A systematic review of the impact of adherence on the effectiveness of e-therapies

Web-Based, Human-Guided, or Computer-Guided Transdiagnostic Cognitive Behavioral Therapy in University Students With Anxiety and Depression: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting.

OBJECTIVE

This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT.

METHODS

A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use-related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test-10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months.

RESULTS

In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002).

CONCLUSIONS

The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials.

TRIAL REGISTRATION

International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795.

App Engagement as a Predictor of Weight Loss in Blended-Care Interventions: Retrospective Observational Study Using Large-Scale Real-World Data

BACKGROUND

Early weight loss is an established predictor for treatment outcomes in weight management interventions for people with obesity. However, there is a paucity of additional, reliable, and clinically actionable early predictors in weight management interventions. Novel blended-care weight management interventions combine coach and app support and afford new means of structured, continuous data collection, informing research on treatment adherence and outcome prediction.

OBJECTIVE

Against this backdrop, this study analyzes app engagement as a predictor for weight loss in large-scale, real-world, blended-care interventions. We hypothesize that patients who engage more frequently in app usage in blended-care treatment (eg, higher logging activity) lose more weight than patients who engage comparably less frequently at 3 and 6 months of intervention.

METHODS

Real-world data from 19,211 patients in obesity treatment were analyzed retrospectively. Patients were treated with 3 different blended-care weight management interventions, offered in Switzerland, the United Kingdom, and Germany by a digital behavior change provider. The principal component analysis identified an overarching metric for app engagement based on app usage. A median split informed a distinction in higher and lower engagers among the patients. Both groups were matched through optimal propensity score matching for relevant characteristics (eg, gender, age, and start weight). A linear regression model, combining patient characteristics and app-derived data, was applied to identify predictors for weight loss outcomes.

RESULTS

For the entire sample (N=19,211), mean weight loss was -3.24% (SD 4.58%) at 3 months and -5.22% (SD 6.29%) at 6 months. Across countries, higher app engagement yielded more weight loss than lower engagement after 3 but not after 6 months of intervention (P3 months<.001 and P6 months=.59). Early app engagement within the first 3 months predicted percentage weight loss in Switzerland and Germany, but not in the United Kingdom (PSwitzerland<.001, PUnited Kingdom=.12, and PGermany=.005). Higher age was associated with stronger weight loss in the 3-month period (PSwitzerland=.001, PUnited Kingdom=.002, and PGermany<.001) and, for Germany, also in the 6-month period (PSwitzerland=.09, PUnited Kingdom=.46, and PGermany=.03). In Switzerland, higher numbers of patients' messages to coaches were associated with higher weight loss (P3 months<.001 and P6 months<.001). Messages from coaches were not significantly associated with weight loss (all P>.05).

CONCLUSIONS

Early app engagement is a predictor of weight loss, with higher engagement yielding more weight loss than lower engagement in this analysis. This new predictor lends itself to automated monitoring and as a digital indicator for needed or adapted clinical action. Further research needs to establish the reliability of early app engagement as a predictor for treatment adherence and outcomes. In general, the obtained results testify to the potential of app-derived data to inform clinical monitoring practices and intervention design.

Engagement With a Mobile Chat-Based Intervention for Smoking Cessation: A Secondary Analysis of a Randomized Clinical Trial

Importance

Determining how individuals engage with digital health interventions over time is crucial to understand and optimize intervention outcomes.

Objective

To identify the engagement trajectories with a mobile chat-based smoking cessation intervention and examine its association with biochemically validated abstinence.

Design, Setting, and Participants

A secondary analysis of a pragmatic, cluster randomized clinical trial conducted in Hong Kong with 6-month follow-up. From June 18 to September 30, 2017, 624 adult daily smokers were recruited from 34 community sites randomized to the intervention group. Data were analyzed from March 6 to October 30, 2023.

Intervention

Chat-based cessation support delivered by a live counselor via a mobile instant messaging app for 3 months from baseline.

Main Outcomes and Measures

Group-based trajectory modeling was used to identify engagement trajectories using the participants' weekly responses to the messages from the counselor over the 3-month intervention period. The outcome measures were biochemically validated tobacco abstinence at 3-month (end of treatment) and 6-month follow-ups. Covariates included sex, age, educational level, nicotine dependence, past quit attempt, and intention to quit at baseline.

Results

Of 624 participants included in the analysis, 479 were male (76.8%), and the mean (SD) age was 42.1 (16.2) years. Four distinct engagement trajectories were identified: low engagement group (447 [71.6%]), where participants maintained very low engagement throughout; rapid-declining group (86 [13.8%]), where participants began with moderate engagement and rapidly decreased to a low level; gradual-declining group (58 [9.3%]), where participants had high initial engagement and gradually decreased to a moderate level; and high engagement group (58 [5.3%]), where participants maintained high engagement throughout. Compared with the low engagement group, the 6-month validated abstinence rates were significantly higher in the rapid-declining group (adjusted relative risk [ARR], 3.30; 95% CI, 1.39-7.81), gradual-declining group (ARR, 5.17; 95% CI, 2.21-12.11), and high engagement group (ARR, 4.98; 95% CI, 1.82-13.60). The corresponding ARRs (95% CI) of 3-month validated abstinence were 4.03 (95% CI, 1.53-10.59), 5.25 (95% CI, 1.98-13.88), and 9.23 (95% CI, 3.29-25.86).

Conclusions and Relevance

The findings of this study suggest that higher levels of engagement with the chat-based smoking cessation intervention were associated with greater biochemically validated tobacco abstinence. Improving engagement with digital interventions may increase intervention benefits.

Trial Registration

ClinicalTrials.gov Identifier: NCT03182790.

Efficacy of a web-based psychoeducational intervention, Fex-can sex, for young adult childhood cancer survivors with sexual dysfunction: A randomized controlled trial

Background

No web-based interventions addressing sexual problems are available for young adult survivors of childhood cancer.

Aim

This study aimed to test the efficacy of a web-based psychoeducational intervention, Fex-Can Sex, to alleviate sexual problems in young adults treated for cancer during childhood.

Method

This randomized controlled trial tested the effects of a 12-week, self-help, web-based intervention. Young adults (aged 19-40) reporting sexual dysfunction were drawn from a population-based national cohort of childhood cancer survivors and randomized to either an intervention group (IG, n = 142) or a wait-list control group (CG, n = 136). The primary outcome was 'Satisfaction with sex life' assessed by the PROMIS® SexFS v 2.0. Secondary outcomes included other SexFS domains, body image (BIS), emotional distress (HADS), health-related quality of life (EORTC QLQ-C30), and sex-related self-efficacy. Surveys were completed at baseline (T0), directly after the intervention (T1), and three months later (T2). The effects of the intervention were tested using t-test and linear mixed models, including intention-to-treat (ITT) and subgroups analysis. Adherence was based on log data extracted from the website system. The intervention included an open-ended question about perceived sexual problems.

Results

No effect of the intervention was found in the primary outcome. Regarding secondary outcomes, the IG reported less vaginal dryness (Lubrication subscale) than the CG at T1 (p = 0.048) and T2 (p = 0.023). Furthermore, at T1, the IG reported less emotional distress than the CG (p = 0.047). Subgroup analyses showed that those with greater sexual problems at T0 improved over time (T1 and T2), regardless of group allocation. Overall, adherence to the intervention was low and participants' activity levels did not change the results. Additionally, some members of the IG reported increased understanding and acceptance of their sexual problems.

Conclusion

The Fex-Can Sex intervention shows potential to improve sexual function, especially among those with greater dysfunction. To increase adherence and effect, we recommend the intervention to be further developed including more tailored content.

Clinical trial registration

ISRCTN Registry, trial number: 33081791 (registered on November 27, 2019).

Engagement With Remote Delivery Channels in a Physical Activity Intervention for Senior Women in the US

PURPOSE

Identify the effects of engagement with different intervention delivery channels on physical activity (PA), and the participant subgroups engaging with the different channels, among Women's Health Initiative Strong and Healthy (WHISH) PA trial participants.

DESIGN

Secondary analysis of data from WHISH, a pragmatic trial that used passive randomized consent.

SETTING

United States (remote intervention in all 50 states).

SAMPLE

18,080 U.S. women, aged 68-99 years, assigned to the WHISH PA intervention arm.

MEASURES

6 dichotomous variables operationalized engagement: Engagement with Targeted Inserts, Email (opened), Email (clicked links), Website (logging in), Website (tracking), Interactive Voice Response (IVR). PA was measured using the CHAMPS PA questionnaire.

ANALYSIS

Linear regressions evaluated effects of engagement on PA. Conditional Inference Trees identified subgroups of participants engaging with different channels based on demographic and psychosocial variables.

RESULTS

Engagement with each channel, except IVR, was associated with significantly more hours/week of PA (square root coefficients .29 - .13, P values <.001). Consistently across channels, features that identified subgroups of participants with higher engagement included younger age, and higher levels of PA and physical function. Subgroups with the highest engagement differed from those with the lowest in most participant characteristics.

CONCLUSIONS

For equitable population-level impact via large-scale remotely-delivered PA programs, it may be necessary to identify strategies to engage and target harder to reach subgroups more precisely.

CLINICAL TRIAL REGISTRATION

The WHISH trial is registered at ClinicalTrials.gov (No. NCT02425345).

Does intervention engagement mediate physical activity change in a web-based computer-tailored physical activity intervention?-Secondary outcomes from a randomised controlled trial

Introduction

The relationship between intervention engagement and behaviour change may vary depending on the specific engagement metric being examined. To counter this composite engagement measures may provide a deeper understanding of the relationship between engagement and behaviour change, though few studies have applied such multidimensional engagement metrics. The aim of this secondary analysis of RCT data was to examine how a composite engagement score mediates the effect of a web-based computer-tailored physical activity intervention.

