Successful Organizational Strategies to Sustain Use of A-CHESS: A Mobile Intervention for Individuals With Alcohol Use Disorders

South African university students' experiences of online group cognitive behavioural therapy: Implications for delivering digital mental health interventions to young people

Mental disorders are common among university students. In the face of a large treatment gap, resource constraints and low uptake of traditional in-person psychotherapy services by students, there has been interest in the role that digital mental health solutions could play in meeting students' mental health needs. This study is a cross-sectional, qualitative inquiry into university students' experiences of an online group cognitive behavioural therapy (GCBT) intervention. A total of 125 respondents who had participated in an online GCBT intervention completed a qualitative questionnaire, and 12 participated in in-depth interviews. The findings provide insights into how the context in which the intervention took place, students' need for and expectations about the intervention; and the online format impacted their engagement and perception of its utility. The findings of this study also suggest that, while online GCBT can capitalise on some of the strengths of both digital and in-person approaches to mental health programming, it also suffers from some of the weaknesses of both digital delivery and those associated with in-person therapies.

Effectiveness and implementation of mPATH™-CRC: a mobile health system for colorectal cancer screening

BACKGROUND

Screening for colorectal cancer (CRC) is widely recommended but underused, even though CRC is the third most diagnosed cancer and the second leading cause of cancer death in the USA. The mPATH™ program is an iPad-based application designed to identify patients due for CRC screening, educate them on the commonly used screening tests, and help them select their best option, with the goal of increasing CRC screening rates.

METHODS

The mPATH™ program consists of questions asked of all adult patients at check-in (mPATH™-CheckIn), as well as a module specific for patients due for CRC screening (mPATH™-CRC). In this study, the mPATH™ program is evaluated through a Type III hybrid implementation-effectiveness design. Specifically, the study consists of three parts: (1) a cluster-randomized controlled trial of primary care clinics comparing a "high touch" evidence-based implementation strategy with a "low touch" implementation strategy; (2) a nested pragmatic study evaluating the effectiveness of mPATH-CRC™ on completion of CRC screening; and (3) a mixed-methods study evaluating factors that facilitate or impede the maintenance of interventions like mPATH-CRC™. The primary objective is to compare the proportion of patients aged 50-74 who are eligible for CRC screening who complete mPATH™-CRC in the 6th month following implementation between the "high touch" and "low touch" implementation strategies. Effectiveness of mPATH™-CRC is evaluated by comparing the proportion who complete CRC screening within 16 weeks of their visit to the clinic between a pre-implementation cohort (8 months before implementation) and a post-implementation cohort (8 months after implementation).

DISCUSSION

This study will provide data on both the implementation of the mPATH™ program and its effectiveness in improving screening rates for CRC. In addition, this work has the potential to have an even broader impact by identifying strategies to support the sustained use of other similar technology-based primary care interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03843957. Registered on 18 February 2019.

The Cultural Adaption of a Sobriety Support App for Alaska Native and American Indian People: Qualitative Feasibility and Acceptability Study

BACKGROUND

Despite high rates of alcohol abstinence, Alaska Native and American Indian (ANAI) people experience a disproportionate burden of alcohol-related morbidity and mortality. Multiple barriers to treatment exist for this population, including a lack of culturally relevant resources; limited access to or delays in receiving treatment; and privacy concerns. Many ANAI people in the state of Alaska, United States, live in sparsely populated rural areas, where treatment access and privacy concerns regarding peer-support programs may be particularly challenging. In addition, prior research demonstrates that many ANAI people prefer a self-management approach to sobriety, rather than formal treatment. Taken together, these factors suggest a potential role for a culturally adapted smartphone app to support ANAI people interested in changing their behavior regarding alcohol use.

OBJECTIVE

This study was the first phase of a feasibility and acceptability study of a culturally tailored version of an off-the-shelf smartphone app to aid ANAI people in managing or reducing their use of alcohol. The aim of this qualitative needs assessment was to gather insights and preferences from ANAI people and health care providers serving ANAI people to guide feature development, content selection, and cultural adaptation before a pilot test of the smartphone app with ANAI people.

METHODS

From October 2018 to September 2019, we conducted semistructured interviews with 24 ANAI patients aged ≥21 years and 8 providers in a tribal health care organization in south-central Alaska.

