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

A systematic review of predictors and moderators of treatment outcomes in internet- and mobile-based interventions for depression

This systematic review aimed to synthesize evidence on predictors and moderators of treatment outcomes in internet- and mobile-based interventions (IMIs) for depression, informing personalized care. A systematic search across PubMed, PsycInfo, and Cochrane yielded 33,002 results. Two reviewers independently performed screening, data extraction, risk of bias assessment, and methodological quality evaluation. Fifty-eight single studies (m = 466 analyses) focusing on baseline-predictors (59.7 %, m = 278), process-predictors (16.5 %, m = 77), and moderators (21.9 %, m = 102), and six individual patient data meta-analyses (m = 93) were included. Only 24.0 % (m = 112/466) of analyses in single studies and 15.1 % (m = 14/93) in individual patient data meta-analyses were significant. Evidence from single studies was rated as insufficient for all variable categories with only 2 out of 40 categories showing >50 % significant results. Baseline depression severity had the strongest predictive value with higher scores linked to better outcomes followed by variables indicative for the course-of-change. Other frequently analyzed and potentially relevant variables with significant results were adherence, age, educational level, ethnicity, relationship status, treatment history, and behavioral variables. More high quality quantitative studies with sufficient power are essential to validate and expand findings, identifying predictors and moderators specifically relevant in IMIs to explain differential treatment effects.

Skill Enactment Among University Students Using a Brief Video-Based Mental Health Intervention: Mixed Methods Study Within a Randomized Controlled Trial

BACKGROUND

Mental health problems are common among university students, yet many students do not seek professional help. Digital mental health interventions can increase students' access to support and have been shown to be effective in preventing and treating mental health problems. However, little is known about the extent to which students implement therapeutic skills from these programs in everyday life (ie, skill enactment) or about the impact of skill enactment on outcomes.

OBJECTIVE

This study aims to assess the effects of a low-intensity video-based intervention, Uni Virtual Clinic Lite (UVC-Lite), in improving skill enactment relative to an attention-control program (primary aim) and examine whether skill enactment influences symptoms of depression and anxiety (secondary aim). The study also qualitatively explored participants' experiences of, and motivations for, engaging with the therapeutic techniques.

METHODS

We analyzed data from a randomized controlled trial testing the effectiveness of UVC-Lite for symptoms of depression and anxiety among university students with mild to moderate levels of psychological distress. Participants were recruited from universities across Australia and randomly assigned to 6 weeks of self-guided use of UVC-Lite (243/487, 49.9%) or an attention-control program (244/487, 50.1%). Quantitative data on skill enactment, depression, and anxiety were collected through baseline, postintervention, and 3- and 6-month follow-up surveys. Qualitative data were obtained from 29 intervention-group participants through open-ended questions during postintervention surveys (n=17, 59%) and semistructured interviews (n=12, 41%) after the intervention period concluded.

RESULTS

Mixed model repeated measures ANOVA demonstrated that the intervention did not significantly improve skill enactment (F3,215.36=0.50; P=.68). Skill enactment was also not found to influence change in symptoms of depression (F3,241.10=1.69; P=.17) or anxiety (F3,233.71=1.11; P=.35). However, higher levels of skill enactment were associated with lower symptom levels among both intervention and control group participants across time points (depression: F1,541.87=134.61; P<.001; anxiety: F1,535.11=73.08; P<.001). Inductive content analysis confirmed low levels of skill enactment among intervention group participants. Participants were motivated to use techniques and skills that were perceived to be personally relevant, easily integrated into daily life, and that were novel or had worked for them in the past.

CONCLUSIONS

The intervention did not improve skill enactment or mental health among students with mild to moderate psychological distress. Low adherence impacted our ability to draw robust conclusions regarding the intervention's impact on outcomes. Factors influencing skill enactment differed across individuals, suggesting that it may be necessary to tailor therapeutic skills and engagement strategies to the individual user. Theoretically informed research involving collaboration with end users is needed to understand the processes underlying skill enactment in digital mental health interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000375853; https://tinyurl.com/7b9ar54r.

Skill enactment and knowledge acquisition among community users of digital mental health interventions: qualitative study with thematic analysis

BACKGROUND

The acquisition of knowledge and use of skills from digital mental health interventions (DMHIs) are considered important for effectiveness. However, our understanding of user experiences implementing skills learned from these interventions is limited, particularly outside of research trials. This qualitative study aimed to investigate how community users learn and apply knowledge and skills from DMHIs based on cognitive behavioural therapy (CBT) in daily life. The study also examined factors influencing the selection and use of skills and explored perceived changes in mental health resulting from the intervention.

METHODS

Thirteen adults aged 26 to 66 years (10 females) were recruited using social media advertising and participated in semi-structured interviews by telephone or videoconference. All participants were living in Australia and had used a digital CBT program within the past 3 months. Interviews lasted on average 45 min. Transcripts were analysed using theoretical thematic analysis.

RESULTS

Participants demonstrated high levels of program engagement. Findings were organised into three topics with six major themes. Participants reported that their chosen intervention reinforced existing knowledge and fostered new skills and insights (Topic 1, Theme 1: knowledge consolidation). Most described actively applying skills (Topic 1, Theme 2: active approach to skill enactment), although the extent of learning and range of skills enacted varied across participants. Influences on skill selection included the perceived relevance of intervention strategies to the user's needs and personal characteristics (Topic 2, Theme 1: relevance of intervention strategies), as well as the perceived or experienced effectiveness of those strategies (Topic 2, Theme 2: perceived and experienced benefit). Challenges to ongoing skill enactment included time scarcity, prioritisation difficulties, and lack of motivation (Topic 2, Theme 3: navigating time constraints and low motivation). Improvements in mental health were generally modest and attributed mainly to participants' proactive efforts (Topic 3, Theme 1: perceived changes).

CONCLUSIONS

DMHIs may reinforce existing understanding of psychotherapeutic strategies, offer new knowledge, and encourage the application of skills in everyday life among community users who actively engage with these interventions. Future research should prioritise personalising DMHIs and investigating methods to optimise the acquisition, retention, and sustained application of knowledge and skills.

An internet-based self-help intervention for the reduction of consumption of ultra-processed products and increase of physical activity in Mexican university population: study protocol for a randomized controlled trial

Introduction

The consumption of ultra-processed products has been associated with the etiology of various diseases, mainly metabolic diseases. On the other hand, physical activity acts as a protective factor that helps prevent the appearance of this type of disease. In addition to the physical effects, both the consumption of ultra-processed products (UPPs) and sedentary behaviors have been associated with a significant impact on people's mental health. These problems occur significantly in university students. Online internet interventions are an alternative that has the advantage of reaching a broader sample size and adapting to various problems.

Methods

A randomized controlled clinical superiority trial with two independent groups will be developed with 176 participants. Participants in both groups will be evaluated in 5 steps: (1) pretest, (2) middle of the intervention, (3) post-test, (4) follow-up at 3 months, and (5) follow-up at 6 months. In the experimental group ("UNISALUD"), participants will receive an intervention composed of 11 sessions with interactive elements such as videos, audio, and infographics created through the user experience (UX) principles and based on the health action process approach (HAPA). The participants in the control group will be on the waiting list and will receive treatment 27 days after fulfilling the inclusion criteria. Thus, participants will not receive the treatment immediately.

Discussion

The study is expected to establish the feasibility of a self-help internet-based intervention created based on the user experience methodology and the health action process model, leading to a significant decrease and increase in the consumption of UPPs, ultra-healthy products, and physical activity, respectively.

Conclusion

Internet-based interventions are scarce in Latin America. Due to their potential, this study will provide data about consumption of UPPs, physical activity, and mental health of the Mexican population, which will influence the reduction of health-related complications through prevention strategies or measures.Clinical Trial Registration:ClinicalTrials.gov, NCT05834842.

Dose‒Response Effects of Patient Engagement on Anxiety and Depression in a Cognitive-Behavioral Intervention: Secondary Analysis of a Pilot Randomized Controlled Trial and a Clinical Controlled Trial

Understanding the dose‒response relationship between patient engagement in cognitive behavioral therapy (CBT) and health outcomes is critical for developing and implementing effective CBT programs. In studies of CBT interventions, patient engagement is measured only at a single time point, and outcomes are typically assessed before and after the intervention. Examination of the dose‒response relationship between patient engagement in CBT and outcomes is limited. It is unclear whether a dose‒response relationship exists between patient engagement in on-site CBT intervention and anxiety and depression in people living with HIV (PLWH). If present, does this dose‒response relationship occur early or later in the intervention? This study aimed to address this gap by examining the dose‒response relationships between patient engagement and anxiety and depression in CBT interventions among PLWH. Utilizing data from a pilot randomized trial (10 participants) and a clinical controlled trial (70 participants), our secondary analysis spans baseline, 3-month, and 6-month assessments. Both trials implemented the nurse-led CBT intervention. Cluster analysis identified two groups based on on-site attendance and WeChat activity. Patients with good adherence (6-10 times) of on-site attendance exhibited significantly lower anxiety and depression scores at 3 months (β = 1.220, P = 0.047; β = 1.270, P = 0.019), with no significant differences observed at 6 months. WeChat activity did not significantly influence anxiety or depression scores. The findings highlight a significant short-term dose‒response relationship, endorsing nurse-led CBT interventions for mental health in PLWH. Organizational strategies should focus on incentivizing and facilitating patient engagement, particularly through enhancing WeChat features.