Methods

501 inactive Australian adults were randomised to a no-treatment control or intervention group. Intervention participants received 8 sessions of web-based personalised physical activity advice over a 12-week intervention period and the ability to complete action plans. Change in physical activity was assessed using Actigraph accelerometers at baseline, 3-months and 9-months. Engagement with the intervention (i.e., a composite score including frequency, intensity, duration and type) was continuously assessed during the intervention period using website tracking software and database metrics. Generalised structural equation models were used to examine how a composite engagement score mediated intervention effects at 3 months and 9 months.

Results

At 3 months, mediation analysis revealed that the intervention group had significantly higher engagement scores than the control group [a-path exp(b) = 6.462, 95% CI = 5.121-7.804, p < 0.001]. Further, increased engagement with the intervention platform was associated with an increased time spent in moderate-to-vigorous physical activity [ab-coefficient exp(b) = 1.008, 95% CI = 1.004-1.014, P < 0.001]; however, the magnitude of this effect was small. There were no significant mediation effects at the 9-month time point.

Discussion

The findings suggest that a composite intervention engagement score has a small positive influence on physical activity changes and that other factors (e.g., behaviour change techniques) are likely to be more important drivers of behaviour change.

How to Enhance Adherence in Patients with Nonalcoholic Fatty Liver Disease: A Thought-Provoking Issue

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An Exploration of the Goodness of Fit of Web-Based Tools for Māori: Qualitative Study Using Interviews and Focus Groups

BACKGROUND

Indigenous communities often have poorer health outcomes and services under traditional models of care. In New Zealand, this holds true for Māori people who are tāngata whenua (the indigenous people). Several barriers exist that decrease the likelihood of indigenous communities often have poorer health outcomes and poor service fit under traditional models of care, including access issues, systemic and provider racism, and a lack of culturally safe and responsive services. Web-based interventions (WBIs) have been shown to be effective in supporting mental health and well-being and can overcome some of these barriers. Despite the large number of WBIs developed, more investigation is needed to know how well WBIs fit with an indigenous worldview and how they meet the needs of indigenous communities so that a digitally based future does not drive social and health inequities.

OBJECTIVE

This study aims to explore the goodness-of-fit of WBIs of Māori individuals, the indigenous people of Aotearoa/New Zealand.

METHODS

We used interviews (n=3) and focus groups (n=5) with 30 Māori participants to explore their views about WBIs. Interviews were analyzed using reflexive thematic analysis by members of the research team.

RESULTS

Overall, there was a perception that the design of WBIs did not align with the Māori worldview, which centers around people, relationships, spirituality, and holistic views of well-being. A total of 4 key themes and several subthemes emerged, indicating that WBIs were generally considered a poor fit for Māori. Specifically, the themes were as follows: (1) WBIs are disconnected from the core values of te ao Māori (the Māori worldview), (2) WBIs could be helpful in the right context, (3) there are significant barriers that may make it harder for Māori to use WBIs than other groups, and (4) ways to improve WBIs to help engagement with Māori.

CONCLUSIONS

While WBIs are often considered a way to reduce barriers to care, they may not meet the needs of Māori when used as a stand-alone intervention. If WBIs are continued to be offered, developers and researchers need to consider how to develop WBIs that are responsive and engaging to the needs of indigenous communities rather than driving inequities. Ideally, WBIs should be developed by the people they are intended for to fit with those populations' world views.

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.

Understanding parent perspectives on engagement with online youth-focused mental health programs

OBJECTIVE

Online youth-focused health programs often include parent modules-that equip parents with skills to assist their child in improving their health-alongside youth-specific content. BRAVE Self-Help, an evidence-based program designed for children and teenagers with early signs of anxiety, is a popular Australian program that includes six parent modules. Despite its popularity and proven efficacy, BRAVE Self-Help shares the same challenge as many online self-help programs-that of low participant engagement. Using parents registered in BRAVE Self-Help as 'information rich' participants, we explored (a) factors that influenced parent engagement in online health programs, and (b) their recommendations for enhancing parent engagement.

DESIGN AND OUTCOME MEASURE

We conducted semi-structured interviews with 14 parents registered in BRAVE Self-Help. Data were analysed through reflexive thematic analysis.

RESULTS

Social-, family- and program-related factors drove parents' program engagement and recommendations. Social sub-themes related to the benefits of professional and community support in promoting more engagement. Family sub-themes included difficulties with program engagement due to competing priorities, perceptions that condition severity influenced engagement, and feelings that previously-acquired health knowledge reduced motivation to engage. Program sub-themes included perceived usefulness and ease-of-use.

CONCLUSION

Program designers could target support systems, include flexible delivery options, and use iterative design processes to enhance parent engagement.

The Role of Mental Health Stigma in University Students' Satisfaction With Web-Based Stress Management Resources: Intervention Study

BACKGROUND

University students frequently report elevated levels of stress and mental health difficulties. Thus, the need to build coping capacity on university campuses has been highlighted as critical to mitigating the negative effects of prolonged stress and distress among students. Since the COVID-19 pandemic, web-based stress management resources such as infographics and web-based workshops have been central to supporting university students' mental health and well-being. However, there is a lack of research on students' satisfaction with and uptake of these approaches. Furthermore, mental health stigma has been suggested to have not only fueled the emergence of these web-based approaches to stress management but may also influence students' help-seeking behaviors and their satisfaction with and uptake of these resources.

OBJECTIVE

This study explored potential differences in students' satisfaction and strategy use in response to an interactive infographic (an emerging resource delivery modality) presenting stress management strategies and a web-based workshop (a more common modality) presenting identical strategies. This study also examined the relative contribution of students' strategy use and family-based mental health stigma in predicting their sustained satisfaction with the 2 web-based stress management approaches.

METHODS

University students (N=113; mean age 20.93, SD 1.53 years; 100/113, 88.5% women) completed our web-based self-report measure of family-based mental health stigma at baseline and were randomly assigned to either independently review an interactive infographic (n=60) or attend a synchronous web-based workshop (n=53). All participants reported their satisfaction with their assigned modality at postintervention (T1) and follow-up (T2) and their strategy use at T2.

RESULTS

Interestingly, a 2-way mixed ANOVA revealed no significant group × time interaction or main effect of group on satisfaction. However, there was a significant decrease in satisfaction from T1 to T2, despite relatively high levels of satisfaction being reported at both time points. In addition, a 1-way ANOVA revealed no significant difference in strategy use between groups. Results from a hierarchical multiple regression revealed that students' strategy use positively predicted T2 satisfaction in both groups. However, only in the web-based workshop group did family-based mental health stigma predict T2 satisfaction over and above strategy use.

CONCLUSIONS

While both approaches were highly satisfactory over time, findings highlight the potential utility of interactive infographics since they are less resource-intensive than web-based workshops and students' satisfaction with them is not impacted by family-based mental health stigma. Moreover, although numerous intervention studies measure satisfaction at a single time point, this study highlights the need for tracking satisfaction over time following intervention delivery. These findings have implications for student service units in the higher education context, emphasizing the need to consider student perceptions of family-based mental health stigma and preferences regarding delivery format when designing programming aimed at bolstering students' coping capacity.

Feasibility and preliminary efficacy of iConquerFear: a self-guided digital intervention for fear of cancer recurrence

PURPOSE

Approximately 50% of cancer survivors experience moderate-severe fear of cancer recurrence (FCR). Self-guided digital interventions have potential to address the high level of FCR-related unmet needs at scale, but existing digital interventions have demonstrated variable engagement and efficacy. This study aimed to evaluate the feasibility and preliminary efficacy of iConquerFear, a five-module self-guided digital FCR intervention.

METHODS

Eligible curatively treated breast cancer survivors were recruited. Participants reporting clinically significant FCR (≥ 13 on the Fear of Cancer Recurrence Inventory-Short Form; FCRI-SF) were given access to iConquerFear. Feasibility was indicated by > 50% of eligible participants enrolling in iConquerFear and recording moderate (≥ 120 min) or greater usage. Preliminary efficacy was evaluated via changes in self-reported FCR severity, anxiety, depression, intrusions and metacognitions from baseline to immediately and 3 months post-intervention.

RESULTS

Fifty-four (83%) of 65 eligible participants enrolled in iConquerFear; six subsequently withdrew. Thirty-nine (83%) participants recorded moderate (n = 24; 120-599 min) or high (n = 15; ≥ 600 min) usage. Engagement levels increased with participant age (p = 0.043), but were lower in participants with higher baseline FCR (p = 0.028). Qualitative feedback indicated engagement was sometimes limited by difficulties with navigation and relating to featured survivors. Participants reported significantly improved FCR (mean reduction (95%CI): baseline to post-intervention - 3.44 (- 5.18, - 1.71), baseline to 3-month follow-up - 4.52 (- 6.25, - 2.78), p =  < 0.001).

CONCLUSION

iConquerFear is a feasible and potentially efficacious intervention for reducing FCR in breast cancer survivors. Easier navigation and more relatable examples may enhance engagement.

IMPLICATIONS FOR CANCER SURVIVORS

iConquerFear may help address moderate but burdensome FCR levels in cancer survivors.

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 .

The relation between usage of an eHealth intervention for stress urinary incontinence and treatment outcomes: an observational study

BACKGROUND

Stress urinary incontinence (SUI), though a prevalent condition among women, is undertreated in primary care. EHealth with pelvic floor muscle training is an evidence-based alternative to care-as-usual. It is unknown, however, how eHealth usage is related to treatment outcome, and this knowledge is required for general practitioners to implement eHealth in their practice. This study examines the relation between usage of eHealth for SUI and treatment outcomes by examining log data. Baseline factors were also explored for associations with treatment success.

METHOD

In this pre-post study, women with SUI participated in "Baasoverjeblaas.nl", a web-based intervention translated from the Swedish internet intervention "Tät®-treatment of stress urinary incontinence". Usage was based on log data and divided into three user groups (low, intermediate and high). Online questionnaires were sent before, after treatment and at six-months follow-up. The relation between usage and the primary outcome - treatment success (PGI-) - was studied with a binomial logistic regression analysis. Changes in the secondary outcomes - symptom severity (ICIQ-UI SF) and quality of life (ICIQ-LUTSqol) - were studied per user group with linear mixed model analysis.