RESULTS

Participants generally endorsed the usefulness of a smartphone app for alcohol self-management. They cited anonymity, 24/7 access, peer support, and patient choice as key attributes of an app. The desired cultural adaptations included ANAI- and land-themed design elements, cultural content (eg, stories from elders), and spiritual resources. Participants considered an app especially useful for rural-dwelling ANAI people, as well as those who lack timely access to treatment services or prefer to work toward managing their alcohol use outside the clinical setting.

CONCLUSIONS

This needs assessment identified key features, content, and cultural adaptations that are being implemented in the next phase of the study. In future work, we will determine the extent to which these changes can be accommodated in a commercially available app, the feasibility of implementation, and the acceptability of the culturally adapted version of the app among ANAI users.

A Comparison of Mathematical and Statistical Modeling with Longitudinal Data: An Application to Ecological Momentary Assessment of Behavior Change in Individuals with Alcohol Use Disorder

Ecological momentary assessment (EMA) has been broadly used to collect real-time longitudinal data in behavioral research. Several analytic methods have been applied to EMA data to understand the changes of motivation, behavior, and emotions on a daily or within-day basis. One challenge when utilizing those methods on intensive datasets in the behavioral field is to understand when and why the methods are appropriate to investigate particular research questions. In this manuscript, we compared two widely used methods (generalized estimating equations and generalized linear mixed models) in behavioral research with three other less frequently used methods (Markov models, generalized linear mixed-effects Markov models, and differential equations) in behavioral research but widely used in other fields. The purpose of this manuscript is to illustrate the application of five distinct analytic methods to one dataset of intensive longitudinal data on drinking behavior, highlighting the utility of each method.

Introducing an implementation framework for augmenting care with digital technology for early psychosis patients: theory and motivation

BACKGROUND

Treatment programs for early-course psychosis are evidence-based interventions that provide specialty care to improve outcomes in patients. Digital technologies offer the potential to augment services and meet the growing demand for care.

AIMS

We introduce a framework to guide the assessment of site readiness for technology and their ability to successfully introduce, implement, and sustain digital technology use. While broader in use that early course psychosis, we focus on this use case to introduce the theory and clinical application.

METHODS

Adapting the replicating effective programs framework, we present an early psychosis focused model. Considering the unique opportunities and challenges of these programs, we present a five-stage evaluation framework. Informed by our clinical experience and recent literature, we present tools and examples to help programs plan and execute successful technology implementation.

RESULTS

The AACCS framework is comprised of five stages: (1) Access (e.g. identifying access to and comfort with technology), (2) Align (e.g. understanding aspects technology can augment), (3) Connect (e.g. customizing technology to stakeholder needs), (4) Care (e.g. implementing technology into treatment), and (5) Sustain (e.g. creating sustainable services). Site visits revealed patients have access to digital tools and are open to implementation into care, while staff prefers digital skills training.

CONCLUSIONS

This framework assists programs in identifying clinical targets to be augmented with technology, stages of implementation, and recommendations for sustaining meaningful technology use.

Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

BACKGROUND

The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.

OBJECTIVE

This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.

METHODS

Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.

RESULTS

A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.

CONCLUSIONS

Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.

Gender differences in lifetime and current use of online support for recovery from alcohol use disorder

Background

Digital recovery support services (D‐RSS) use technology to engage individuals seeking recovery from alcohol use disorder (AUD). Given sparse data on use of these emergent services as well as longstanding and stark gender disparities in use of traditional alcohol treatment services, we sought to quantify lifetime and current D‐RSS use and to test associations with several recovery outcomes, with particular attention to gender differences.

Methods

We analyzed data obtained in fall 2020 in a national survey of adults with a resolved alcohol problem (n = 1487). We estimated lifetime and current D‐RSS use, prevalence of various types of D‐RSS, and related outcomes (e.g., recovery stability, relapse events, quality of life). Stratified logistic regression models identified correlates of D‐RSS use for women and men, controlling for demographic and AUD characteristics.