Effects of a Chatbot-Based Intervention on Stress and Health-Related Parameters in a Stressed Sample: Randomized Controlled Trial

BACKGROUND

Stress levels and the prevalence of mental disorders in the general population have been rising in recent years. Chatbot-based interventions represent novel and promising digital approaches to improve health-related parameters. However, there is a lack of research on chatbot-based interventions in the area of mental health.

OBJECTIVE

The aim of this study was to investigate the effects of a 3-week chatbot-based intervention guided by the chatbot ELME, specifically with respect to the ability to reduce stress and improve various health-related parameters in a stressed sample.

METHODS

In this multicenter two-armed randomized controlled trial, 118 individuals with medium to high stress levels were randomized to the intervention group (n=59) or the treatment-as-usual control group (n=59). The ELME chatbot guided participants of the intervention group through 3 weeks of training based on the topics stress, mindfulness, and interoception, with practical and psychoeducative elements delivered in two daily interactive intervention sessions via a smartphone (approximately 10-20 minutes each). The primary outcome (perceived stress) and secondary outcomes (mindfulness; interoception or interoceptive sensibility; subjective well-being; and emotion regulation, including the subfacets reappraisal and suppression) were assessed preintervention (T1), post intervention (T2; after 3 weeks), and at follow-up (T3; after 6 weeks). During both conditions, participants also underwent ecological momentary assessments of stress and interoceptive sensibility.

RESULTS

There were no significant changes in perceived stress (β03=-.018, SE=.329; P=.96) and momentary stress. Mindfulness and the subfacet reappraisal significantly increased in the intervention group over time, whereas there was no change in the subfacet suppression. Well-being and momentary interoceptive sensibility increased in both groups over time.

CONCLUSIONS

To gain insight into how the intervention can be improved to achieve its full potential for stress reduction, besides a longer intervention duration, specific sample subgroups should be considered. The chatbot-based intervention seems to have the potential to improve mindfulness and emotion regulation in a stressed sample. Future chatbot-based studies and interventions in health care should be designed based on the latest findings on the efficacy of rule-based and artificial intelligence-based chatbots.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00027560; https://drks.de/search/en/trial/DRKS00027560.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi.org/10.3389/fdgth.2023.1046202.

Predictors, mediators, and moderators of response to digital interventions for eating disorders: A systematic review

OBJECTIVE

Digital interventions show promise as an effective prevention or self-management option for eating disorders (EDs). However, it remains unclear how, for whom, and through what mechanisms they work in this population, as a synthesis of outcome predictors, moderators, and mediators is lacking. This systematic review synthesized empirical research investigating predictors, mediators, and moderators of response to digital interventions for EDs.

METHOD

Six databases were searched (PROSPERO CRD42022295565) for studies that assessed predictors, moderators, or mediators of response (i.e., uptake, drop-out, engagement, and symptom level change) to a digital prevention or treatment program for EDs. Variables were grouped into several overarching categories (demographic, symptom severity, psychological, etc.) and were synthesized qualitatively across samples without a formally diagnosed ED (typically prevention-focused) and samples with a formally diagnosed ED (typically treatment-focused).

RESULTS

Eighty-six studies were included. For studies recruiting samples without a formal diagnosis (n = 70 studies), most predictors explored were statistically unrelated to outcome, although participant age, baseline symptom severity, confidence to change, motivation, and program engagement showed preliminary evidence of prognostic potential. No robust moderators or mediators were identified. Few studies recruiting samples with a formal diagnosis emerged (n = 16), of which no reliable predictors, moderators, or mediators were identified.

DISCUSSION

It remains unclear how, for whom, and under what circumstances digital programs targeting EDs work. We offer several recommendations for future research with the aim of advancing understanding of client characteristics and intervention elements that signal success from this intervention modality.

PUBLIC SIGNIFICANCE

Digital interventions have shown potential as an effective, scalable, and accessible intervention option for EDs. However, responsiveness varies, so advancing understanding of predictors, mediators, and moderators of outcome to digital interventions for EDs is needed. Such knowledge is important for enabling safe and efficient treatment matching, and for informing future development of effective digital interventions.

Thinking flexibly about who digital mental health interventions are for and how they should be evaluated and used: Commentary on McClure et al. (2023)

Less than 20% of individuals with eating disorders (EDs) ever receive treatment. Digital interventions offer one solution to this problem and have demonstrated promise, but there is a need to understand predictors, moderators, and mediators of response, which McClure and colleagues aimed to do in their systematic review. Yet their review also raised key definitional and measurement issues pertinent to conducting research on digital interventions for EDs and other mental health problems, which may have impacted the conclusions drawn and which may stem from applying what has "always been done" in research on more traditional psychological interventions to research on digital interventions. This commentary suggests that digital interventions for EDs and other mental health problems should not be conceived as a 1:1 replacement for individual psychotherapy, and rather, these interventions should be viewed as one option in a wide-ranging menu of services that should be available, as the reality is that not all individuals want or can access the same type of care. If we accept that digital interventions need not be viewed as a 1:1 replacement for psychotherapy, then it logically follows that we should not evaluate or use these two approaches in the exact same manner.

Effects of niacin on apo A1 and B levels: a systematic review and meta-analysis of randomised controlled trials

Niacin has been investigated for its potential impact on lipid metabolism and cardiovascular health. This meta-analysis aims to systematically evaluate the effects of niacin interventions on apo A1 and apo B levels, key regulators of lipoprotein metabolism and markers of cardiovascular risk. A comprehensive search of the literature was performed on five databases of PubMed, Scopus, Web of Science, Embase and Cochrane library, from inception up to 15 July 2023. This search identified 1452 publications, from which twelve randomised controlled trials met the inclusion criteria. The intervention dosages ranged from 500 to 3000 mg/d, and the study durations spanned from 6 to 102·8 weeks. The niacin intervention demonstrated a significant reduction in apo B levels (weighted mean differences (WMD): -24·37 mg/dl, P = 0·01). Subgroup analyses indicated that intervention duration played a role, with trials of ≤ 16 weeks showing a greater reduction in apo B. Regarding apo A1, niacin significantly increased its levels (WMD: 8·23 mg/dl, P < 0·001). Subgroup analyses revealed that the beneficial effects of niacin on apo A1 were observed at a dosage of > 1500 mg/d (P < 0·001), and extended-release niacin was more effective compared with other forms (P < 0·001). According to the Begg's regression test, no publication bias was observed in this systematic review and meta-analysis. This meta-analysis highlights niacin's potential role in improving lipid profiles and cardiovascular health. Further well-designed clinical trials are needed to elucidate and confirm optimal dosages and durations of niacin interventions for influencing apo A1 and B.

Methodological Frameworks and Dimensions to Be Considered in Digital Health Technology Assessment: Scoping Review and Thematic Analysis

BACKGROUND

Digital health technologies (dHTs) offer a unique opportunity to address some of the major challenges facing health care systems worldwide. However, the implementation of dHTs raises some concerns, such as the limited understanding of their real impact on health systems and people's well-being or the potential risks derived from their use. In this context, health technology assessment (HTA) is 1 of the main tools that health systems can use to appraise evidence and determine the value of a given dHT. Nevertheless, due to the nature of dHTs, experts highlight the need to reconsider the frameworks used in traditional HTA.

OBJECTIVE

This scoping review (ScR) aimed to identify the methodological frameworks used worldwide for digital health technology assessment (dHTA); determine what domains are being considered; and generate, through a thematic analysis, a proposal for a methodological framework based on the most frequently described domains in the literature.

METHODS

The ScR was performed in accordance with the guidelines established in the PRISMA-ScR guidelines. We searched 7 databases for peer reviews and gray literature published between January 2011 and December 2021. The retrieved studies were screened using Rayyan in a single-blind manner by 2 independent authors, and data were extracted using ATLAS.ti software. The same software was used for thematic analysis.

RESULTS

The systematic search retrieved 3061 studies (n=2238, 73.1%, unique), of which 26 (0.8%) studies were included. From these, we identified 102 methodological frameworks designed for dHTA. These frameworks revealed great heterogeneity between them due to their different structures, approaches, and items to be considered in dHTA. In addition, we identified different wording used to refer to similar concepts. Through thematic analysis, we reduced this heterogeneity. In the first phase of the analysis, 176 provisional codes related to different assessment items emerged. In the second phase, these codes were clustered into 86 descriptive themes, which, in turn, were grouped in the third phase into 61 analytical themes and organized through a vertical hierarchy of 3 levels: level 1 formed by 13 domains, level 2 formed by 38 dimensions, and level 3 formed by 11 subdimensions. From these 61 analytical themes, we developed a proposal for a methodological framework for dHTA.

CONCLUSIONS

There is a need to adapt the existing frameworks used for dHTA or create new ones to more comprehensively assess different kinds of dHTs. Through this ScR, we identified 26 studies including 102 methodological frameworks and tools for dHTA. The thematic analysis of those 26 studies led to the definition of 12 domains, 38 dimensions, and 11 subdimensions that should be considered in dHTA.