RESULTS

Included were 515 users with a mean age of 50.5 years (12.0 SD). The majority were low users (n = 295, 57.3%). Treatment success (PGI-I) was reached by one in four women and was more likely in high and intermediate users than in low users (OR 13.2, 95% CI 6.1-28.5, p < 0.001 and OR 2.92, 95% CI 1.35-6.34, p = 0.007, respectively). Symptom severity decreased and quality of life improved significantly over time, especially among high users. The women's expected ability to train their pelvic floor muscles and the frequency of pelvic floor muscle exercises at baseline were associated with treatment success.

CONCLUSION

This study shows that usage of eHealth for SUI is related to all treatment outcomes. High users are more likely to have treatment success. Treatment success is more likely in women with higher expectations and pelvic floor muscle training at baseline. These findings indicate that general practitioners can select patients that would be more likely to benefit from eHealth treatment, and they can enhance treatment effect by stimulating eHealth usage.

TRIAL REGISTRATION

Landelijk Trial Register NL6570;  https://onderzoekmetmensen.nl/nl/trial/25463 .

Digital safety plan effectiveness and use: Findings from a three-month longitudinal study

Few studies have examined the effectiveness of self-guided smartphone apps for suicide safety planning, despite their increasing use. Participants (n = 610) were self-selected users of the Beyond Now suicide prevention safety planning app with a history of suicidal thoughts and behaviours. Surveys were completed (baseline, one and three months), safety plan content and app usage data was shared. Repeated-measures ANOVAs examined changes in suicidal ideation and suicide-related coping over three months. Multiple regression models were used to predict suicidal ideation and suicide-related coping at one- and three-month follow-ups with plan-related variables: perceived usefulness, personalised content, app use time and co-authoring of the plan with a third party. Significant reductions in suicidal ideation and increases in suicide-related coping were found over three months. Higher suicide-related coping at three months predicted lower suicidal ideation. Higher perceived usefulness and personalised content at three months were associated with higher suicide-related coping, but not suicidal ideation. App use time and co-authoring were not significantly related to suicidal ideation or suicide-related coping. Practitioners should empower clients to create safety plans with personalised (not generic) strategies that a client perceives to be useful. Such plans may strengthen beliefs about coping with suicidal ideation, which in turn reduces suicidal ideation over time.

Bridging the adherence gap in internet interventions: A randomized controlled trial study protocol investigating context-specific self-efficacy

Low adherence in self-guided internet interventions is linked to poorer outcomes. Although some predictors of adherence have been identified, few are modifiable for widespread application. One personal variable with the potential to increase adherence in internet interventions is context-specific self-efficacy. This protocol outlines a randomized controlled trial design, divided into two phases. In Phase 1 (students, N = 216), participants will complete a self-efficacy-enhancing exercise, which will be compared to a waitlist control group to test its effectiveness in increasing internet intervention adherence self-efficacy. Phase 2 will be the main two-arm trial, where all participants (medical students, N = 952) will undergo an internet intervention called Med-Stress Student. In the experimental group, the program will be preceded by the self-efficacy-enhancing exercise developed in Phase 1. We anticipate that participants in the experimental group will show higher adherence (primary outcome) to the intervention and greater improvement in intervention outcomes (secondary outcomes i.e., lower stress and higher work engagement) at posttest, as well as at six-month and one-year follow-ups. If effective, enhancing context-specific self-efficacy could be recommended before any internet intervention as a relatively simple way to boost participants' adherence.

The Role of Artificial Intelligence in Identifying Depression and Anxiety: A Comprehensive Literature Review

This narrative literature review undertakes a comprehensive examination of the burgeoning field, tracing the development of artificial intelligence (AI)-powered tools for depression and anxiety detection from the level of intricate algorithms to practical applications. Delivering essential mental health care services is now a significant public health priority. In recent years, AI has become a game-changer in the early identification and intervention of these pervasive mental health disorders. AI tools can potentially empower behavioral healthcare services by helping psychiatrists collect objective data on patients' progress and tasks. This study emphasizes the current understanding of AI, the different types of AI, its current use in multiple mental health disorders, advantages, disadvantages, and future potentials. As technology develops and the digitalization of the modern era increases, there will be a rise in the application of artificial intelligence in psychiatry; therefore, a comprehensive understanding will be needed. We searched PubMed, Google Scholar, and Science Direct using keywords for this. In a recent review of studies using electronic health records (EHR) with AI and machine learning techniques for diagnosing all clinical conditions, roughly 99 publications have been found. Out of these, 35 studies were identified for mental health disorders in all age groups, and among them, six studies utilized EHR data sources. By critically analyzing prominent scholarly works, we aim to illuminate the current state of this technology, exploring its successes, limitations, and future directions. In doing so, we hope to contribute to a nuanced understanding of AI's potential to revolutionize mental health diagnostics and pave the way for further research and development in this critically important domain.

User engagement with organizational mHealth stress management intervention - A mixed methods study

Mobile health (mHealth) demonstrates great promise for providing effective and accessible interventions within an organizational context. Compared with traditional workplace interventions, mHealth solutions may be significantly more scalable and easier to standardize. However, inadequate user engagement is a major challenge with mHealth solutions that can negatively impact the potential benefits of an intervention. More research is needed to better understand how to ensure sufficient engagement, which is essential for designing and implementing effective interventions. To address this issue, this study employed a mixed methods approach to investigate what factors influence user engagement with an organizational mHealth intervention. Quantitative data were collected using surveys (n = 1267), and semi-structured interviews were conducted with a subset of participants (n = 17). Primary findings indicate that short and consistent interactions as well as user intention are key drivers of engagement. These results may inform future development of interventions to increase engagement and effectiveness.

Digital Care Pathway for Patients With Sleep Apnea in Specialized Care: Mixed Methods Study

BACKGROUND

Sleep apnea is a significant public health disorder in Finland, with a prevalence of 3.7%. Continuous positive airway pressure (CPAP) therapy is the first-line treatment for moderate or severe sleep apnea. From November 18, 2019, all patients who started their CPAP therapy at Oulu University Hospital were attached to a sleep apnea digital care pathway (SA-DCP) and were instructed on its use. Some patients still did not use the SA-DCP although they had started their CPAP therapy.

OBJECTIVE

We aimed to study health care professionals' (HCPs') perspectives on the SA-DCP and its usefulness for their work; whether the main targets of SA-DCP can be reached: shortening the initial guiding sessions of CPAP therapy, reducing patient calls and contact with HCPs, and improving patients' adherence to CPAP therapy; and patients' perspectives on the SA-DCP and its usefulness to them.

METHODS

Overall, 6 HCPs were interviewed in May and June 2021. The survey for SA-DCP users (58/91, 64%) and SA-DCP nonusers (33/91, 36%) was conducted in 2 phases: from May to August 2021 and January to June 2022. CPAP device remote monitoring data were collected from SA-DCP users (80/170, 47.1%) and SA-DCP nonusers (90/170, 52.9%) in May 2021. The registered phone call data were collected during 2019, 2020, and 2021. Feedback on the SA-DCP was collected from 446 patients between February and March 2022.

RESULTS

According to HCPs, introducing the SA-DCP had not yet significantly improved their workload and work practices, but it had brought more flexibility in some communication situations. A larger proportion of SA-DCP users familiarized themselves with prior information about CPAP therapy before the initial guiding session than nonusers (43/58, 74% vs 16/33, 49%; P=.02). Some patients still had not received prior information about CPAP therapy; therefore, most of the sessions were carried out according to their needs. According to the patient survey and remote monitoring data of CPAP devices, adherence to CPAP therapy was high for both SA-DCP users and nonusers. The number of patients' phone calls to HCPs did not decrease during the study. SA-DCP users perceived their abilities to use information and communications technology to be better than nonusers (mean 4.2, SD 0.8 vs mean 3.2, SD 1.2; P<.001).

CONCLUSIONS

According to this study, not all the goals set for the introduction of the SA-DCP have been achieved. Despite using the SA-DCP, some patients still wanted to communicate with HCPs by phone. The most significant factors explaining the nonuse of the SA-DCP were lower digital literacy and older age of the patients. In the future, more attention should be paid to these user groups when designing and introducing upcoming digital care pathways.

A Novel Casual Video Game With Simple Mental Health and Well-Being Concepts (Match Emoji): Mixed Methods Feasibility Study

BACKGROUND

Adolescence is a crucial phase for early intervention and prevention of mental health problems. Casual video games are popular and have promise as a novel mechanism for reaching young people, but this potential has seldom been explored.

OBJECTIVE

This study aimed to explore the acceptability, feasibility, and possible indicators of therapeutic changes after playing a purpose-built novel casual video game (Match Emoji) with simple mental health and well-being content among young adolescents.

METHODS

We conducted a single-arm, nonrandomized trial of Match Emoji with 12- to 14-year-old school students (N=45; 26 [57%] New Zealand European, 12 [26%] Māori; 7 [15%] Asian or Pacific; 27 [60%] boys, 3 [6%] non-binary). Participants were invited to play Match Emoji for 15 minutes, 2-3 times a week over 2 weeks (a total of 60 minutes). Acceptability was assessed through the frequency and duration of use (analytics analyzed at the end of the 2-week intervention period and at weeks 4 and 6) and through participant reports. The Child and Adolescent Mindfulness Measure (CAMM), General Help-Seeking Questionnaire (GHSQ), Flourishing Scale (FS), and Revised Children's Anxiety and Depression Scale (RCADS) were assessed at baseline and week 2 to indicate possible effects. Focus groups were held in week 4.

RESULTS

Most participants (n=39, 87%) used Match Emoji for at least 60 minutes over the 2-week intervention, with 80% (36/45) continuing to play the game after the intervention period. Mean change (from baseline to 2 weeks) on each measure was 1.38 (95% CI -0.03 to 2.79; P=.06) for CAMM; 0.8 (95% CI -2.71 to 4.31; P=.64) for GHSQ; -1.09 (95% CI -2.83 to 0.66; P=.21) for FS; and -3.42 (95% CI -6.84 to -0.001; P=0.49) for RCADS. Focus group feedback suggested that Match Emoji was enjoyable and helpful.

