inclusion and exclusion criteria. A qualitative content analysis according to Mayring was carried out. The topics 'intervention', 'context of use' and 'user' were chosen as overarching themes. Out of 1377 potentially relevant articles, 73 were included. User-related barriers were mentioned in most of the analysed studies, followed by barriers related to the intervention. The analysis provides the basis for overcoming non-use issues in telemedicine.

Barriers to and Facilitators of User Engagement With Digital Mental Health Interventions: Systematic Review

Background

Digital mental health interventions (DMHIs), which deliver mental health support via technologies such as mobile apps, can increase access to mental health support, and many studies have demonstrated their effectiveness in improving symptoms. However, user engagement varies, with regard to a user’s uptake and sustained interactions with these interventions.

Objective

This systematic review aims to identify common barriers and facilitators that influence user engagement with DMHIs.

Methods

A systematic search was conducted in the SCOPUS, PubMed, PsycINFO, Web of Science, and Cochrane Library databases. Empirical studies that report qualitative and/or quantitative data were included.

Results

A total of 208 articles met the inclusion criteria. The included articles used a variety of methodologies, including interviews, surveys, focus groups, workshops, field studies, and analysis of user reviews. Factors extracted for coding were related to the end user, the program or content offered by the intervention, and the technology and implementation environment. Common barriers included severe mental health issues that hampered engagement, technical issues, and a lack of personalization. Common facilitators were social connectedness facilitated by the intervention, increased insight into health, and a feeling of being in control of one’s own health.

Conclusions

Although previous research suggests that DMHIs can be useful in supporting mental health, contextual factors are important determinants of whether users actually engage with these interventions. The factors identified in this review can provide guidance when evaluating DMHIs to help explain and understand user engagement and can inform the design and development of new digital interventions.

The Quality of Life in Bipolar Disorder (QoL.BD) Scale: Validation of a French Cross-Cultural Adaptation

OBJECTIVE

The goal of this study was to validate the French version of the Quality of Life in Bipolar Disorder (QoL.BD) scale, a condition-specific measure for bipolar disorder (BD).

METHOD

The QoL.BD scale was translated into French in accordance with the recommendations for transcultural adaptation. It was administered to 125 participants with BD living in Quebec, Canada. Construct validity was evaluated through correlations with other measures of self-reported quality of life (QoL), functioning, and symptoms. Factorial structure was examined through an exploratory factor analysis.

RESULTS

Internal reliability and test-retest reliability standards were met. Correlations in expected directions with other QoL, functioning, and depressive symptom scales supported convergent validity. The item loadings structure of the French QoL.BD largely replicated the original English version, with some modifications.

CONCLUSION

The French version of the QoL.BD (full and brief) is comparable in its psychometric properties to the English version. It is a valid and sound measure for the evaluation of the QoL of French-speaking patients with BD.

The Quality of Life in Bipolar Disorder (QoL.BD) questionnaire a decade on - A systematic review of the measurement of condition-specific aspects of quality of life in bipolar-disorder

BACKGROUND

Condition-specific quality of life (QoL) instruments are more representative of the priorities of people with lived experience. As such, the development of the first and only bipolar disorder (BD) specific measurement instrument, the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire, marked an important step forward for the literature. The present systematic review aims to characterise applications of the QoL.BD in the BD literature and review empirical findings obtained from studies using this measure.

METHODS

A systematic search identified 37 peer-reviewed publications which reported original empirical data using the QoL.BD in a BD population. No restrictions were placed on language/study type.

RESULTS

Adaptations to the QoL.BD displayed appropriate psychometric properties. Although clinical trials were typically underpowered, promising effect sizes for a number of treatment modalities were reported. QoL.BD scores were moderately correlated with depressive symptoms; a number of candidate predictors were identified.

LIMITATIONS

Due to resource limitations, the present review used one database (Google Scholar), and a single author reviewed articles for eligibility. On balance the risks of missing relevant studies were deemed minimal.

CONCLUSION

A sizeable, international body of evidence now exists regarding the measurement, presentation, and treatment of condition-specific aspects of QoL in BD. Key avenues for future research include large scale, randomized control clinical trials using the QoL.BD as a primary outcome, and granular exploration of potential correlates of QoL.BD domain scores. Finally, longer follow-up periods are required to inform understanding of the dynamic relationship between clinical variables and condition-specific aspects of QoL in BD.