Precision computerised cognitive behavioural therapy (cCBT) for adolescents with depression: a pilot and feasibility randomised controlled trial protocol for SPARX-UK

BACKGROUND

A serious game called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), originally developed in New Zealand and incorporating cognitive behavioural therapy (CBT) principles, has been shown to help reduce symptoms of depression and anxiety in adolescents with mild to moderate depression in studies undertaken in Australasia. However, SPARX has never been trialled in the United Kingdom (UK), and there have been issues relating to low engagement when it has been used in a real-world context.

AIMS

To conduct the first pilot and feasibility randomised controlled trial (RCT) in England to explore the use of SPARX in different settings. The trial will explore whether SPARX supported by an e-coach (assistant psychologists) improves adherence and engagement compared with self-directed (i.e. self-help) use. The trial results will be used to inform the optimal mode of delivery (SPARX supported vs. SPARX self-directed), to calculate an appropriate sample size for a full RCT, and to decide which setting is most suitable.

METHODS

Following consultation with young people to ensure study suitability/appropriateness, a total of 120 adolescents (11-19 years) will be recruited for this three-arm study. Adolescents recruited for the study across England will be randomised to receive either SPARX with human support (from an e-coach), self-directed SPARX, or a waitlist control group. Assessments will be conducted online at baseline, week 4, and 8-10-week post-randomisation. The assessments will include measures which capture demographic, depression (Patient Health Questionnaire modified for adolescents [PHQ-A]) and anxiety (Revised Child Anxiety and Depression Scale [RCADS]) symptomatology, and health-related quality-of-life data (EQ-5D-Y and proxy version). Analyses will be primarily descriptive. Qualitative interviews will be undertaken with a proportion of the participants and clinical staff as part of a process evaluation, and the qualitative data gathered will be thematically analysed. Finally, feasibility data will be collected on recruitment details, overall study uptake and engagement with SPARX, participant retention, and youth-reported acceptability of the intervention.

DISCUSSION

The findings will inform the design of a future definitive RCT of SPARX in the UK. If the subsequent definitive RCT demonstrates that SPARX is effective, then an online serious game utilising CBT principles ultimately has the potential to improve the provision of care within the UK's health services if delivered en masse.

TRIAL REGISTRATION

ISRCTN: ISRCTN15124804. Registered on 16 January 2023, https://www.isrctn.com/ISRCTN15124804 .

Adherence to a reproductive health intervention for young adults with sickle cell

BACKGROUND

The CHOICES intervention is tailored specifically for young adults with sickle cell disease (SCD) or sickle cell trait (SCT). The face-to-face (F2F) delivery format is feasible with efficacy for improving knowledge about reproductive health for those with SCD or SCT.

PURPOSE

The purpose of the study was to compare the participant adherence to a remote online CHOICES intervention study (N = 107) and a F2F CHOICES intervention study (N = 234).

METHODOLOGY

In both studies, participants with SCD or SCT were randomized into experimental or usual care control groups. Descriptive statistics were collected for all participants by group in both studies. Adherence was measured by retention at each data collection time point. Independent t-tests were conducted to compare mean participant adherence of the F2F and online studies postbaseline (6, 12, 18, and 24 months).

RESULTS

There was a significant difference in mean adherence postbaseline between the studies (p = .005). The results suggest that more research is necessary for proper online participant retention.

CONCLUSION

Advance practice nurses that are well informed on CHOICES can transmit the availability of this evidence-based intervention to this special population. Special referral for the CHOICES intervention, which is tailored specifically for young adults with SCD or SCT, may increase adherence to the intervention if it comes from trusted health care providers.

IMPLICATIONS

Nurse practitioners are educators in primary and acute care settings. Encounters with reproductive age populations with SCD or SCT can occur in both settings.

A systematic review on adherence to continuous positive airway pressure (CPAP) treatment for obstructive sleep apnoea (OSA) in individuals with mild cognitive impairment and Alzheimer's disease dementia

Obstructive sleep apnoea (OSA) is highly prevalent in mild cognitive impairment (MCI) and Alzheimer's disease (AD). The gold standard treatment for OSA is continuous positive airway pressure (CPAP). Long-term, well-powered efficacy trials are required to understand whether CPAP could slow cognitive decline in individuals with MCI/AD, but its tolerability in this group remains uncertain. The present review investigates CPAP adherence among individuals with OSA and MCI/AD. Electronic searches were performed on 8 databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Six independent studies and four secondary analyses included 278 unique participants (mean age = 72.1 years). In five of the retained studies, around half of participants (45% N = 85 MCI, 56% N = 22 AD) were adherent to CPAP, where ≥4 h use per night was considered adherent. Three of the retained studies also reported average CPAP use to range between 3.2 and 6.3 h/night. CPAP adherence in individuals with MCI and AD is low, albeit similar to the general elderly population. Reporting adherence in future studies as both average duration as well as using a binary cut-off would improve our understanding of the optimum CPAP use in dementia clinical trials and care.

Dataset size versus homogeneity: A machine learning study on pooling intervention data in e-mental health dropout predictions

Objective

This study proposes a way of increasing dataset sizes for machine learning tasks in Internet-based Cognitive Behavioral Therapy through pooling interventions. To this end, it (1) examines similarities in user behavior and symptom data among online interventions for patients with depression, social anxiety, and panic disorder and (2) explores whether these similarities suffice to allow for pooling the data together, resulting in more training data when prediction intervention dropout.

Methods

A total of 6418 routine care patients from the Internet Psychiatry in Stockholm are analyzed using (1) clustering and (2) dropout prediction models. For the latter, prediction models trained on each individual intervention's data are compared to those trained on all three interventions pooled into one dataset. To investigate if results vary with dataset size, the prediction is repeated using small and medium dataset sizes.

Results

The clustering analysis identified three distinct groups that are almost equally spread across interventions and are instead characterized by different activity levels. In eight out of nine settings investigated, pooling the data improves prediction results compared to models trained on a single intervention dataset. It is further confirmed that models trained on small datasets are more likely to overestimate prediction results.

Conclusion

The study reveals similar patterns of patients with depression, social anxiety, and panic disorder regarding online activity and intervention dropout. As such, this work offers pooling different interventions' data as a possible approach to counter the problem of small dataset sizes in psychological research.

Self-directed versus peer-supported digital self-management programmes for mental and sexual wellbeing after acquired brain injury (HOPE4ABI): protocol for a feasibility randomised controlled trial

BACKGROUND

Acquired brain injury (ABI) can lead to biopsychosocial changes such as depression, low self-esteem and fatigue. These changes can cause, and be caused by, sexual issues affecting relationships and wellbeing. Given the relationship between sexual wellbeing and mental health, it is feasible that supporting sexual wellbeing will benefit psychological wellbeing. However, neurorehabilitation is inconsistent and often fragmented across the UK, and psychological, sexual and social support are lacking. Research shows that self-management and peer-support programmes can improve quality of life, self-efficacy and psychological wellbeing after brain injury. This protocol describes a feasibility randomised controlled trial (RCT) of a digital self-management programme to support mental and sexual wellbeing (known as HOPE4ABI), co-designed with and for people with ABI.

METHODS

This mixed-methods feasibility RCT has two parallel trial arms of the 8-week digital HOPE4ABI self-management programme. Eligibility criteria include age > 18 years, diagnosed or suspected ABI > 3 months prior to trial entry, access to an Internet-enabled device and ability to engage with the intervention. Referrals to the study website will be made via the National Health Service (NHS), social media and partnering organisations. Sixty eligible participants will be randomised at a ratio of 1:1 to peer-supported (n = 30) or self-directed (n = 30) HOPE4ABI programmes. Primary feasibility outcomes include recruitment and retention rates, engagement, adherence and usage. Secondary outcomes related to standardised measures of quality of life, sexual wellbeing and mental wellbeing. Participants and peer facilitators will be interviewed after the course to assess acceptability across both trial arms.

DISCUSSION

This feasibility trial data is not sufficiently powered for inferential statistical analyses but will provide evidence of the feasibility of a full RCT. Quantitative trial data will be analysed descriptively, and participant screening data representing age, ethnicity and gender will be presented as proportions at the group level. These data may indicate trends in reach to particular demographic groups that can inform future recruitment strategies to widen participation. Progression to a definitive trial will be justified if predetermined criteria are met, relating to recruitment, retention, engagement and acceptability.

TRIAL REGISTRATION

ISRCTN46988394 registered on March 1, 2023.

Rates of attrition and engagement in randomized controlled trials of mindfulness apps: Systematic review and meta-analysis

Randomized controlled trials (RCT) have established the efficacy of mindfulness apps for numerous mental health and behavioral outcomes. However, studies of this kind are characterized by significant problems with attrition and engagement, making it challenging to interpret these findings and realize the full potential of mindfulness app-based solutions. This systematic review and meta-analysis aimed to examine rates of attrition from, and engagement in, mindfulness apps in 70 RCTs located through four databases. The weighted meta-analytic attrition rate from 9258 participants allocated to a mindfulness app was 24.7%. This estimate was higher (38.7%) when restricting analyses to larger studies (n ≥ 100 per condition) and for specific target samples (e.g., general population of adults). Studies that offered participants monetary compensation and required in-person enrolment methods were associated with the lowest attrition rates. Attrition was higher in mindfulness app conditions relative to waitlists, but was not different to placebo or active apps. Although engagement data were inadequately reported, qualitative synthesis highlighted clear problems with sustained user engagement with mindfulness apps. Findings have implications for powering, designing and appraising research trials of mindfulness apps, as well as the development of potentially effective retention and engagement strategies worthy of evaluation in future work.