CONCLUSIONS

The casual video game with mental health content appeared to be acceptable and provided a promising indication of possible therapeutic effects. This approach is worthy of further investigation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31588.

The additional value of e-Health for patients with a temporomandibular disorder: a mixed methods study on the perspectives of orofacial physical therapists and patients

PURPOSE

To assess the experience and perceived added value of an e-Health application during the physical therapy treatment of patients with temporomandibular disorders (TMD).

MATERIALS AND METHODS

A mixed-methods study including semi-structured interviews was performed with orofacial physical therapists (OPTs) and with TMD patients regarding their experience using an e-Health application, Physitrack. The modified telemedicine satisfaction and usefulness questionnaire and pain intensity score before and after treatment were collected from the patients.

RESULTS

Ten OPTs, of which nine actively used Physitrack, described that the e-Health application can help to provide personalised care to patients with TMD, due to the satisfying content, user-friendliness, accessibility, efficiency, and ability to motivate patients. Ten patients, of which nine ended up using Physitrack, felt that shared decision-making was very important. These patients were positive towards the application as it was clear, convenient, and efficient, it helped with reassurance and adherence to the exercises and overall increased self-efficacy. This was mostly built on their experience with exercise videos, as this feature was most used. None of the OPTs or patients used all features of Physitrack. The overall satisfaction of Physitrack based on the telemedicine satisfaction and usefulness questionnaire (TSUQ) was 20.5 ± 4.0 and all patients (100%) showed a clinically relevant reduction of TMD pain (more than 2 points and minimally 30% difference).

CONCLUSION

OPTs and patients with TMD shared the idea that exercise videos are of added value on top of usual physical therapy care for TMD complaints, which could be delivered through e-Health.Implications for RehabilitationPhysical therapists and patients with temporomandibular disorders do not use all features of the e-Health application Physitrack in a clinical setting.Exercise videos were the most often used feature and seen as most valuable by physical therapists and patients.Based on a small number of participants, e-Health applications such as Physitrack may be perceived as a valuable addition to the usual care, though this would need verification by a study designed to evaluate the therapeutic effect (e.g., a randomised clinical trial).

Challenges and opportunities in mobile e-coaching

Background

Mobile e-health technologies have proven to provide tailored assessment, intervention, and coaching capabilities for various usage scenarios. Thanks to their spread and adoption, smartphones are one of the most important carriers for such applications.

Problem

However, the process of design, realization, evaluation, and implementation of these e-health solutions is wicked and challenging, requiring multiple stakeholders and expertise.

Method

Here, we present a tailorable intervention and interaction e-health solution that allows rapid prototyping, development, and evaluation of e-health interventions at scale. This platform allows researchers and clinicians to develop ecological momentary assessment, just-in-time adaptive interventions, ecological momentary intervention, cohort studies, and e-coaching and personalized interventions quickly, with no-code, and in a scalable way.

Result

The Twente Intervention and Interaction Instrument (TIIM) has been used by over 320 researchers in the last decade. We present the ecosystem and synthesize the main scientific output from clinical and research studies in different fields.

Discussion

The importance of mobile e-coaching for prediction, management, and prevention of adverse health outcomes is increasing. A profound e-health development strategyand strategic, technical, and operational investments are needed to prototype, develop, implement, and evaluate e-health solutions. TIIM ecosystem has proven to support these processes. This paper ends with the main research opportunities in mobile coaching, including intervention mechanisms, fine-grained monitoring, and inclusion of objective biomarker data.

A Retrospective Observational Study on Telemedicine in Prescribing Low-Dose Pills for Patients with Dysmenorrhea

Introduction

In Japan, telemedicine has gradually expanded due to deregulation in response to the COVID-19 pandemic. However, its current status remains unclear, as it is primarily provided by general practitioners. Meanwhile, telemedicine has begun to be utilized for low-dose estrogen-progestin (LEP) prescriptions for dysmenorrhea.

Methods

We conducted a retrospective analysis of medical record data from two gynecology clinics and performed an exploratory evaluation between a group that combined telemedicine and in-person visits during the initial 6 months of LEP treatment, and another group with only in-person visits.

Results

After propensity score matching, 89 and 83 patients were eligible for the telemedicine and in-person groups, respectively, with 53 patients in both. The characteristics of both groups were similar after matching. There were no significant differences in the probability of abnormal uterine bleeding during the first 6 months of treatment (25% and 43% in each group; p = 0.064), side effects, or treatment efficacy between the two groups. The withdrawal rate at 6 months was significantly higher in the telemedicine group than in the in-person group (13% and 0%, p = 0.013). The average copayment for patients who covered 30% of the total cost was also significantly higher in the telemedicine group after 1 and 3 months of LEP prescription.

Conclusion

The appropriate combination of telemedicine and in-person visits is currently employed in hospital visits, which does not differ significantly from in-person visits. Given the retrospective nature of this study and the limited number of cases, further investigation is necessary in the future.

Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial

BACKGROUND

Primary headaches, including migraine and tension-type headaches, are widespread and have a social, physical, mental, and economic impact. Among the key components of treatment are behavior interventions such as lifestyle modification. Scalable conversational agents (CAs) have the potential to deliver behavior interventions at a low threshold. To our knowledge, there is no evidence of behavioral interventions delivered by CAs for the treatment of headaches.

OBJECTIVE

This study has 2 aims. The first aim was to develop and test a smartphone-based coaching intervention (BalanceUP) for people experiencing frequent headaches, delivered by a CA and designed to improve mental well-being using various behavior change techniques. The second aim was to evaluate the effectiveness of BalanceUP by comparing the intervention and waitlist control groups and assess the engagement and acceptance of participants using BalanceUP.

METHODS

In an unblinded randomized controlled trial, adults with frequent headaches were recruited on the web and in collaboration with experts and allocated to either a CA intervention (BalanceUP) or a control condition. The effects of the treatment on changes in the primary outcome of the study, that is, mental well-being (as measured by the Patient Health Questionnaire Anxiety and Depression Scale), and secondary outcomes (eg, psychosomatic symptoms, stress, headache-related self-efficacy, intention to change behavior, presenteeism and absenteeism, and pain coping) were analyzed using linear mixed models and Cohen d. Primary and secondary outcomes were self-assessed before and after the intervention, and acceptance was assessed after the intervention. Engagement was measured during the intervention using self-reports and usage data.

RESULTS

A total of 198 participants (mean age 38.7, SD 12.14 y; n=172, 86.9% women) participated in the study (intervention group: n=110; waitlist control group: n=88). After the intervention, the intention-to-treat analysis revealed evidence for improved well-being (treatment: β estimate=-3.28, 95% CI -5.07 to -1.48) with moderate between-group effects (Cohen d=-0.66, 95% CI -0.99 to -0.33) in favor of the intervention group. We also found evidence of reduced somatic symptoms, perceived stress, and absenteeism and presenteeism, as well as improved headache management self-efficacy, application of behavior change techniques, and pain coping skills, with effects ranging from medium to large (Cohen d=0.43-1.05). Overall, 64.8% (118/182) of the participants used coaching as intended by engaging throughout the coaching and completing the outro.

CONCLUSIONS

BalanceUP was well accepted, and the results suggest that coaching delivered by a CA can be effective in reducing the burden of people who experience headaches by improving their well-being.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00017422; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00017422.

Virtual agents among participants with methamphetamine use disorders: Acceptability and usability study

INTRODUCTION

While the potential future role of virtual agents (VAs) in treating addiction is promising, participants' attitudes toward the use of VAs in psychotherapy remain insufficiently investigated. This lack of investigation could pose barriers to the adoption of VA-led psychotherapy for people with substance use disorders (SUD). This research aims to explore the acceptability and usability of VAs for people with methamphetamine use disorder.

METHODS

Following a single session of psychotherapy led by VAs through the Echo-app, a group of 49 individuals actively seeking treatment for current DSM-V substance dependence (with a mean age of 39.06 ± 8.02) completed self-administered questionnaires and participated in focus group interviews. These questionnaires aimed to investigate participants' preference regarding the type of psychotherapy and their willingness to engage in VA-led psychotherapy, taking into account their diverse psychological needs.

RESULTS

Quantitative data were subjected to analysis through both descriptive and inferential statistical methods. Interestingly, participants exhibited a significantly higher acceptability for traditional face-to-face psychotherapy compared to email-based psychotherapy (p = 0.042), but there was no statistically significant difference between their acceptance of traditional psychotherapy and VA-led psychotherapy (p = 0.059). The questionnaire outcomes indicated participants' willingness to engage in VA-led psychotherapy for purposes such as relapse prevention intervention, addressing emotional issues, managing somatic experiences, and facilitating social and family functional recovery. Furthermore, the participants' attitudes toward VA-led psychotherapy were predicted by factors including the need for anxiety-focused psychotherapy (p = 0.027; OR [95%CI] = 0.14[0.03,0.80]), the presence of chronic somatic diseases (p = 0.017; OR [95%CI] = 13.58[1.59,116.03]), and marital status (p = 0.031; OR [95%CI] = 5.02[1.16,21.79]).

DISCUSSION

Through the interviews, the study uncovered the factors that either supported or hindered participants' experiences with VA-led psychotherapy, while also gathering suggestions for future improvements. This research highlights the willingness and practicality of individuals with SUD in embracing VA-led psychotherapy. The findings are anticipated to contribute to the refinement of VA-led tools to better align with the preferences and needs of the users.

Digital psychosocial interventions for individuals with spinal cord injury: a scoping review

Objective

To provide an overview of the digital mental health care landscape for individuals with spinal cord injury (SCI).