Results

Overall, an estimated 14.9% of the population of adults with a resolved alcohol problem reported lifetime use of D‐RSS, with no difference by gender. Current use was lower and was reported by more men than women (9.9% vs. 5.8%, respectively). Men had higher odds of D‐RSS use if they had <1 year of recovery (adjusted odds ratio [aOR] 7.84), 1 to 5 years of recovery (aOR 2.17), and if never married (aOR 3.29). Among women, higher odds of D‐RSS were associated with AUD symptom count (aOR 1.30), being unemployed (aOR 9.85), and having minor children in the household (aOR 3.58). Among women, there was no association between D‐RSS use and recovery stability, relapse events, and quality of life. However, among men D‐RSS use was associated with reporting that the COVID‐19 pandemic had made it more difficult to resist alcohol or drugs and with lower self‐reported quality of life.

Conclusions

D‐RSS are a promising technological approach to support recovery. There is room to increase their use, and gender‐specific approaches may be needed given different correlates of use for women and men. In addition, further research is needed to explore whether D‐RSS may confer benefits through similar mechanisms as in‐person recovery services.

Lessons for Uptake and Engagement of a Smartphone App (SURE Recovery) for People in Recovery From Alcohol and Other Drug Problems: Interview Study of App Users

Background

Mobile health apps promoting health and well-being have substantial potential but low uptake and engagement. Barriers common to addiction treatment app uptake and engagement include poor access to mobile technology, Wi-Fi, or mobile data, plus low motivation among non–treatment-seeking users to cut down or quit. Working with people who used substances, we had previously designed and published an app to support recovery from alcohol and other drug problems. The app, which is available for free from the Apple App Store and Google Play, is called SURE Recovery.

Objective

The aim of this paper is to undertake a qualitative study to ascertain end users’ views and experiences of the SURE Recovery app, including how it might be improved, and present the findings on uptake and engagement to assist other researchers and app developers working on similar apps for people experiencing alcohol and other drug problems.

Methods

Semistructured telephone interviews were conducted with 20 people (n=12, 60%, men and n=8, 40%, women aged 25-63 years; all identifying as White British) who had varied patterns of using the app. The audio recordings were transcribed, and the data were coded and analyzed through Iterative Categorization.

Results

Analyses identified three main factors relevant to uptake (discoverability of the app, personal relevance, and expectations and motivations) and three main factors relevant to engagement (the appeal and relevance of specific features, perceived benefits, and the need for improvements). The findings on uptake and engagement were largely consistent with our own earlier developmental work and with other published literature. However, we additionally found that uptake was strongly affected by first impressions, including trust and personal recommendations; that users were attracted to the app by their need for support and curiosity but had relatively modest expectations; that engagement increased if the app made users feel positive; and that people were unlikely to download, or engage with, the app if they could not relate to, or identify with, aspects of its content.

Conclusions

Incorporating end-user views into app design and having a network of supportive partners (ie, credible organizations and individuals who will champion the app) seem to increase uptake and engagement among people experiencing alcohol and other drug problems. Although better digital literacy and access to devices and mobile data are needed if addiction recovery apps are to reach their full potential, we should not evaluate them based only on observable changes in substance use behaviors. How using an app makes a person feel is more transient and difficult to quantify but also relevant to uptake and engagement.

Feasibility of a Mobile Health App for Routine Outcome Monitoring and Feedback in SMART Recovery Mutual Support Groups: Stage 1 Mixed Methods Pilot Study

Background

Mutual support groups are an important source of long-term help for people impacted by addictive behaviors. Routine outcome monitoring (ROM) and feedback are yet to be implemented in these settings. SMART Recovery mutual support groups focus on self-empowerment and use evidence-based techniques (eg, motivational and behavioral strategies). Trained facilitators lead all SMART Recovery groups, providing an opportunity to implement ROM.

Objective

The aim of this stage 1 pilot study is to explore the feasibility, acceptability, and preliminary outcomes of a novel, purpose-built mobile health ROM and feedback app (SMART Track) in mutual support groups coordinated by SMART Recovery Australia (SRAU) over 8 weeks.

Methods

SMART Track was developed during phase 1 of this study using participatory design methods and an iterative development process. During phase 2, 72 SRAU group participants were recruited to a nonrandomized, prospective, single-arm trial of the SMART Track app. Four modes of data collection were used: ROM data directly entered by participants into the app; app data analytics captured by Amplitude Analytics (number of visits, number of unique users, visit duration, time of visit, and user retention); baseline, 2-, and 8-week follow-up assessments conducted through telephone; and qualitative telephone interviews with a convenience sample of study participants (20/72, 28%) and facilitators (n=8).