A systematic review and meta-analysis of self-guided online acceptance and commitment therapy as a transdiagnostic self-help intervention

Online Acceptance and Commitment Therapy (ACT) interventions use websites and smartphone apps to deliver ACT exercises and skills. The present meta-analysis provides a comprehensive review of online ACT self-help interventions, characterizing the programs that have been studied (e.g. platform, length, content) and analyzing their efficacy. A transdiagnostic approach was taken, including studies that addressed a range of targeted problems and populations. Multi-level meta-analyses were used to nest multiple measures of a single construct within their respective studies. A total of 53 randomized controlled trials were included (n = 10,730). Online ACT produced significantly greater outcomes than waitlist controls at post-treatment for anxiety, depression, quality of life, psychological flexibility, and all assessed outcomes (i.e. omnibus effect), which were generally maintained at follow-up. However, only psychological flexibility and all assessed outcomes at post-treatment were found to be significantly greater for online ACT when compared to active controls, with no significant follow-up effects. Overall, these results further clarify that ACT can be effectively delivered in an online format to target a wide range of mental health concerns, although it is less clear if and when online ACT is more efficacious than other online interventions.

A Three-Armed Randomized Controlled Trial to Evaluate the Effectiveness, Acceptance, and Negative Effects of StudiCare Mindfulness, an Internet- and Mobile-Based Intervention for College Students with No and "On Demand" Guidance

The college years can be accompanied by mental distress. Internet- and mobile-based interventions (IMIs) have the potential to improve mental health but adherence is problematic. Psychological guidance might promote adherence but is resource intensive. In this three-armed randomized controlled trial, "guidance on demand" (GoD) and unguided (UG) adherence-promoting versions of the seven-module IMI StudiCare Mindfulness were compared with a waitlist control group and each other. The GoD participants could ask for guidance as needed. A total of 387 students with moderate/low mindfulness were recruited. Follow-up assessments took place after 1 (t1), 2 (t2), and 6 (t3) months. Post-intervention (t2), both versions significantly improved the primary outcome of mindfulness (d = 0.91-1.06, 95% CI 0.66-1.32) and most other mental health outcomes (d = 0.25-0.69, 95% CI 0.00-0.94) compared with WL, with effects generally persisting after 6 months. Exploratory comparisons between UG and GoD were mostly non-significant. Adherence was low but significantly higher in GoD (39%) vs. UG (28%) at the 6-month follow-up. Across versions, 15% of participants experienced negative effects, which were mostly mild. Both versions effectively promoted mental health in college students. Overall, GoD was not associated with substantial gains in effectiveness or adherence compared with UG. Future studies should investigate persuasive design to improve adherence.

A chatbot-based intervention with ELME to improve stress and health-related parameters in a stressed sample: Study protocol of a randomised controlled trial

Background

Stress levels in the general population had already been increasing in recent years, and have subsequently been exacerbated by the global pandemic. One approach for innovative online-based interventions are "chatbots" - computer programs that can simulate a text-based interaction with human users via a conversational interface. Research on the efficacy of chatbot-based interventions in the context of mental health is sparse. The present study is designed to investigate the effects of a three-week chatbot-based intervention with the chatbot ELME, aiming to reduce stress and to improve various health-related parameters in a stressed sample.

Methods

In this multicenter, two-armed randomised controlled trial with a parallel design, a three-week chatbot-based intervention group including two daily interactive intervention sessions via smartphone (á 10-20 min.) is compared to a treatment-as-usual control group. A total of 130 adult participants with a medium to high stress levels will be recruited in Germany. Assessments will take place pre-intervention, post-intervention (after three weeks), and follow-up (after six weeks). The primary outcome is perceived stress. Secondary outcomes include self-reported interoceptive accuracy, mindfulness, anxiety, depression, personality, emotion regulation, psychological well-being, stress mindset, intervention credibility and expectancies, affinity for technology, and attitudes towards artificial intelligence. During the intervention, participants undergo ecological momentary assessments. Furthermore, satisfaction with the intervention, the usability of the chatbot, potential negative effects of the intervention, adherence, potential dropout reasons, and open feedback questions regarding the chatbot are assessed post-intervention.

Discussion

To the best of our knowledge, this is the first chatbot-based intervention addressing interoception, as well as in the context with the target variables stress and mindfulness. The design of the present study and the usability of the chatbot were successfully tested in a previous feasibility study. To counteract a low adherence of the chatbot-based intervention, a high guidance by the chatbot, short sessions, individual and flexible time points of the intervention units and the ecological momentary assessments, reminder messages, and the opportunity to postpone single units were implemented.

Trial registration

The trial is registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (DRKS00027560; date of registration: 06 January 2022). This is protocol version No. 1. In case of important protocol modifications, trial registration will be updated.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Effectiveness of online mindfulness-based interventions in improving mental health during the COVID-19 pandemic: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Psychotherapies, such as mindfulness-based interventions (MBIs), are currently needed to tackle mental health problems. Online MBIs have become promising since face-to-face interventions are limited during the COVID-19 pandemic due to lockdown and social distancing. This systematic review and meta-analysis aimed to investigate the effect of online MBIs in improving mental health, mainly depression, anxiety, and stress.

MATERIALS AND METHODS

A systematic literature search was conducted according to the PRISMA 2020 guidelines on several databases for eligible studies up to October 17, 2021. Study quality was assessed using the Cochrane's Risk of Bias 2 tool. Effect sizes were presented as standardized mean difference (Hedges' g) between the online MBIs and control groups at post-test and follow-up using a random-effects model.

RESULTS

Eight randomized controlled trials involving 868 participants were included in this meta-analysis. The pooled adherence rate to online MBIs was 94% (95% CI = 91% to 98%). The findings revealed that online MBIs had a statistically significant small to moderate effect in reducing depression (g = -0.32; 95% CI = -0.49 to -0.14; I2 = 0%), a small effect on anxiety (g = -0.25; 95% CI = -0.43 to -0.06; I2 = 27%), and a moderate effect on stress (g = -0.62; 95% CI = -1.09 to -0.16; I2 = 83%). In addition, significant small effects at follow-up were observed for depression (g = -0.26; 95% CI = -0.48 to -0.04; I2 = 0%) and anxiety (g = -0.28; 95% CI = -0.48 to -0.08; I2 = 0%), but not for stress.

CONCLUSION

Online MBIs have beneficial effects on mental health, particularly depression, anxiety, and stress, during the COVID-19 pandemic. Given the limitations of the current study, future trials that specifically consider potential effect influencing factors, longer follow-up evaluation, and methodological quality are warranted.

Trajectories of symptoms in digital interventions for depression and anxiety using Routine Outcome Monitoring data: A secondary analysis study (Preprint)

BACKGROUND

Research suggests there is heterogeneity in treatment response for internet-delivered cognitive behavioral therapy (iCBT) users, but few studies have investigated the trajectory of individual symptom change across iCBT treatment. Large patient data sets using routine outcome measures allows the investigation of treatment effects over time as well as the relationship between outcomes and platform use. Understanding trajectories of symptom change, as well as associated characteristics, may prove important for tailoring interventions or identifying patients who may not benefit from the intervention.

OBJECTIVE

We aimed to identify latent trajectories of symptom change during the iCBT treatment course for depression and anxiety and to investigate the patients' characteristics and platform use for each of these classes.

METHODS

This is a secondary analysis of data from a randomized controlled trial designed to examine the effectiveness of guided iCBT for anxiety and depression in the UK Improving Access to Psychological Therapies (IAPT) program. This study included patients from the intervention group (N=256) and followed a longitudinal retrospective design. As part of the IAPT's routine outcome monitoring system, patients were prompted to complete the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) after each supporter review during the treatment period. Latent class growth analysis was used to identify the underlying trajectories of symptom change across the treatment period for both depression and anxiety. Differences in patient characteristics were then evaluated between these trajectory classes, and the presence of a time-varying relationship between platform use and trajectory classes was investigated.

RESULTS

Five-class models were identified as optimal for both PHQ-9 and GAD-7. Around two-thirds (PHQ-9: 155/221, 70.1%; GAD-7: 156/221, 70.6%) of the sample formed various trajectories of improvement classes that differed in baseline score, the pace of symptom change, and final clinical outcome score. The remaining patients were in 2 smaller groups: one that saw minimal to no gains and another with consistently high scores across the treatment journey. Baseline severity, medication status, and program assigned were significantly associated (P<.001) with different trajectories. Although we did not find a time-varying relationship between use and trajectory classes, we found an overall effect of time on platform use, suggesting that all participants used the intervention significantly more in the first 4 weeks (P<.001).