Methods

PubMed, PsycInfo, and PSYNDEX were searched for articles meeting the following criteria: (1) article written in English or German; (2) digital psychosocial intervention; (3) SCI only; (4) treatment of individuals with SCI and not their relatives or caregivers. Records were screened by title and abstract and records meeting the inclusion criteria were obtained for full text screening. The references of identified articles were screened to find further relevant articles. The literature search was updated before submission. Risk of Bias was assessed by using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and a narrative synthesis was conducted.

Results

Ten randomized-controlled trials (RCT) and ten non-randomized-controlled trials were identified and compared in this review, evaluating twelve internet- and mobile-based interventions, five smartphone apps, and three virtual reality applications. The interventions were primarily used as stand-alone aftercare programs. While some were not based on any theory, cognitive behavioral therapy mostly served as the theoretical basis for the online interventions. The extent of human support also varied greatly between the studies. The number of intervention modules ranged between 2 and 72. There were also major differences in outcome variables and effects. A meta-analytical evaluation of the data was not conducted due to heterogeneity of studies.

Conclusion

Digital applications to promote the psychosocial health of individuals with SCI are an emerging field of research with many treatment approaches still to come. First high quality RCT studies report promising results. Unfortunately, not all studies are of high quality or the interventions have been insufficiently adapted to the needs of people with SCI. Therefore, more research is needed to further develop applications, and to generalize and test the effects found in the long term.

Feasibility and acceptability of an online parenting intervention to address behaviour problems in moderately to extremely preterm pre-school and school-age children

BACKGROUND

Preterm birth is associated with adverse mental health outcomes, including internalizing problems, social difficulties and inattention. Interventions are needed beyond infancy and toddlerhood to support children and their families. We examined the feasibility and acceptability of the I-InTERACT Preterm pilot study, an online parenting intervention for preterm children ages 3-8.

METHOD

Families participated in a weekly intervention comprised of seven sessions with online modules followed by videoconference coaching sessions with a therapist. Following completion of the study, caregivers completed a survey to assess their satisfaction and were asked to participate in a voluntary semi-structured interview to provide feedback. We anticipated greater than a 50% participation rate (enrollment feasibility) and 75% completion rate (adherence feasibility). We also hypothesized that at least 80% of participants would be satisfied with the intervention (acceptability).

RESULTS

Nineteen of 32 families (59%) enrolled in the study, suggesting adequate enrollment feasibility. Feasibility of programme completion (adherence) was lower than anticipated (59%). Regarding satisfaction, all caregivers agreed that the programme's information was relevant to them and their family. Nearly all participants (92%) indicated that they had a better understanding of the effects of preterm birth on behaviour, that they enjoyed the programme, that it met their expectations and that they recommend the programme to others. In qualitative interviews, caregivers expressed satisfaction with the content, skills they learned, and receiving direct coaching. Caregivers suggested improvements to increase intervention feasibility and skill implementation, including offering biweekly sessions and more hands-on coaching.

CONCLUSION

Our largely satisfactory acceptability rates suggest the value of and need for a parenting intervention for children born preterm past the initial period of early development. Future directions include modifying the intervention in response to caregiver feedback to improve recruitment, engagement and adherence.

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.

The acceptability, usability, engagement and optimisation of a mHealth service promoting healthy lifestyle behaviours: A mixed method feasibility study

Objective

Mobile health (mHealth) services suffer from high attrition rates yet represent a viable strategy for adults to improve their health. There is a need to develop evidence-based mHealth services and to constantly evaluate their feasibility. This study explored the acceptability, usability, engagement and optimisation of a co-developed mHealth service, aiming to promote healthy lifestyle behaviours.

Methods

The service LongLife Active® (LLA) is a mobile app with coaching. Adults were recruited from the general population. Quantitative results and qualitative findings guided the reasoning for the acceptability, usability, engagement and optimisation of LLA. Data from: questionnaires, log data, eight semi-structured interviews with users, feedback comments from users and two focus groups with product developers and coaches were collected. Inductive content analysis was used to analyse the qualitative data. A mixed method approach was used to interpret the findings.

Results

The final sample was 55 users (82% female), who signed up to use the service for 12 weeks. Engagement data was available for 43 (78%). The action plan was the most popular function engaged with by users. The mean scores for acceptability and usability were 3.3/5.0 and 50/100, respectively, rated by 15 users. Users expressed that the service's health focus was unique, and the service gave them a 'kickstart' in their behaviour change. Many ways to optimise the service were identified, including to increase personalisation, promote motivation and improve usability.

Conclusion

By incorporating suggestions for optimisation, this service has the potential to support peoples' healthy lifestyle behaviours.

Feasibility of a mobile health app-based self-management program for Chinese patients with breast cancer receiving chemotherapy: A randomized controlled pilot study

Objective

There are currently an increasing number of mobile health (mHealth) programs offered to patients with breast cancer undergoing chemotherapy, but their rate of adherence to app usage has remained low. This study aimed to examine the feasibility of an mHealth app-based program such as the adherence rate of app usage and determine the preliminary effects on self-efficacy, quality of life, symptom burden and healthcare utilization in these patients.

Methods

We conducted a randomized controlled pilot trial. Ninety-six participants were randomly allocated into either an intervention group or a control group (routine care plus a placebo app). The intervention group engaged in a 6-week self-regulation activity and received nurse-led social support via the app. The intention-to-treat principle was adopted. The generalized estimating equation was utilized to analyze the between-group, within-group and interaction effectiveness of this program.

Results

Totally 96 participants were enrolled from 16 May to 23 August 2022. The average rate of adherence to app usage increased from 4.8% at week 3 to 51.2% at week 6. There was a statistically significant reduction in the physiological efficacy scores of the intervention (p < .001) and control groups (p < .001) at week 6, compared with the baseline. At week 6, the intervention group reported a significantly lower symptom burden (p = .042) and significantly better physical well-being than the control group (p = .024).

Conclusions

It is feasible to perform an mHealth app-based self-management program for patients with breast cancer receiving chemotherapy. Nurses can utilize this program to facilitate patient self-management of symptoms during chemotherapy.

Registration

Clinicaltrials.gov, https://clinicaltrials.gov, (NCT05192525).

Assessing the implementation of a comprehensive quality management system for cross-sectoral psycho-oncology in Germany

INTRODUCTION

Quality management in healthcare is essential for safe, effective, and patient-centered services. Quality management systems (QMS) monitor and improve healthcare quality. Integrating QMS is crucial for optimal quality of care, but previous studies show gaps in integration. This study aims to assess program adherence to a QMS in cross-sectoral psycho-oncological care and to develop strategies for better integration, ultimately improving healthcare quality.

MATERIALS AND METHODS

The study used a utility analysis to assess the program adherence of a cross-sectoral psycho-oncology care program using a 5-point scale. The evaluation process involved breaking down the program into distinct areas, and used key figures and developed indicators to assess adherence. Descriptive statistics were used.

RESULTS

The study conducted a comprehensive assessment of program adherence in a complex care program, analysing 4460 evaluation cases based on 128 quality indicators. The results showed a score of 4.2 out of 5 points (84%), indicating a highly effective implementation of the QMS. Notably, the study observed successful implementation of top-down elements, while encountering more challenges in integrating bottom-up aspects.

CONCLUSION

The study demonstrates effective implementation of a comprehensive QMS. Successful integration was observed in areas such as care concept, care management, quality assurance, and IT-based documentation, while challenges remain in quality development and indicators. Active leadership involvement, staff training, data collection, and a learning culture are essential for successful implementation. Future research should assess the impact and cost-effectiveness of QMSs and develop tailored approaches to sustain healthcare professionals' motivation in quality improvement efforts.

Home-based exercise interventions delivered by technology in older adults: A scoping review of technological tools usage

BACKGROUND

Despite technology-based systems being considered promising tools to stimulate and increase physical function at home, most older adults are unfamiliar with technology, which may pose some difficulties. Technology-related parameters, such as adherence, acceptance, and acceptability, are crucial to achieving higher efficacy levels of home-based exercise interventions delivered by technology. In this scoping review, we aimed to revise the use of home-based technological tools to improve physical function in the older population, focusing on the user's experience and perspective. Methods This scoping review was conducted following PRISMA guidelines. The search was conducted in April 2022 and updated in April 2023. A total of 45 studies were included in the review. Results Most studies (95.5%) met the technology usage levels defined by the research team or reported satisfactory technology usage levels. Positive health-related outcomes were reported in 80% of studies. Although the existence of guidelines to correctly define and use measures associated with technology use, including adherence, acceptance and acceptability, some terms are still being used interchangeably. Some concerns related to the lack of an international consensus regarding technology usage measures and the exclusion of older adults who did not own or have previous experience with technology in a large percentage of the included studies may have limited the results obtained. Conclusions Altogether, home-based exercise interventions delivered through technology were associated with positive health-related outcomes in older adults, and technology usage levels are considered satisfactory. Older adults are willing and able to use technology autonomously if adequate support is provided.

The Effectiveness of Strategies to Improve User Engagement With Digital Health Interventions Targeting Nutrition, Physical Activity, and Overweight and Obesity: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions (DHIs) are effective in improving poor nutrition, physical inactivity, overweight and obesity. There is evidence suggesting that the impact of DHIs may be enhanced by improving user engagement. However, little is known about the overall effectiveness of strategies on engagement with DHIs.

OBJECTIVE

This study aims to assess the overall effectiveness of strategies to improve engagement with DHIs targeting nutrition, physical activity, and overweight or obesity and explore associations between strategies and engagement outcomes. The secondary aim was to explore the impact of these strategies on health risk outcomes.

METHODS

The MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, Scopus, and Academic Source Complete databases were searched up to July 24, 2023. Eligible studies were randomized controlled trials that evaluated strategies to improve engagement with DHIs and reported on outcomes related to DHI engagement (use or user experience). Strategies were classified according to behavior change techniques (BCTs) and design features (eg, supplementary emails). Multiple-variable meta-analyses of the primary outcomes (usage and user experience) were undertaken to assess the overall effectiveness of strategies. Meta-regressions were conducted to assess associations between strategies and use and user experience outcomes. Synthesis of secondary outcomes followed the "Synthesis Without Meta-Analysis" guidelines. The methodological quality and evidence was assessed using the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation tool respectively.