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

OBJECTIVES

To provide advice and guidance regarding the management of mood disorders, derived from scientific evidence and supplemented by expert clinical consensus to formulate s that maximise clinical utility.

METHODS

Articles and information sourced from search engines including PubMed, EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (e.g. books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Relevant information was appraised and discussed in detail by members of the mood disorders committee, with a view to formulating and developing consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous consultation and external review involving: expert and clinical advisors, key stakeholders, professional bodies and specialist groups with interest in mood disorders.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines 2020 (MDcpg²⁰²⁰) provide up-to-date guidance regarding the management of mood disorders that is informed by evidence and clinical experience. The guideline is intended for clinical use by psychiatrists, psychologists, primary care physicians and others with an interest in mental health care.

CONCLUSION

The MDcpg²⁰²⁰ builds on the previous 2015 guidelines and maintains its joint focus on both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

MOOD DISORDERS COMMITTEE

Gin S Malhi (Chair), Erica Bell, Darryl Bassett, Philip Boyce, Richard Bryant, Philip Hazell, Malcolm Hopwood, Bill Lyndon, Roger Mulder, Richard Porter, Ajeet B Singh and Greg Murray.

Engaging Youth in the Bipolar Youth Action Project: Community-Based Participatory Research

BACKGROUND

We describe the methodological dimensions of community-based participatory research through a description of study design, youth engagement, and methods/processes in the cocreation of knowledge within a Canadian study, the Bipolar Youth Action Project. This collaborative partnership-carried out by a team composed of academic, community, and youth partners-was designed to investigate self-management and wellness strategies for young adults living with bipolar disorder.

OBJECTIVE

The aim is to describe the opportunities and challenges of this collaboration and to reflect upon the process of involving youth with bipolar disorder in health research that concerns them, and share lessons learned.

METHODS

The project was conducted in multiple phases over 2 years: (1) grant-writing, with youth contributing to the process; (2) recruitment, in which 12 youth were selected and trained to help shape and conduct two research forums; (3) the first research forum, where more youth were consulted about the strategies they apply to stay well (self-management strategies); (4) data analysis of Forum I findings; (5) research Forum II, which consulted youth with bipolar disorder about knowledge translation of Forum I findings; and (6) data analysis of Forum II findings. Youth peer researchers with bipolar disorder were involved in a significant capacity at every stage in the process.

RESULTS

Of the initial 12 youth peer researchers, 7 remained on the project from the recruitment phase until the project ended. They collaborated in the creation of two youth research forums that consulted youth with bipolar disorder on their self-management strategies.

CONCLUSIONS

This article shares what was learned from the process of partnering with youth with bipolar disorder in a community-based participatory research study.

Digital solutions for shaping mood and behavior among individuals with mood disorders

Mood disorders present on-going challenges to the medical field, with difficulties ranging from establishing effective treatments to understanding complexities of one's mood. One solution is the use of mobile apps and wearables for measuring physiological symptoms and real-time mood in order to shape mood and behavior. Current digital research is focused on increasing engagement in monitoring mood, uncovering mood dynamics, predicting mood, and providing digital microinterventions. This review discusses the importance and risks of user engagement, as well as barriers to improving it. Research on mood dynamics highlights the possibility to reveal data-driven computational phenotypes that could guide treatment. Mobile apps are being used to track voice patterns, GPS, and phone usage for predicting mood and treatment response. Future directions include utilizing mobile apps to deliver and evaluate microinterventions. To continue these advances, standardized reporting and study designs should be considered to improve digital solutions for mood disorders.

A Web-Based Adaptation of the Quality of Life in Bipolar Disorder Questionnaire: Psychometric Evaluation Study

BACKGROUND

Quality of life (QoL) is considered a key treatment outcome in bipolar disorder (BD) across research, clinical, and self-management contexts. Web-based assessment of patient-reported outcomes offer numerous pragmatic benefits but require validation to ensure measurement equivalency. A web-based version of the Quality of Life in Bipolar Disorder (QoL.BD) questionnaire was developed (QoL Tool).