CONCLUSIONS

Most patients benefit from treatment, and the various patterns of improvement have implications for how the iCBT intervention is delivered. Identifying predictors of nonresponse or early response might inform the level of support and monitoring required for different types of patients. Further work is necessary to explore the differences between these trajectories to understand what works best for whom and to identify early on those patients who are less likely to benefit from treatment.

Effectiveness of an Online Intervention to Prevent Anxiety in the Children of Anxious Parents: A Study Protocol for a Randomised Controlled Trial. (Preprint)

Background

Anxiety is the most common childhood mental health condition and is associated with impaired child outcomes, including increased risk of mental health difficulties in adulthood. Anxiety runs in families: when a parent has anxiety, their child has a 50% higher chance of developing it themselves. Environmental factors are predominant in the intergenerational transmission of anxiety and, of these, parenting processes play a major role. Interventions that target parents to support them to limit the impact of any anxiogenic parenting behaviors are associated with reduced anxiety in their children. A brief UK-based group intervention delivered to parents within the UK National Health Service led to a 16% reduction in children meeting the criteria for an anxiety disorder. However, this intervention is not widely accessible. To widen access, a 9-module web-based version of this intervention has been developed. This course comprises psychoeducation and home practice delivered through text, video, animations, and practice tasks.

Objective

This study seeks to evaluate the feasibility of delivering this web-based intervention and assess its effectiveness in reducing child anxiety symptoms.

Methods

 This is the protocol for a randomized controlled trial (RCT) of a community sample of 1754 parents with self-identified high levels of anxiety with a child aged 2-11 years. Parents in the intervention arm will receive access to the web-based course, which they undertake at a self-determined rate. The control arm receives no intervention. Follow-up data collection is at months 6 and months 9-21. Intention-to-treat analysis will be conducted on outcomes including child anxiety, child mental health symptoms, and well-being; parental anxiety and well-being; and parenting behaviors.

Results

Funding was received in April 2020, and recruitment started in February 2021 and is projected to end in October 2022. A total of 1350 participants have been recruited as of May 2022.

Conclusions

The results of this RCT will provide evidence on the utility of a web-based course in preventing intergenerational transmission of anxiety and increase the understanding of familial anxiety.

Trial Registration

ClinicalTrials.gov NCT04755933; https://clinicaltrials.gov/ct2/show/NCT04755933

International Registered Report Identifier (IRRID)

DERR1-10.2196/40707

Posttraumatic stress disorder in burn patient: A systematic review

INTRODUCTION

Burns often cause severe physical and mental suffering and can become a trigger for the development of permanent psychological diseases, even after wound healing. Posttraumatic stress disorder (PTSD) is one such disorder, which involves the re-experiencing of many symptoms provoked by a previous traumatic situation.

METHOD

This study is a systematic review of interventions used to reduce or prevent PTSD symptoms in burn victims. We included randomized clinical trials that described therapeutic interventions for the prevention of PTSD in burn patients. The search was conducted in the databases EMBASE and PUBMED/Medline between 2009 and 2020, and the main variables evaluated were%TBSA, age, number of hospitalization days, type of intervention, follow-up time and results. The analysis of the bias risk was carried out according to the guidance in the Cochrane Handbook for Bias Risk Assessment.

RESULTS

Eight clinical trials were selected: three of them were performed in children, and five involved adults. The most common bias risks were related to participant/researcher blinding and loss of follow-up. Two interventions were identified: a pharmacological intervention and a psychological intervention. Medications (sertraline and propanolol) were not effective in reducing stress symptoms. Four studies used cognitive-behavioral therapies, which achieved the best results for PTSD improvement in burn patients. Hypnosis and an informational education program were also evaluated and did not show success in reducing PTSD.

CONCLUSION

Cognitive-behavioral therapies may work to reduce PTSD symptoms in burn patients, and when they are adopted early by burn units, they may improve the psychological condition of burn patients.

Measuring Adherence Within a Self-Guided Online Intervention for Depression and Anxiety: Secondary Analyses of a Randomized Controlled Trial

BACKGROUND

Self-guided online interventions offer users the ability to participate in an intervention at their own pace and address some traditional service barriers (eg, attending in-person appointments, cost). However, these interventions suffer from high dropout rates, and current literature provides little guidance for defining and measuring online intervention adherence as it relates to clinical outcomes.

OBJECTIVE

This study aims to develop and test multiple measures of adherence to a specific self-guided online intervention, as guided by best practices from the literature.

METHODS

We conducted secondary analyses on data from a randomized controlled trial of an 8-week online cognitive behavioral program that targets depression and anxiety in college students. We defined multiple behavioral and attitudinal adherence measures at varying levels of effort (ie, low, moderate, and high). Linear regressions were run with adherence terms predicting improvement in the primary outcome measure, the 21-item Depression, Anxiety, and Stress Scale (DASS-21).

RESULTS

Of the 947 participants, 747 initiated any activity and 449 provided posttest data. Results from the intent-to-treat sample indicated that high level of effort for behavioral adherence significantly predicted symptom change (F4,746=17.18, P<.001; and β=-.26, P=.04). Moderate level of effort for attitudinal adherence also significantly predicted symptom change (F4,746=17.25, P<.001; and β=-.36, P=.03). Results differed in the initiators-only sample, such that none of the adherence measures significantly predicted symptom change (P=.09-.27).

CONCLUSIONS

Our findings highlight the differential results of dose-response models testing adherence measures in predicting clinical outcomes. We summarize recommendations that might provide helpful guidance to future researchers and intervention developers aiming to investigate online intervention adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/ct2/show/NCT04361045.

Effects of self-guided stress management interventions in college students: A systematic review and meta-analysis

BACKGROUND

College students face several sources of stress. Self-guided stress management interventions offer an excellent opportunity for scaling up evidence-based interventions for self-management of these stresses. However, little is known about the overall effects of these interventions. Increasing this understanding is essential because self-guided stress management interventions might be a cost-effective and acceptable way of providing help to this important segment of the population during a critical life course stage.

METHODS

We carried out a systematic literature search of bibliographical databases (PubMed, PsycINFO, Embase, and Cochrane Library) for randomized controlled trials (RCTs) of self-guided stress management interventions published up through April 2020. We conducted two separate meta-analyses for perceived stress, depression, and anxiety. The first included interventions for general college student samples. The second included studies for students with high levels of perceived stress.

RESULTS

The first meta-analysis included 26 studies with 29 intervention-control comparisons based on a total of 4468 students. The pooled effect size was small but statistically significant (g = 0.19; 95% CI [0.10, 0.29]; p < 0.001). Results showed moderate heterogeneity across studies [I ² = 48%; 95% CI (19, 66%)]. The second meta-analysis, included four studies based on a total of 491 students with high levels of stress. The pooled effect size was small but statistically significant (g = 0.34; 95% CI [0.16, 0.52]; p < 0.001). Results showed no heterogeneity across studies (I ² = 0%; 95% CI [0, 79%]), but risk of bias was substantial.

DISCUSSION

Our results suggest that self-guided stress management programs may be effective when compared to control conditions, but with small average effects. These programs might be a useful element of a multi-component intervention system. Given the psychological barriers to treatment that exist among many college students, self-help interventions might be a good first step in facilitating subsequent help-seeking among students reluctant to engage in other types of treatment. More studies should be conducted to investigate these interventions, sample specifications, mediating effects, and individual-level heterogeneity of effects.

Engagement Strategies to Improve Adherence and Retention in Web-Based Mindfulness Programs: Systematic Review

Background

Web-based mindfulness programs may be beneficial in improving the well-being outcomes of those living with chronic illnesses. Adherence to programs is a key indicator in improving outcomes; however, with the digitization of programs, it is necessary to enhance engagement and encourage people to return to digital health platforms. More information is needed on how engagement strategies have been used in web-based mindfulness programs to encourage adherence.

Objective

The aim of this study is to develop a list of engagement strategies for web-based mindfulness programs and evaluate the impact of engagement strategies on adherence.

Methods

A narrative systematic review was conducted across the MEDLINE Complete, CINAHL Complete, APA PsycINFO, and Embase databases and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Articles were screened using the population, intervention, comparator, and outcome framework. Adults aged >18 years with chronic health conditions were included in the study. Mindfulness interventions, including those in combination with mindfulness-based cognitive therapy, delivered on the web through the internet or smartphone technology were included. Interventions lasted at least 2 weeks. Studies with a randomized controlled trial design or a pilot randomized controlled trial design were included. Engagement strategies, including web-based program features and facilitator-led strategies, adherence, and retention, were included.

Results

A total of 1265 articles were screened, of which 19 were relevant and were included in the review. On average, 70.98% (2258/3181) of the study participants were women with a mean age of 46 (SD 13) years. Most commonly, mindfulness programs were delivered to people living with mental health conditions (8/19, 42%). Of the 19 studies, 8 (42%) used only program features to encourage adherence, 5 (26%) used facilitator-led strategies, and 6 (32%) used a combination of the two. Encouraging program adherence was the most common engagement strategy used, which was used in 77% (10/13) of the facilitator-led studies and 57% (8/14) of the program feature studies. Nearly two-thirds (63%) of the studies provided a definition of adherence, which varied between 50% and 100% completion across studies. The overall mean participant compliance to the mindfulness programs was 56% (SD 15%). Most studies (10/19, 53%) had a long-term follow-up, with the most common follow-up period being 12 weeks after intervention (3/10, 30%). After the intervention, the mean retention was 78% (SD 15%).