RESULTS

Overall, 54 studies (across 62 publications) were included. Pooled analysis found very low-certainty evidence of a small-to-moderate positive effect of the use of strategies to improve DHI use (standardized mean difference=0.33, 95% CI 0.20-0.46; P<.001) and very low-certainty evidence of a small-to-moderate positive effect on user experience (standardized mean difference=0.29, 95% CI 0.07-0.52; P=.01). A significant positive association was found between the BCTs social support (effect size [ES]=0.40, 95% CI 0.14-0.66; P<.001) and shaping knowledge (ES=0.39, 95% CI 0.03-0.74; P=.03) and DHI use. A significant positive association was found among the BCTs social support (ES=0.70, 95% CI 0.18-1.22; P=.01), repetition and substitution (ES=0.29, 95% CI 0.05-0.53; P=.03), and natural consequences (ES=0.29, 95% CI 0.05-0.53; P=.02); the design features email (ES=0.29, 95% CI 0.05-0.53; P=.02) and SMS text messages (ES=0.34, 95% CI 0.11-0.57; P=.01); and DHI user experience. For secondary outcomes, 47% (7/15) of nutrition-related, 73% (24/33) of physical activity-related, and 41% (14/34) of overweight- and obesity-related outcomes reported an improvement in health outcomes.

CONCLUSIONS

Although findings suggest that the use of strategies may improve engagement with DHIs targeting such health outcomes, the true effect is unknown because of the low quality of evidence. Future research exploring whether specific forms of social support, repetition and substitution, natural consequences, emails, and SMS text messages have a greater impact on DHI engagement is warranted.

TRIAL REGISTRATION

PROSPERO CRD42018077333; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77333.

Are digital health interventions valuable to support patients with cancer and caregivers? An umbrella review of web-based and app-based supportive care interventions

BACKGROUND

Digital health technologies have expanded tremendously in the last two decades, creating an emerging research and clinical field. They are regarded as cost-effective, and their use in healthcare is prioritized by many countries. However, the constant evolution of these technologies has led to an abundance of related literature. Thus, we conducted an umbrella review to identify and characterize digital supportive care interventions for patients with cancer and their relatives.

METHODS

A preregistered umbrella review was conducted (PROSPERO registration number CRD42022333110). Five databases were searched (Embase, PsycINFO, PubMed, CINAHL, and the Cochrane Library). To be considered, studies had to be systematic reviews or meta-analyses, be performed on pediatric or adult patients with cancer or survivors or their relatives, report results on web-based or app-based supportive care interventions, and measure psychological, functional, or behavioral variables or quality of life related to cancer. The methodological quality of the studies was assessed using the AMSTAR-2 tool.

FINDINGS

Twenty eligible studies were identified. Most of the included studies reported results from adult patients with cancer. Globally, digital interventions were shown to be effective for physical activity in patients with cancer but had mixed results regarding emotional outcomes and quality of life. Additionally, a lack of methodological quality was noted for most of the included reviews.

DISCUSSION

Digital supportive care interventions could be an effective tool in cancer care for some outcomes. Recommendations have been formulated for further research in this field using adapted methodologies for the development of digital health interventions.

Perceived Quality of Online Music Therapy Sessions by Older Adults Aging at Home

Online delivery is new to the field of music therapy (MT). This research investigated older adults' perceived quality of MT online by certified music therapists. In this feasibility study, applying both process and outcome assessments, nine older adults volunteered to participate. Zoom was used, and a virtual music therapy (VMT) kit was developed as a resource. Surveys and observed technical difficulties revealed that perceived quality varied slightly by level of technical difficulty experienced; however, overall mean perceived quality was 7.2 out of 9. Post-study interviews revealed three main themes: (a) individual experiences with VMT, (b) individuals' suggestions for further development of VMT sessions, and (c) individuals' personal outcomes from VMT sessions. Participants reported overall positive experiences with VMT. Despite a slight decline in perceived quality when more technical difficulties were present, each participant reported a desire for more sessions, and they would recommend it to others.

Finding the Best Match - a Case Study on the (Text-)Feature and Model Choice in Digital Mental Health Interventions

With the need for psychological help long exceeding the supply, finding ways of scaling, and better allocating mental health support is a necessity. This paper contributes by investigating how to best predict intervention dropout and failure to allow for a need-based adaptation of treatment. We systematically compare the predictive power of different text representation methods (metadata, TF-IDF, sentiment and topic analysis, and word embeddings) in combination with supplementary numerical inputs (socio-demographic, evaluation, and closed-question data). Additionally, we address the research gap of which ML model types - ranging from linear to sophisticated deep learning models - are best suited for different features and outcome variables. To this end, we analyze nearly 16.000 open-text answers from 849 German-speaking users in a Digital Mental Health Intervention (DMHI) for stress. Our research proves that - contrary to previous findings - there is great promise in using neural network approaches on DMHI text data. We propose a task-specific LSTM-based model architecture to tackle the challenge of long input sequences and thereby demonstrate the potential of word embeddings (AUC scores of up to 0.7) for predictions in DMHIs. Despite the relatively small data set, sequential deep learning models, on average, outperform simpler features such as metadata and bag-of-words approaches when predicting dropout. The conclusion is that user-generated text of the first two sessions carries predictive power regarding patients' dropout and intervention failure risk. Furthermore, the match between the sophistication of features and models needs to be closely considered to optimize results, and additional non-text features increase prediction results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41666-023-00148-z.

Use of tailoring features and reasons for dropout in a guided internet-based transdiagnostic individually-tailored cognitive behavioral therapy for symptoms of depression and/or anxiety in college students

Transdiagnostic individually-tailored digital interventions reduce symptoms of depression and anxiety in adults with moderate effects. However, research into these approaches for college students is scarce and contradicting. In addition, the exact reasons for intervention dropout in this target group are not well known, and the use of individually-tailored intervention features, such as optional modules, has not yet been explored. The current study aimed to (1) investigate reasons for dropout from a guided internet-based transdiagnostic individually-tailored intervention for college students assessed in a randomized controlled trial (RCT) and (2) evaluate whether participants used tailoring features intended for their baseline symptoms. A sample of college students with mild to moderate depression and/or anxiety symptoms (n = 48) in the Netherlands (partially) followed a guided internet-based transdiagnostic individually-tailored intervention. We contacted those who did not complete the entire intervention (n = 29) by phone to report the reasons for intervention dropout. Further, we descriptively explored the use of tailoring features (i.e., depression versus anxiety trajectory) and optional modules of the intervention in the whole sample. We identified a range of person- and intervention-related reasons for intervention dropout, most commonly busy schedules, needs for different kinds of help, or absence of personal contact. Furthermore, only less than half of the participants used the individually-tailoring features to address the symptoms they reported as predominant. In conclusion, digital interventions clear about the content and targeted symptoms, tested in user research could prevent dropout and create reasonable expectations of the intervention. Participants would benefit from additional guidance when using tailoring features of digital interventions, as they often do not choose the tailoring features targeting their baseline symptoms.

Exploring factors affecting Chinese adolescents' perceived usefulness and engagement with a stress management app: a qualitative study

Introduction

Providing adolescents with stress management interventions via mobile apps has potential for overcoming barriers to traditional in-person services, such as stigma, cost and travel. However, the effectiveness remains uncertain and engagement level remains low. Therefore, it is essential to understand adolescents' user experience of such apps, however, such research is scarce. This study aimed to address this research gap by exploring factors affecting Chinese adolescents' perceived usefulness and engagement of a stress management app, which was developed for them.

Methods

A qualitative study design involving focus group interviews and inductive thematic analysis was adopted. A purposive sampling method was employed, resulting in five focus groups (n = 39 adolescents).

Results

Two themes emerged: (1) mechanism and determinants of usefulness and (2) facilitators and barriers to engagement. The app was found to be helpful in managing chronic and simple stressors by promoting positive behavior, cognition, and physical changes. Relevance to real-life situations, peer support, and planning and monitoring features were found to increase usefulness. Participants suggested adding one-on-one chat support for managing acute stressors. Multimedia, logical content arrangement, combining psychoeducation and skills training, gamification, customization, and an appealing user interface were engaging factors for adolescents, whilst text-heavy content, pedagogical and monotonous tones, technical issues were found to disengage adolescents.

Conclusion

Stress management apps should involve simple and evidence-based coping skills training, target adolescents' real-life problems, promote positive peer influence, address both chronic and acute stressors. Additionally, such apps should have logical arrangement of content, be interactive and customizable, and involve multimedia and gamification features to engage adolescents.

Predictors of users' adherence to a fully automated digital intervention to manage insomnia complaints

OBJECTIVE

Fully automated digital interventions show promise for disseminating evidence-based strategies to manage insomnia complaints. However, an important concept often overlooked concerns the extent to which users adopt the recommendations provided in these programs into their daily lives. Our objectives were evaluating users' adherence to the behavioral recommendations provided by an app, and exploring whether users' perceptions of the app had an impact on their adherence behavior.

MATERIAL AND METHODS

Case series study of individuals completing a fully automated insomnia management program, conducted by a virtual agent, during December 2020 to September 2022. Primary outcome was self-reported adherence to the behavioral recommendations provided. Perceptions of the app and of the virtual agent were measured with the Acceptability E-Scale and ECA-Trust Questionnaire. Insomnia was evaluated with the Insomnia Severity Index at baseline (phase 1), after 7 days of sleep monitoring (phase 2) and post-intervention (phase 3).

RESULTS

A total of 824 users were included, 62.7% female, mean age 51.85 (±12.55) years. Of them, 32.7% reported having followed at least one recommendation. Users' trust in the virtual agent and acceptance of the app were related to a pre-intervention effect in insomnia severity (phase 2). In turn, larger pre-intervention improvements predicted better adherence. Mediational analyses showed that higher levels of trust in the virtual agent and better acceptance of the app exerted statistically significant positive effects on adherence (β = 0.007, 95% CI, 0.001-0.017 and β = 0.003, 95% CI 0.0004-0.008, respectively).