Results

Of the 72 study participants, 68 (94%) created a SMART Track account, 64 (88%) used SMART Track at least once, and 42 (58%) used the app for more than 5 weeks. During week 1, 83% (60/72) of participants entered ROM data for one or more outcomes, decreasing to 31% (22/72) by the end of 8 weeks. The two main screens designed to provide personal feedback data (Urges screen and Overall Progress screen) were the most frequently visited sections of the app. Qualitative feedback from participants and facilitators supported the acceptability of SMART Track and the need for improved integration into the SRAU groups. Participants reported significant reductions between the baseline and 8- week scores on the Severity of Dependence Scale (mean difference 1.93, SD 3.02; 95% CI 1.12-2.73) and the Kessler Psychological Distress Scale-10 (mean difference 3.96, SD 8.31; 95% CI 1.75-6.17), but no change on the Substance Use Recovery Evaluator (mean difference 0.11, SD 7.97; 95% CI –2.02 to 2.24) was reported.

Conclusions

Findings support the feasibility, acceptability, and utility of SMART Track. Given that sustained engagement with mobile health apps is notoriously difficult to achieve, our findings are promising. SMART Track offers a potential solution for ROM and personal feedback, particularly for people with substance use disorders who attend mutual support groups.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619000686101; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377336

International Registered Report Identifier (IRRID)

RR2-10.2196/15113

Mobile Mental Health Apps from the National Center for PTSD: Digital Self-Management Tools for Co-Occurring Disorders

Mobile mental health apps can help bridge gaps in access to care for those with substance use disorders and dual diagnoses. The authors describe a portfolio of free, publicly available mobile mental health apps developed by the National Center for PTSD. The authors also demonstrate how this suite of primarily non-substance use disorder-specific mobile mental health apps may support the active ingredients of substance use disorder treatment or be used for self-management of substance use disorder and related issues. The potential advantages of these apps, as well as limitations and considerations for future app development, are discussed.

Patient and provider perceptions on utilizing a mobile technology platform to improve surgical outcomes in the perioperative setting

BACKGROUND AND OBJECTIVES

Patient engagement software is a ubiquitous and expensive commercially available tool designed to improve transitions of care. There are currently no high-quality patient and provider-level data about the usability of these products for surgical oncology patients. This study aims to better understand patient and provider attitudes and perceptions about the implementation of such technology.

METHODS

Focused interviews were conducted following the demonstration of a provider-built mobile technology platform. Interviews were audio-recorded, transcribed, and analyzed. Data were consensus coded inductively and categorized into themes regarding patient and provider perspectives on the usability and implementation of MobiMD.

RESULTS

Our interviews revealed four consistent themes: (1) patients feel there is a lack of reliable resources for patient education; (2) both patients and providers are supportive of using a mobile application; (3) providers perceive patient onboarding as an added burden on current workflows; and (4) after onboarding, providers express that such an application would optimize current workflows.

CONCLUSIONS

Patients perceive a need for improved perioperative education. Providers and patients agree that a mobile technology platform would be an effective solution in addressing this need. Effective implementation of such an intervention may improve patient education and engagement, leading to improved patient outcomes.

Influence of participation in a quality improvement collaborative on staff perceptions of organizational sustainability

BACKGROUND

Sustainability capacity (SC), which is an organization's ability to implement and maintain change, is influenced by internal attributes, environmental contextual influencers, and intervention attributes. Temporal changes in staff SC perceptions, as well as the influence of quality improvement collaborative (QIC) participation, has generally not been explored. This project addresses this gap, measuring staff SC perceptions at four time points (baseline and every 9 months) for clinics participating in an intervention - the Network for the Improvement of Addiction Treatment QIC initiative (called NIATx200).

METHODS

A mixed linear model repeated measures analysis was applied to matched staff members (n = 908, representing 2329 total cases) across the evaluation timeframe. Three separate statistical models assessed potential predictors of SC perceptions: Time (Models I-III); NIATx200 intervention, staff job function, and tenure (Models II &III); and NIATx200 participation hours and four organizational variables (Model III).