Conclusions

Engagement strategies in web-based mindfulness programs comprise reminders to use the program. Other features may be suitable for encouraging adherence to interventions, and a facilitator-led component may result in higher retention. There is variance in the way adherence is measured, and intervention lengths and follow-up periods are inconsistent. More thorough reporting and a standardized framework for measuring adherence are needed to more accurately assess adherence and engagement strategies.

Dose-Response Effects of Patient Engagement on Health Outcomes in an mHealth Intervention: Secondary Analysis of a Randomized Controlled Trial

Background

The dose–response relationship between patient engagement and long-term intervention effects in mobile health (mHealth) interventions are understudied. Studies exploring long-term and potentially changing relationships between patient engagement and health outcomes in mHealth interventions are needed.

Objective

This study aims to examine dose–response relationships between patient engagement and 3 psychosocial outcomes in an mHealth intervention, Run4Love, using repeated measurements of outcomes at baseline and 3, 6, and 9 months.

Methods

This study is a secondary analysis using longitudinal data from the Run4Love trial, a randomized controlled trial with 300 people living with HIV and elevated depressive symptoms to examine the effects of a 3-month mHealth intervention on reducing depressive symptoms and improving quality of life (QOL). We examined the relationships between patient engagement and depressive symptoms, QOL, and perceived stress in the intervention group (N=150) using 4–time-point outcome measurements. Patient engagement was assessed using the completion rate of course assignments and frequency of items completed. Cluster analysis was used to categorize patients into high- and low-engagement groups. Generalized linear mixed effects models were conducted to investigate the dose–response relationships between patient engagement and outcomes.

Results

The cluster analysis identified 2 clusters that were distinctively different from each other. The first cluster comprised 72 participants with good compliance to the intervention, completing an average of 74% (53/72) of intervention items (IQR 0.22). The second cluster comprised 78 participants with low compliance to the intervention, completing an average of 15% (11/72) of intervention items (IQR 0.23). Results of the generalized linear mixed effects models showed that, compared with the low-engagement group, the high-engagement group had a significant reduction in more depressive symptoms (β=−1.93; P=.008) and perceived stress (β=−1.72; P<.001) and an improved QOL (β=2.41; P=.01) over 9 months. From baseline to 3, 6, and 9 months, the differences in depressive symptoms between the 2 engagement groups were 0.8, 1.6, 2.3, and 3.7 points, respectively, indicating widening between-group differences over time. Similarly, between-group differences in QOL and perceived stress increased over time (group differences in QOL: 0.9, 1.9, 4.7, and 5.1 points, respectively; group differences in the Perceived Stress Scale: 0.9, 1.4, 2.3, and 3.0 points, respectively).

Conclusions

This study revealed a positive long-term dose–response relationship between patient engagement and 3 psychosocial outcomes among people living with HIV and elevated depressive symptoms in an mHealth intervention over 9 months using 4 time-point repeat measurement data. The high- and low-engagement groups showed significant and widening differences in depressive symptoms, QOL, and perceived stress at the 3-, 6-, and 9-month follow-ups. Future mHealth interventions should improve patient engagement to achieve long-term and sustained intervention effects.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019

Impact of guidance on intervention adherence in computerised interventions for mental health problems: a meta-analysis

Web-based interventions are increasingly used for the prevention, treatment and aftercare of mental disorders. A crucial factor to the efficacy of such online programmes is adherence to the intervention content and procedure. It has been frequently suggested that adherence in web-based interventions is low and little is known about which factors influence adherence. To increase intervention uptake and completion, studies increasingly include interventions with some form of guidance. Guided interventions have been shown to have higher efficacy, however, evidence for the impact on adherence is limited and mixed. This meta-analysis explored the impact of human guidance on intervention completion in web-based mental health interventions. A total of 22 studies were included with interventions primarily targeting symptoms of depression and anxiety disorders. Results showed that guidance significantly increases the average amount of intervention completion [g = 0.29, 95% confidence interval (CI) 0.18-0.40] and the proportion of intervention completers [log odds ratio (OR) = 0.50, 95% CI 0.34-0.66] with small effects. On average, full completion rates were 12% higher in guided intervention groups. This meta-analysis demonstrated that guidance in web-based mental health interventions does increase adherence, but more research is required to better understand the specific mechanisms between guidance, adherence and outcomes.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

A Digital Self-management Program (Help to Overcome Problems Effectively) for People Living With Cancer: Feasibility Randomized Controlled Trial

BACKGROUND

We present the results of a feasibility, randomized waitlist control group (CG) parallel design study with a 1:1 allocation ratio. Participants were randomized into an intervention group (IG) or a waitlist CG. The intervention was a 6-week digital self-management program, Help to Overcome Problems Effectively (HOPE), for people with cancer.

OBJECTIVE

This study aims to test the feasibility of a digitally delivered self-management program for people with cancer. This will inform the design of a definitive randomized controlled trial. In addition, a preliminary assessment of the impact of the HOPE program via secondary outcomes will be used to assess signals of efficacy in a trial context.

METHODS

Participants were drawn from an opportunity sample, referred by Macmillan Cancer Support, and were invited via email to participate in the study (N=61). Primary outcomes were rates of recruitment, retention, follow-up, completion and adherence, sample size and effect size estimation, and assessment of progression criteria for a definitive trial. Secondary outcomes were self-report measures of participants' positive mental well-being, depression, anxiety, and patient activation (ie, confidence in managing their cancer). The intervention and data collection took place on the web.

RESULTS

The recruitment rate was 77% (47/61). A total of 41 participants completed the baseline questionnaires and were randomized to either the IG (n=21) or the waitlist CG (n=20). The retention rate (attending all program sessions) was greater than 50% (all: 21/41, 51%, IG: 10/21, 48%; and CG: 11/20, 55%). The follow-up rate (completing all questionnaires) was greater than 80% (all: 33/41, 80%; IG: 16/21, 76%; and CG: 17/20, 85%). The completion rate (attending ≥3 sessions and completing all questionnaires) was greater than 60% (all: 25/41, 61%; IG: 13/21, 62%; and CG: 12/20, 60%). Engagement data showed that participants viewed between half (5.1/10, 51%) and three-quarters (12.2/16, 76%) of the pages in each session.

CONCLUSIONS

All progression criteria for a definitive trial were met, as supported by the primary outcome data. The IG showed improved postprogram scores on measures of positive mental well-being, depression, anxiety, and patient activation. A full-scale trial of the digital HOPE program for people with cancer will allow us to fully evaluate the efficacy of the intervention relative to a CG.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN79623250; http://www.isrctn.com/ISRCTN79623250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/24264.

Real-world Evidence for Adherence and Persistence with Atorvastatin Therapy

Atorvastatin, which has been approved by regulatory agencies for primary- and secondary-prevention patients with dyslipidemia, has historically been the most commonly prescribed statin and is now widely available in generic formulations. Despite widespread statin usage, many patients fail to attain recommended (LDL-C) targets. While several factors impact the successful treatment of dyslipidemia, suboptimal patient adherence is a major limiting factor to medication effectiveness. In this narrative review we sought to investigate patient adherence and persistence with atorvastatin in a real-world setting and to identify barriers to LDL-C goal attainment and therapy outcomes beyond the realm of clinical trials. Moreover, in light of growing generic usage, we carried out targeted literature searches to investigate the impact of generic atorvastatin availability on patient adherence/persistence, and on lipid and efficacy outcomes, compared with branded formulations. Unsurprisingly, real-world data suggest that patient adherence/persistence to atorvastatin is suboptimal, but few studies have attempted to address factors impacting adherence. Data from studies comparing adherence/persistence in patients prescribed branded or generic atorvastatin are limited and show no clear evidence that initiation of a specific preparation of atorvastatin impacts adherence/persistence. Furthermore, results from studies comparing adherence/persistence of patients who switched from the branded to the generic drug are conflicting, although they do suggest that switching may negatively impact adherence over the long term. Additional real-world studies are clearly required to understand potential differences in adherence and persistence between patients initiating treatment with branded versus generic atorvastatin and, moreover, the factors that influence adherence. Targeted education initiatives and additional research are needed to understand and improve patient adherence in a real-world setting.

Health technology assessment for digital technologies that manage chronic disease: a systematic review

OBJECTIVE

A growing number of evaluation frameworks have emerged over recent years addressing the unique benefits and risk profiles of new classes of digital health technologies (DHTs). This systematic review aims to identify relevant frameworks and synthesize their recommendations into DHT-specific content to be considered when performing Health Technology Assessments (HTAs) for DHTs that manage chronic noncommunicable disease at home.

METHODS

Searches were undertaken of Medline, Embase, Econlit, CINAHL, and The Cochrane Library (January 2015 to March 2020), and relevant gray literature (January 2015 to August 2020) using keywords related to HTA, evaluation frameworks, and DHTs. Included framework reference lists were searched from 2010 until 2015. The EUNetHTA HTA Core Model version 3.0 was selected as a scaffold for content evaluation.