DISCUSSION

Users' adherence is motivated by positive perceptions of the app's features and pre-intervention improvements.

CONCLUSIONS

Determinants of adherence should be assessed, and targeted, to increase the impact of fully automated digital interventions.

A Guided, Internet-Based Stress Management Intervention for University Students With High Levels of Stress: Feasibility and Acceptability Study

BACKGROUND

Transitioning to adulthood and challenges in university life can result in increased stress levels among university students. Chronic and severe stress is associated with deleterious psychological and physiological effects. Digital interventions could succeed in approaching and helping university students who might be at risk; however, the experiences of students with internet-based stress management interventions are insufficiently understood.

OBJECTIVE

This study aims to explore the feasibility; acceptability; and changes in perceived stress, depressive symptoms, and quality of life from baseline to posttest assessment of a 5-session, internet-based stress management intervention guided by an e-coach, developed for university students experiencing high levels of stress.

METHODS

A single-arm study was conducted. Students were recruited from different channels, mainly from a web survey. Students were eligible if they (1) scored ≥20 on the Perceived Stress Scale-10, (2) were aged ≥18 years, and (3) were studying at one of the participating universities. Feasibility and acceptability of the intervention were investigated using several indications, including satisfaction (Client Satisfaction Questionnaire-8) and usability (System Usability Scale-10). We also investigated the indicators of intervention adherence using use metrics (eg, the number of completed sessions). Our secondary goal was to explore the changes in perceived stress (Perceived Stress Scale-10), depressive symptoms (Patient Health Questionnaire-9), and quality of life (EQ-5D-5L scale) from baseline to posttest assessment. In addition, we conducted semistructured interviews with intervention completers and noncompleters to understand user experiences in depth. For all primary outcomes, descriptive statistics were calculated. Changes from baseline to posttest assessment were examined using 2-tailed paired sample t tests or the Wilcoxon signed rank test. Qualitative data were analyzed using thematic analysis.

RESULTS

Of 436 eligible students, 307 (70.4%) students started using the intervention. Overall, 25.7% (79/307) completed the core sessions (ie, sessions 1-3) and posttest assessment. A substantial proportion of the students (228/307, 74.3%) did not complete the core sessions or the posttest assessment. Students who completed the core sessions reported high satisfaction (mean 25.78, SD 3.30) and high usability of the intervention (mean 86.01, SD 10.25). Moreover, this group showed large reductions in perceived stress (Cohen d=0.80) and moderate improvements in depression score (Cohen d=0.47) and quality of life (Cohen d=-0.35) from baseline to posttest assessment. Qualitative findings highlight that several personal and intervention-related factors play a role in user experience.

CONCLUSIONS

The internet-based stress management intervention seems to be feasible, acceptable, and possibly effective for some university students with elevated stress levels. However, given the high dropout rate and qualitative findings, several adjustments in the content and features of the intervention are needed to maximize the user experience and the impact of the intervention.

TRIAL REGISTRATION

Netherlands Trial Register 8686; https://onderzoekmetmensen.nl/nl/trial/20889.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.invent.2021.100369.

Effectiveness of online mindfulness-based interventions for cancer patients: a systematic review and meta-analysis

PURPOSE

Cancer is the second leading cause of mortality worldwide. Cancer negatively affects individuals' quality of life and overall health. Mindfulness-based interventions appear to be promising in the reduction of cancer- and treatment-related symptoms. This review aimed to determine the effectiveness of online mindfulness-based interventions on distress, anxiety, depression, stress, mindfulness, sleep disturbance, quality of life, rumination, fear of cancer recurrence, fatigue and post-traumatic growth among adult cancer patients.

METHODS

A literature search was conducted across five electronic databases. Only randomized controlled trials were eligible. Two reviewers independently screened the studies, extracted data, and performed quality assessment using the Cochrane risk of bias assessment tool. Meta-analyses were conducted using review manager software, and standardized mean difference was used to determine intervention effects. Heterogeneity was examined using the I2 statistics.

RESULTS

Ten studies were included with a total of 962 participants. Analyses revealed that online mindfulness-based interventions was effective in reducing distress (I2 = 98%；standardized mean difference = -2.21，95% confidence interval: -3.84 to 0.57；P = 0.008)， depression (I2 = 45%；standardized mean difference = -0.33，95% confidence interval: -0.64 to -0.03；P = 0.03), stress (I2 = 97%；standardized mean difference = -2.14，95% confidence interval: -4.24 to -0.03；P = 0.05) and sleep disturbance (I2 = 54%；standardized mean difference = -0.30，95% confidence interval: -0.59 to -0.01；P = 0.04), and improving quality of life (I2 = 94%；standardized mean difference = 0.92，95% confidence interval: 0.09-1.76；P = 0.03). The online mindfulness-based interventions had no significant effects on anxiety, mindfulness, rumination, fear of cancer recurrence, fatigue and post-traumatic growth. Subgroup analyses revealed that online mindfulness-based interventions resulted in higher effect sizes for distress when delivered by website than application, significantly higher effect sizes were also found for online mindfulness-based interventions with guidance, but not on treatment or cancer type. For sleep disturbance, and quality of life, no significant differences between subgroups were found.

CONCLUSION

These results provide preliminary support that online mindfulness-based interventions may be feasible and acceptable, which can be used as an adjuvant therapy for the management of cancer-related symptoms among cancer patients.

A Guided Web-Based Intervention Targeting Procrastination in College Students: Protocol for an Open Trial

BACKGROUND

Academic procrastination is a widespread problem among college students. It is linked to poor academic performance and increased college dropout intentions, as well as several mental health problems such as depression, anxiety, and stress. Guided web-based interventions can help reduce procrastination. However, guidance by professional clinicians draws upon valuable and limited societal resources, and a more efficient, scalable form of guidance is needed. Guidance by trained clinical psychology students has not yet been examined.

OBJECTIVE

The aim of this open trial is to examine the feasibility and acceptability of a web-based procrastination intervention for college students under the guidance of student digital coaches (e-coaches).

METHODS

We developed a single-arm trial of a guided web-based intervention targeting procrastination for the Dutch student population. Guidance is delivered by trained clinical psychology students asynchronously in the form of textual feedback on intervention progress, with the aim of supporting and motivating the participant. Participants are recruited at 7 Dutch universities. Primary outcomes are intervention satisfaction, usability, and adherence, which are assessed by the Client Satisfaction Scale (CSQ-8), System Usability Scale (SUS-10), and number of completed modules, respectively. The primary outcomes will be examined by calculating descriptive statistics. Secondary outcomes are e-coach satisfaction and changes to procrastination, depression, stress, and quality of life from pre- to posttest and follow-up.

RESULTS

The project was funded in 2019, and recruitment began in January 2021. As of May 2023, a total of 985 participants were enrolled, of which 372 had completed the posttest and 192 had completed the follow-up. The expected date of analysis and publication of the results is 2024.

CONCLUSIONS

The results are expected to contribute to the body of literature regarding eHealth in 3 ways. First, we will examine whether students who procrastinate adhere to and are satisfied with an eHealth intervention targeting this problem. Second, we will explore whether an intervention targeting procrastination can also decrease depression and stress. Lastly, we will investigate whether trained psychology students can effectively guide their peers in web-based interventions. Given the shortage of licensed psychologists, exploring alternative sources of guidance is much needed in order to provide students with the mental health support they need.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44907.

Effects of Adherence to an mHealth Tool for Self-Management of COPD Exacerbations

Purpose

Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients.

Patients and Methods

We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes.

Results

We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients.

Conclusion

Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.

Effectiveness of Human-Supported and Self-Help eHealth Lifestyle Interventions for Patients With Cardiometabolic Risk Factors: A Meta-Analysis

OBJECTIVE

eHealth is a useful tool to deliver lifestyle interventions for patients with cardiometabolic diseases. However, there are inconsistent findings about whether these eHealth interventions should be supported by a human professional, or whether self-help interventions are equally effective.

METHODS

Databases were searched between January 1995 and October 2021 for randomized controlled trials on cardiometabolic diseases (cardiovascular disease, chronic kidney disease, type 1 and 2 diabetes mellitus) and eHealth lifestyle interventions. A multilevel meta-analysis was used to pool clinical and behavioral health outcomes. Moderator analyses assessed the effect of intervention type (self-help versus human-supported), dose of human support (minor versus major part of intervention), and delivery mode of human support (remote versus blended). One hundred seven articles fulfilled eligibility criteria and 102 unique ( N = 20,781) studies were included.

RESULTS

The analysis showed a positive effect of eHealth lifestyle interventions on clinical and behavioral health outcomes ( p < .001). However, these effects were not moderated by intervention type ( p = .169), dose ( p = .698), or delivery mode of human support ( p = .557).

CONCLUSIONS

This shows that self-help eHealth interventions are equally effective as human-supported ones in improving health outcomes among patients with cardiometabolic disease. Future studies could investigate whether higher-quality eHealth interventions compensate for a lack of human support.Meta-analysis registration: PROSPERO CRD42021269263 .

Examining engagement effects in an adaptive preventive intervention for college student drinking

OBJECTIVE

This study determined the characteristics of engagement and whether engagement in an adaptive preventive intervention (API) was associated with reduced binge drinking and alcohol-related consequences.

METHOD

Incoming students were recruited for a sequential multiple assignment randomized trial (SMART; N = 891, 62.4% female, 76.8% non-Hispanic White) with an assessment-only control group. The API occurred during the first semester of college, with outcomes assessed at the end of the semester. The API involved two stages. Stage 1 included universal intervention components (personalized normative feedback [PNF] and self-monitoring). Stage 2 bridged heavy drinkers to access additional resources. We estimated the effect of engagement in Stage 1 only and in the whole API (Stages 1 and 2) among the intervention group, and the effect of the API versus control had all students assigned an API engaged, on alcohol-related outcomes.