OBJECTIVE

This study aimed to evaluate the psychometric properties of a web-based QoL self-report questionnaire for BD (QoL Tool). Key aims were to (1) characterize the QoL of the sample using the QoL Tool, (2) evaluate the internal consistency of the web-based measure, and (3) determine whether the factor structure of the original version of the QoL.BD instrument was replicated in the web-based instrument.

METHODS

Community-based participatory research methods were used to inform the development of a web-based adaptation of the QoL.BD instrument. Individuals with BD who registered for an account with the QoL Tool were able to opt in to sharing their data for research purposes. The distribution of scores and internal consistency estimates, as indicated by Cronbach alpha, were inspected. An exploratory factor analysis using maximum likelihood and oblique rotation was conducted. Inspection of the scree plot, eigenvalues, and minimum average partial correlation were used to determine the optimal factor structure to extract.

RESULTS

A total of 498 people with BD (349/498, 70.1% female; mean age 39.64, SD 12.54 years; 181/498, 36.3% BD type I; 195/498, 39.2% BD type II) consented to sharing their QoL Tool data for the present study. Mean scores across the 14 QoL Tool domains were, in general, significantly lower than that of the original QoL.BD validation sample. Reliability estimates for QoL Tool domains were comparable with that observed for the QoL.BD instrument (Cronbach alpha=.70-.93). Exploratory factor analysis supported the extraction of an 11-factor model, with item loadings consistent with the factor structure suggested by the original study. Findings for the sleep and physical domains differed from the original study, with this analysis suggesting one shared latent construct.

CONCLUSIONS

The psychometric properties of the web-based QoL Tool are largely concordant with the original pen-and-paper QoL.BD, although some minor differences in the structure of the sleep and physical domains were observed. Despite this small variation from the factor structure identified in the QoL.BD instrument, the latent factor structure of the QoL Tool largely reproduced the original findings and theoretical structure of QoL areas relevant to people with BD. These findings underscore the research and clinical utility of this instrument, but further comparison of the psychometric properties of the QoL Tool relative to the QoL.BD instrument is warranted. Future adaptations of the QoL Tool, including the production of an app-based version of the QoL Tool, are also discussed.

Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration

BACKGROUND

Self-monitoring of symptoms is a cornerstone of psychological interventions in bipolar disorder (BD), but individuals with lived experience also value tracking holistic outcomes, such as quality of life (QoL). Importantly, self-monitoring is not always experienced positively by people with BD and may have lower than expected rates of engagement. Therefore, before progressing into QoL tracking tools, it is important to explore user perspectives to identify possible risks and benefits, optimal methods to support engagement, and possible avenues to integrate QoL self-monitoring practices into clinical work.

OBJECTIVE

This study aimed to conduct a qualitative exploration of how individuals with BD engaged with a Web-based version of a BD-specific QoL self-monitoring instrument, the QoL tool.

METHODS

A total of 43 individuals with BD engaged with a self-management intervention with an optional Web-based QoL self-assessment tool as part of an overarching mixed method study. Individuals were later interviewed about personal experiences of engagement with the intervention, including experiences of gauging their own QoL. A thematic analysis was used to identify salient aspects of the experience of QoL self-monitoring in BD.

RESULTS

In total, 4 categories describing people's experiences of QoL self-monitoring were identified: (1) breadth of QoL monitoring, (2) highlighting the positive, (3) connecting self-monitoring to action, and (4) self-directed patterns of use.

CONCLUSIONS

The findings of this research generate novel insights into ways in which individuals with BD experience the Web-based QoL self-assessment tool. The value of tracking the breadth of domains was an overarching aspect, facilitating the identification of both areas of strength and life domains in need of intervention. Importantly, monitoring QoL appeared to have an inherently therapeutic quality, through validating flourishing areas and reinforcing self-management efforts. This contrasts the evidence suggesting that symptom tracking may be distressing because of its focus on negative experiences and positions QoL as a valuable adjunctive target of observation in BD. Flexibility and personalization of use of the QoL tool were key to engagement, informing considerations for health care providers wishing to support self-monitoring and future research into Web- or mobile phone-based apps.