RESULTS

Forty-four frameworks were identified, mainly covering clinical effectiveness (n = 30) and safety (n = 23) issues. DHT-specific content recommended by framework authors fell within 28 of the 145 HTA Core Model issues. A further twenty-two DHT-specific issues not currently in the HTA Core Model were recommended.

CONCLUSIONS

Current HTA frameworks are unlikely to be sufficient for assessing DHTs. The development of DHT-specific content for HTA frameworks is hampered by DHTs having varied benefit and risk profiles. By focusing on DHTs that actively monitor/treat chronic noncommunicable diseases at home, we have extended DHT-specific content to all nine HTA Core Model domains. We plan to develop a supplementary evaluation framework for designing research studies, undertaking HTAs, and appraising the completeness of HTAs for DHTs.

Online Indicated Preventive Mental Health Interventions for Youth: A Scoping Review

Objective: Between the ages of 12 and 25 the onset of mental disorders typically occurs, and the burden of mental health problems is greatest for this group. Indicated preventive interventions to target individuals with subclinical symptoms to prevent the transition to clinical levels of disorders have gained considerable traction. However, the threshold to seek help appears to be high even when help is needed. Online interventions could offer a solution, especially during the COVID-19 pandemic. This scoping review will present an overview of the recent research of indicated online preventive interventions for youth (12-25 years) experiencing the early stages of mental health complaints with the aim of identifying the nature and extent of the research evidence. Methods: The 5-stage framework by Arksey and O'Malley was used. Academic literature published from 2013 onwards in printed or electronic format was included from Scopus, PsychINFO, and Ovid MEDLINE(R) ALL. Results: The search yielded 11,122 results, with the final selection resulting in inclusion of 30 articles for this review. In total, the articles included 4,950 participants. 26.7% of the selected articles focused on youth between 12 and 25 years. Of the articles 60% did not screen for, nor exclude participants with clinical levels of symptoms. Most studies used a common evidence-based therapy for the disorder-category targeted. More than half of the online interventions included some form of human support. Adherence levels ranged between 27.9 and 98%. The results indicate general effectiveness, usability and acceptability of online indicated preventive interventions. The most commonly used approach was CBT (n = 12 studies). Studies varied in their size, rigor of study, effectiveness and outcome measures. Online interventions with a combination of clinical and peer moderation (n = 3 studies) appear to result in the most stable and highest effect sizes. Conclusion: Online indicated preventive mental health interventions for youth with emerging mental health issues show promise in reducing various mental health complaints, and increasing positive mental health indicators such as well-being and resilience. Additionally, high levels of usability and acceptability were found. However, the included studies show important methodological shortcomings. Also, the research has mainly focused on specific diagnostic categories, meaning there is a lack of transdiagnostic approaches. Finally, clear definitions of- as well as instruments to measure- emerging or subclinical mental health symptoms in youth remain are missing.

Design Guidelines of a Computer-Based Intervention for Computer Vision Syndrome: Focus Group Study and Real-World Deployment

Background

Prolonged time of computer use increases the prevalence of ocular problems, including eye strain, tired eyes, irritation, redness, blurred vision, and double vision, which are collectively referred to as computer vision syndrome (CVS). Approximately 70% of computer users have vision-related problems. For these reasons, properly designed interventions for users with CVS are required. To design an effective screen intervention for preventing or improving CVS, we must understand the effective interfaces of computer-based interventions.

Objective

In this study, we aimed to explore the interface elements of computer-based interventions for CVS to set design guidelines based on the pros and cons of each interface element.

Methods

We conducted an iterative user study to achieve our research objective. First, we conducted a workshop to evaluate the overall interface elements that were included in previous systems for CVS (n=7). Through the workshop, participants evaluated existing interface elements. Based on the evaluation results, we eliminated the elements that negatively affect intervention outcomes. Second, we designed our prototype system LiquidEye that includes multiple interface options (n=11). Interface options included interface elements that were positively evaluated in the workshop study. Lastly, we deployed LiquidEye in the real world to see how the included elements affected the intervention outcomes. Participants used LiquidEye for 14 days, and during this period, we collected participants’ daily logs (n=680). Additionally, we conducted prestudy and poststudy surveys, and poststudy interviews to explore how each interface element affects participation in the system.

Results

User data logs collected from the 14 days of deployment were analyzed with multiple regression analysis to explore the interface elements affecting user participation in the intervention (LiquidEye). Statistically significant elements were the instruction page of the eye resting strategy (P=.01), goal setting of the resting period (P=.009), compliment feedback after completing resting (P<.001), a mid-size popup window (P=.02), and CVS symptom-like effects (P=.004).

Conclusions

Based on the study results, we suggested design implications to consider when designing computer-based interventions for CVS. The sophisticated design of the customization interface can make it possible for users to use the system more interactively, which can result in higher engagement in managing eye conditions. There are important technical challenges that still need to be addressed, but given the fact that this study was able to clarify the various factors related to computer-based interventions, the findings are expected to contribute greatly to the research of various computer-based intervention designs in the future.

Monitoring, implementation and reporting of interventions in a selection of trials assessing exercise therapy for the management of shoulder subacromial pain: a cross-sectional investigation

OBJECTIVES

To review the reporting of monitoring and implementation of interventions in a selection of trials that assessed the effectiveness of manual therapy and exercise in the management of shoulder subacromial pain.

DESIGN

A review of trials assessing the effectiveness of manual therapy and exercise in the management of patients with shoulder subacromial pain.

METHODS

We included in our review a selection of 10 trials that were included in a Cochrane review and compared manual therapy and exercise intervention with another intervention. Trials were assessed independently by two reviewers using two checklists: the Template for Intervention Description and Replication (TIDieR) and the Health Behavior Change Consortium treatment fidelity (National Institutes of Health Behaviour Change Consortium/NIHBCC).

RESULTS

TIDieR overall scores for individual trials ranged from 11.1% to 45% and fidelity scores ranged from 7% to 50%. On average, trials scored the following within each domain of NIHBCC: study design 51%; training of providers 8%; treatment delivery 15%; treatment receipt 14% and treatment enactment 2.5%.

CONCLUSIONS

Little information about the monitoring, implementation and reporting of interventions was provided by trials and that is a barrier for implementing or replicating these interventions. The lack of information regarding the implementation of interventions needs to be taken into account when assessing whether effectiveness of interventions was impacted by their design or due to deviations from the protocol within trials.

Relationship Between Patient Engagement and Depressive Symptoms Among People Living With HIV in a Mobile Health Intervention: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Associations between higher levels of patient engagement and better health outcomes have been found in face-to-face interventions; studies on such associations with mobile health (mHealth) interventions have been limited and the results are inconclusive.

OBJECTIVE

The objective of this study is to investigate the relationship between patient engagement in an mHealth intervention and depressive symptoms using repeated measures of both patient engagement and patient outcomes at 4 time points.

METHODS

Data were drawn from a randomized controlled trial (RCT) of an mHealth intervention aimed at reducing depressive symptoms among people living with HIV and elevated depressive symptoms. We examined the association between patient engagement and depressive symptoms in the intervention group (n=150) where participants received an adapted cognitive-behavioral stress management (CBSM) course and physical activity promotion on their WeChat social media app. Depressive symptoms were repeatedly measured using the Patient Health Questionnaire (PHQ-9) at baseline and 1 month, 2 months, and 3 months. Patient engagement was correspondingly measured by the completion rate, frequency of items completed, and time spent on the program at 1 month, 2 months, and 3 months. Latent growth curve models (LGCMs) were used to explore the relationship between patient engagement and depressive symptoms at multiple time points in the intervention.

RESULTS

The mean PHQ-9 scores were 10.2 (SD 4.5), 7.7 (SD 4.8), 6.5 (SD 4.7), and 6.7 (SD 4.1) at baseline, 1 month, 2 months, and 3 months, respectively. The mean completion rates were 50.6% (SD 31.8%), 51.5% (SD 32.2%), and 50.8% (SD 33.7%) at 1, 2, and 3 months, respectively; the average frequencies of items completed were 18.0 (SD 14.6), 32.6 (SD 24.8), and 47.5 (SD 37.2) at 1, 2, and 3 months, respectively, and the mean times spent on the program were 32.7 (SD 66.7), 65.4 (SD 120.8), and 96.4 (SD 180.4) minutes at 1, 2, and 3 months, respectively. LGCMs showed good model fit and indicated that a higher completion rate (β at 3 months=-2.184, P=.048) and a greater frequency of items completed (β at 3 months=-0.018, P=.04) were associated with fewer depressive symptoms at 3 months. Although not significant, similar trends were found in the abovementioned relationships at 1 and 2 months. There was no significant relationship between time spent on the program and depressive symptoms.

CONCLUSIONS

This study revealed a positive association between patient engagement and health outcomes at 3 months of an mHealth intervention using LGCMs and repeated measures data. The results underscore the importance of improving patient engagement in mHealth interventions to improve patient-centered health outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://tinyurl.com/yxb64mef.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-018-5693-1.