RESULTS

Precollege binge drinking, intention to pledge a fraternity/sorority, and higher conformity motives were most associated with lower odds of Stage 1 engagement. Action (readiness to change) and PNF engagement were associated with Stage 2 engagement. API engagement was associated with significant reductions in alcohol-related consequences among heavy drinkers. Compared to the control, we estimated the API would reduce the relative increase in alcohol-related consequences from baseline to follow-up by 25%, had all API students engaged.

CONCLUSIONS

Even partial engagement in each component of the "light-touch" API rendered benefits. Analyses suggested that had all students in the intervention group engaged, the API would significantly reduce the change in alcohol-related consequences over the first semester in college. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness of remote physiotherapeutic e-Health interventions on pain in patients with musculoskeletal disorders: a systematic review

PURPOSE

To systematically review the literature on effectiveness of remote physiotherapeutic e-Health interventions on pain in patients with musculoskeletal disorders.

MATERIALS AND METHODS

Using online data sources PubMed, Embase, and Cochrane in adults with musculoskeletal disorders with a pain-related complaint. Remote physiotherapeutic e-Health interventions were analysed. Control interventions were not specified. Outcomes on effect of remote e-Health interventions in terms of pain intensity.

RESULTS

From 11,811 studies identified, 27 studies were included. There is limited evidence for the effectiveness for remote e-Health for patients with back pain based on five articles. Twelve articles studied chronic pain and the effectiveness was dependent on the control group and involvement of healthcare providers. In patients with osteoarthritis (five articles), total knee surgery (two articles), and knee pain (three articles) no significant effects were found for remote e-Health compared to control groups.

CONCLUSIONS

There is limited evidence for the effectiveness of remote physiotherapeutic e-Health interventions to decrease pain intensity in patients with back pain. There is some evidence for effectiveness of remote e-Health in patients with chronic pain. For patients with osteoarthritis, after total knee surgery and knee pain, there appears to be no effect of e-Health when solely looking at reduction of pain. Implications for rehabilitationThis review shows that e-Health can be an effective way of reducing pain in some populations.Remote physiotherapeutic e-Health interventions may decrease pain intensity in patients with back pain.Autonomous e-Health is more effective than no treatment in patients with chronic pain.There is no effect of e-Health in reduction of pain for patients with osteoarthritis, after total knee surgery and knee pain.

Attrition rate and predictors of a monitoring mHealth application in adolescents with obesity

BACKGROUND

Integrating mobile health (mHealth) into paediatric obesity treatment can provide opportunities for more personalized and lifetime treatment. However, high attrition rates pose a significant challenge. The current study attempts to better understand attrition by exploring (1) attrition rates of a monitoring mHealth application for usage over 14 days and (2) testing predictors of attrition in adolescents with obesity.

METHODS

Participants were 69 adolescents between 12 and 16 years old who engaged in a multidisciplinary obesity treatment centre (either outpatient or inpatient) in two countries (Belgium and France). To assess the attrition rates, frequency distributions were used. To test the predictors of attrition, zero-inflated negative binomial regression was performed.

RESULTS

Attrition rates were high, in the outpatient group, more than half of the participants (53.3%) used the app for only 0-7 days. In the inpatient group, this percentage was 24.1%. Only deficits in initiating (a component of executive functions) were a negative predictor of attrition, indicating that deficits in initiating lead to lower attrition rates.

CONCLUSIONS

This study provides evidence for high attrition rates in mHealth interventions for adolescents with obesity and was the first to investigate psychological predictors of attrition to an mHealth monitoring tool in adolescents with obesity in treatment. Findings regarding predictors of attrition should be approached with caution due to the small sample size.

A Digital Gaming Intervention to Strengthen the Social Networks of Older Dutch Adults: Mixed Methods Process Evaluation of a Digitally Conducted Randomized Controlled Trial

BACKGROUND

Digital loneliness interventions for older adults are promising, yet conclusive evidence is lacking due to a lack of randomized controlled trials (RCTs) and difficulties with recruitment. Process evaluation of performed RCTs is essential to inform future interventions. Still, it is rarely carried out, resulting in an overly optimistic view of the impact of eHealth interventions on loneliness in older adults and options to conduct such research entirely remotely.

OBJECTIVE

We describe a mixed methods process evaluation of a digitally conducted RCT assessing the effectiveness of a mobile social gaming app to facilitate meaningful social interactions in older adults.

METHODS

We analyzed the questionnaire and game data of the RCT participants to evaluate recruitment and onboarding, intervention adherence, and intervention acceptability. The RCT participants were allocated either to the main group of older adults (aged 65 years or older) or the side group (aged between 18 and 64 years). The side group used networking to play with the older adults. We also conducted 6 post-RCT evaluation interviews and 1 focus group with a total of 4 RCT participants and 5 welfare organization representatives that aided in RCT recruitment.

RESULTS

In total, 371 people aged 18 years or older signed up for the RCT, of which 64% (238/371) were aged 65 years or older. Of the total sample, 20% (76/371) installed the app and signed informed consent, showing a large dropout during onboarding. The high number of questions was a relevant barrier for participants. Both questionnaire and gameplay adherence were low. Participants indicated that the games elicited contact and a feeling of togetherness and proposed challenging and competitive games with increasing difficulty levels. They suggested focusing on enjoying the games rather than administering questionnaires.

CONCLUSIONS

Conducting a remote digital trial of a social gaming intervention for older adults is a great challenge. Remote recruitment and informed consent acquisition may often not result in sufficient participation. Personal engagement with fellow participants and researchers might be essential for adherence and enjoyment. Future digital gaming interventions should start with small-scale studies with in-person contact, repeated instructions, and fewer questionnaires.

E-Health intervention for subthreshold depression: Reach and two-year effects of a randomized controlled trial

BACKGROUND

There is evidence for e-Health interventions for full-blown depression. Little is known regarding commonly untreated subthreshold depression in primary care. This randomized controlled multi-centre trial assessed reach and two-year-effects of a proactive e-Health intervention (ActiLife) for patients with subthreshold depression.

METHODS

Primary care and hospital patients were screened for subthreshold depression. Over 6 months, ActiLife participants received three individualized feedback letters and weekly messages promoting self-help strategies against depression, e.g., dealing with unhelpful thoughts or behavioural activation. The primary outcome depressive symptom severity (Patient Health Questionnaire;PHQ-8) and secondary outcomes were assessed 6, 12 and 24 months.

RESULTS

Of those invited, n = 618(49.2 %) agreed to participate. Of them, 456 completed the baseline interview and were randomized to ActiLife (n = 227) or assessment only (n = 226). Generalised estimation equation analyses adjusting for site, setting and baseline depression revealed that depressive symptom severity declined over time, with no significant group differences at 6 (mean difference = 0.47 points; d = 0.12) and 24 months (mean difference = -0.05 points; d = -0.01). Potential adverse effects were observed at 12 months, with higher depressive symptom severity for ActiLife than control participants (mean difference = 1.33 points; d = 0.35). No significant differences in rates of reliable deterioration or reliable improvement of depressive symptoms were observed. ActiLife increased applied self-help strategies at 6 (mean difference = 0.32; d = 0.27) and 24 months (mean difference = 0.22; d = 0.19), but not at 12 months (mean difference = 0.18; d = 0.15).

LIMITATIONS

Self-report measures and lack of information on patients' mental health treatment.

DISCUSSION

ActiLife yielded satisfactory reach and increased the use of self-help strategies. Data were inconclusive in terms of depressive symptom changes.

User Engagement Clusters of an 8-Week Digital Mental Health Intervention Guided by a Relational Agent (Woebot): Exploratory Study

BACKGROUND

With the proliferation of digital mental health interventions (DMHIs) guided by relational agents, little is known about the behavioral, cognitive, and affective engagement components associated with symptom improvement over time. Obtaining a better understanding could lend clues about recommended use for particular subgroups of the population, the potency of different intervention components, and the mechanisms underlying the intervention's success.

OBJECTIVE

This exploratory study applied clustering techniques to a range of engagement indicators, which were mapped to the intervention's active components and the connect, attend, participate, and enact (CAPE) model, to examine the prevalence and characterization of each identified cluster among users of a relational agent-guided DMHI.

METHODS

We invited adults aged 18 years or older who were interested in using digital support to help with mood management or stress reduction through social media to participate in an 8-week DMHI guided by a natural language processing-supported relational agent, Woebot. Users completed assessments of affective and cognitive engagement, working alliance as measured by goal and task working alliance subscale scores, and enactment (ie, application of therapeutic recommendations in real-world settings). The app passively collected data on behavioral engagement (ie, utilization). We applied agglomerative hierarchical clustering analysis to the engagement indicators to identify the number of clusters that provided the best fit to the data collected, characterized the clusters, and then examined associations with baseline demographic and clinical characteristics as well as mental health outcomes at week 8.

RESULTS

Exploratory analyses (n=202) supported 3 clusters: (1) "typical utilizers" (n=81, 40%), who had intermediate levels of behavioral engagement; (2) "early utilizers" (n=58, 29%), who had the nominally highest levels of behavioral engagement in week 1; and (3) "efficient engagers" (n=63, 31%), who had significantly higher levels of affective and cognitive engagement but the lowest level of behavioral engagement. With respect to mental health baseline and outcome measures, efficient engagers had significantly higher levels of baseline resilience (P<.001) and greater declines in depressive symptoms (P=.01) and stress (P=.01) from baseline to week 8 compared to typical utilizers. Significant differences across clusters were found by age, gender identity, race and ethnicity, sexual orientation, education, and insurance coverage. The main analytic findings remained robust in sensitivity analyses.

CONCLUSIONS

There were 3 distinct engagement clusters found, each with distinct baseline demographic and clinical traits and mental health outcomes. Additional research is needed to inform fine-grained recommendations regarding optimal engagement and to determine the best sequence of particular intervention components with known potency. The findings represent an important first step in disentangling the complex interplay between different affective, cognitive, and behavioral engagement indicators and outcomes associated with use of a DMHI incorporating a natural language processing-supported relational agent.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05672745; https://classic.clinicaltrials.gov/ct2/show/NCT05672745.