Twelve-Month Follow-Up to a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention for Rural Adults With Depression Symptoms: Single-Arm Longitudinal Study

Background

Internet-based cognitive behavior therapy (iCBT) interventions have the potential to help individuals with depression, regardless of time and location. Yet, limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions.

Objective

The primary aim of this study was to evaluate the longitudinal (12 months) effectiveness of a fully automated, self-guided iCBT intervention called Thrive, designed to enhance engagement with a rural population of adults with depression symptoms. The secondary aim was to determine whether the program adherence enhanced the effectiveness of the Thrive intervention.

Methods

We analyzed data from 181 adults who used the Thrive intervention. Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation (ninth item of the PHQ-9 scale) scores. The Thrive program adherence was measured using the numbers of program logins, page views, and lessons completed.

Results

The assessment response rates for 8-week, 6-month, and 12-month outcomes were 58.6% (106/181), 50.3% (91/181), and 51.4% (93/181), respectively. By 8 weeks, significant improvements were observed for all outcome measures. These improvements were maintained at 12 months with mean reductions in severities of depression (mean –6.5; P<.001) and anxiety symptoms (mean –4.3; P<.001). Improvements were also observed in work and social functioning (mean –6.9; P<.001) and resilience (mean 4.3; P<.001). Marked decreases were observed in suicidal ideation (PHQ-9 ninth item score >1) at 6 months (16.5%) and 12 months (17.2%) compared to baseline (39.8%) (P<.001). In regard to the program adherence, cumulative counts of page views and lessons completed were significantly related to lower PHQ-9, GAD-7, and WSAS scores and higher CD-RISC-10 scores (all P values <.001 with an exception of page views with WSAS for which P value was .02).

Conclusions

The Thrive intervention was effective at reducing depression and anxiety symptom severity and improving functioning and resilience among a population of adults from mostly rural communities in the United States. These gains were maintained at 1 year. Program adherence, measured by the number of logins and lessons completed, indicates that users who engage more with the program benefit more from the intervention.

Trial Registration

ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878

Effectiveness and acceptance of technology-based psychological interventions for the acute treatment of unipolar depression: a systematic review and meta-analysis (Preprint)

Background

Evidence on technology-based psychological interventions (TBIs) for the acute treatment of depression is rapidly growing. Despite extensive research in this field, there is a lack of research determining effectiveness and acceptance of TBIs considering different application formats in people with a formally diagnosed depressive disorder.

Objective

The goal of the review was to investigate the effectiveness and acceptance of TBIs in people with diagnosed depression with particular focus on application formats (stand-alone interventions, blended treatments, collaborative and/or stepped care interventions).

Methods

Studies investigating adults with diagnosed unipolar depressive disorders receiving any kind of psychotherapeutic treatment delivered (at least partly) by a technical medium and conducted as randomized controlled trials (RCTs) were eligible for inclusion. We searched CENTRAL (Cochrane Central Register of Controlled Trials; August 2020), MEDLINE, PsycINFO, PSYNDEX, CINAHL (January 2018), clinical trial registers, and sources of grey literature (January 2019). Two independent authors decided about study inclusion and extracted data. We performed random effects meta-analyses to synthesize the data.

Results

Database searches resulted in 15,546 records of which 78 completed studies were included. TBIs delivered as stand-alone interventions showed positive effects on posttreatment depression severity when compared to treatment as usual (SMD –0.44, 95% CI –0.73 to –0.15, k=10; I²=86%), attention placebo (SMD –0.51, 95% CI –0.73 to –0.30; k=12; I²=66%), and waitlist controls (SMD –1.01, 95% CI –1.23 to –0.79; k=19; I²=73%). Superior long-term effects on depression severity were shown when TBIs were compared to treatment as usual (SMD –0.24, 95% CI –0.41 to –0.07; k=6; I²=48%) attention placebo (SMD –0.23, 95% CI –0.40 to –0.07; k=7; I²=21%) and waitlist controls (SMD –0.74, 95% CI –1.31 to –0.18; k=3; I²=79%). TBIs delivered as blended treatments (providing a TBI as an add-on to face-to-face treatment) yielded beneficial effects on posttreatment depression severity (SMD –0.27, 95% CI –0.48 to –0.05; k=8; I²=53%) compared to face-to-face treatments only. Additionally, TBIs delivered within collaborative care trials were more effective in reducing posttreatment (SMD –0.20, 95% CI –0.36 to –0.04; k=2; I²=0%) and long-term (SMD –0.23, 95% CI –0.39 to –0.07; k=2; I²=0%) depression severity than usual care. Dropout rates did not differ between the intervention and control groups in any comparison (all P≥.09).

Conclusions

We found that TBIs are effective not only when delivered as stand-alone interventions but also when they are delivered as blended treatments or in collaborative care trials for people with diagnosed depression. Our results may be useful to inform routine care, since we focused specifically on different application formats, formally diagnosed patients, and the long-term effectiveness of TBIs.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42016050413; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42016050413

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028042

Using Digital Technology to Reduce the Prevalence of Mental Health Disorders in Populations: Time for a New Approach

Digital technology, which includes the collection, analysis, and use of data from a variety of digital devices, has the potential to reduce the prevalence of disorders and improve mental health in populations. Among the many advantages of digital technology is that it allows preventive and clinical interventions, both of which are needed to reduce the prevalence of mental health disorders, to be feasibly integrated into health care and community delivery systems and delivered at scale. However, the use of digital technology also presents several challenges, including how systems can manage and implement interventions in a rapidly changing digital environment and handle critical issues that affect population-wide outcomes, including reaching the targeted population, obtaining meaningful levels of uptake and use of interventions, and achieving significant outcomes. We describe a possible solution, which is to have an outcome optimization team that focuses on the dynamic use of data to adapt interventions for populations, while at the same time, addressing the complex relationships among reach, uptake, use, and outcome. We use the example of eating disorders in young people to illustrate how this solution could be implemented at scale. We also discuss system, practitioner-related, and other issues related to the adaptation of such an approach. Digital technology has great potential for facilitating the reduction of mental illness rates in populations. However, achieving this goal will require the implementation of new approaches. As a solution, we argue for the need to create outcome optimization teams, tasked with integrating data from various sources and using advanced data analytics and new designs to develop interventions/strategies to increase reach, uptake, use/engagement, and outcomes for both preventive and treatment interventions.

Accelerating Telemedicine for Cerebral Palsy During the COVID-19 Pandemic and Beyond

The effects of COVID-19 extend beyond the pandemic and are expected to transform healthcare in various ways, many of which remain unknown. With social distancing, telemedicine may become the preferred communication channel between caregivers and patients. Implications for cerebral palsy (CP) children are that this will pose a challenge within this transformation. CP, as a discreet entity, is not considered a risk factor. However, specific comorbidities in individuals with CP, such as chronic lung disease, are known as COVID-19 risk factors. The overall risk for the CP population is probably a factor of age and comorbidities. Staying at home for CP children is both a challenge and an opportunity. Escalation of behavioral conflicts or improved participation and equality within the household may emerge. Interestingly, restricted mobility for the general population narrows existing gaps of ambulation. Telemedicine is the primary way of providing services for chronic conditions during the pandemic and is expected to expand beyond pre-Coronavirus era use. The advantages of telemedicine vary, more so during pandemic times, according to severity, restrictions, and availably of telemedicine. A multidisciplinary therapeutic presence is more accessible with telemedicine, bringing together various specialties and approaches to the child's natural environment. Accessible, continuous care is expected to lower comorbidities, as demonstrated for other chronic conditions. Enhanced monitoring is crucial for younger children as devastating complications, such as hip dysplasia, could be minimized. Last but not least, we will discuss digital health care as an accelerator for participatory medicine, including networked patients and families, as responsible drivers of their health as full partners.

Adherence to Electronic Health Tools Among Vulnerable Groups: Systematic Literature Review and Meta-Analysis

Background

Electronic health (eHealth) tools are increasingly being applied in health care. They are expected to improve access to health care, quality of health care, and health outcomes. Although the advantages of using these tools in health care are well described, it is unknown to what extent eHealth tools are effective when used by vulnerable population groups, such as the elderly, people with low socioeconomic status, single parents, minorities, or immigrants.

Objective

This study aimed to examine whether the design and implementation characteristics of eHealth tools contribute to better use of these tools among vulnerable groups.

Methods

In this systematic review, we assessed the design and implementation characteristics of eHealth tools that are used by vulnerable groups. In the meta-analysis, we used the adherence rate as an effect size measure. The adherence rate is defined as the number of people who are repetitive users (ie, use the eHealth tool more than once). We also performed a meta-regression analysis to examine how different design and implementation characteristics influenced the adherence rate.

Results

Currently, eHealth tools are continuously used by vulnerable groups but to a small extent. eHealth tools that use multimodal content (such as videos) and have the possibility for direct communication with providers show improved adherence among vulnerable groups.

Conclusions

eHealth tools that use multimodal content and provide the possibility for direct communication with providers have a higher adherence among vulnerable groups. However, most of the eHealth tools are not embedded within the health care system. They are usually focused on specific problems, such as diabetes or obesity. Hence, they do not provide comprehensive services for patients. This limits the use of eHealth tools as a replacement for existing health care services.