RESULTS

For Model I, staff perceptions of total SC increased throughout most of the study (t1,4 = - 6.74, p < .0001; t2,4 = - 3.100, p < .036; t3,4 = - 0.23, p = ns). Model II did not change Model I's overall Time effect, but combined NIATx200 services (t = - 2.23, p = .026), staff job function (t = - 3.27, p = .001), and organizational administrators (t = - 3.50, p = .001) were also significantly associated with greater perceptions of total SC. Inclusion of additional variables in Model III demonstrated the importance of a higher participation level (t = - 3.09, p < .002) and being in a free-standing clinic (t = - 2.06, p < .04) on staff perceptions of total SC.

CONCLUSION

Although staff exposure to sustainability principals was minimal in NIATx200, staff perceptions about their organization's SC significantly differed over time. However, an organization's participation level in a QIC became the principal predictor of staff SC perceptions, regardless of other factors' influence. Given these findings, it is possible to develop and introduce specific sustainability content within the structure of a QIC to assess the impact on staff SC perceptions over time and the sustainment of organizational change.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT00934141 . Registered July 6, 2009. Retrospectively registered.

Scaling evidence-based treatments through digital mental health

A large number of Internet websites, mobile apps, wearable devices, and video games that are hoped to improve behavioral, cognitive, and affective targets associated with mental health have been developed. Although technology provides the promising potential to help spread evidence-based mental health treatments, that potential is still largely unrealized. The vast majority of technology-based mental health products, deemed digital mental health interventions (DMHIs), have not been tested and show little fidelity to evidence-based treatments. Furthermore, best practices around the use of technologies in clinical services are underdeveloped and few clinicians have been trained to integrate these tools in their practice. We present an overview of DMHIs and discuss key aspects related to their implementation. We organize these aspects according to the Consolidating Framework for Implementation Research, a framework that identifies constructs related to effective implementation. These constructs are categorized into 5 domains including characteristics of DMHIs, the individuals involved, associated processes, the inner setting, and the outer setting. Our goal is to highlight key areas of consideration for leveraging technology to support the implementation of evidence-based treatments and to emphasize challenges and opportunities that come from using technology to scale evidence-based mental health treatments. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

NIATx-TI versus typical product training on e-health technology implementation: a clustered randomized controlled trial study protocol

BACKGROUND

Substance use disorders (SUDs) lead to tens-of-thousands of overdose deaths and other forms of preventable deaths in the USA each year. This results in over $500 billion per year in societal and economic costs as well as a considerable amount of grief for loved ones of affected individuals. Despite these health and societal consequences, only a small percentage of people seek treatment for SUDs, and the majority of those that seek help fail to achieve long-term sobriety. E-health applications in healthcare have proven to be effective at sustaining treatment and reaching patients traditional treatment pathways would have missed. However, e-health adoption and sustainment rates in healthcare are poor, especially in the SUD treatment sector. Implementation engineering can address this gap in the e-health field by augmenting existing implementation models, which explain organizational and individual e-health behaviors retrospectively, with prospective resources that can guide implementation.

METHODS

This cluster randomized control trial is designed to test two implementation strategies at adopting an evidence-based mobile e-health technology for SUD treatment. The proposed e-health implementation model is the Network for the Improvement of Addiction Treatment-Technology Implementation (NIATx-TI) Framework. This project, based in Iowa, will compare a control condition (using a typical software product training approach that includes in-person staff training followed by access to on-line support) to software implementation utilizing NIATx-TI, which includes change management training, followed by coaching on how to implement and use the mobile application. While e-health spans many modalities and health disciplines, this project will focus on implementing the Addiction Comprehensive Health Enhancement Support System (A-CHESS), an evidence-based SUD treatment recovery app framework. This trial will be conducted in Iowa at 46 organizational sites within 12 SUD treatment agencies. The control arm consists of 23 individual treatment sites based at five organizations, and the intervention arm consists of 23 individual SUD treatment sites based at seven organizations DISCUSSION: This study addresses an issue of substantial public health significance: enhancing the uptake of the growing inventory of patient-centered evidence-based addiction treatment e-health technologies.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03954184 . Posted 17 May 2019.

Current reporting of usability and impact of mHealth interventions for substance use disorder: A systematic review

BACKGROUND

Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD.

METHODS

A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool.

RESULTS

A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high.

CONCLUSION

Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research.

Digital navigators to implement smartphone and digital tools in care

While smartphone apps and other digital health tools have the clear potential to increase both quality of and access to care, actual successful implementation remains limited. Challenges often encountered in seeking to use apps in care include selecting safe/effective tools, spending clinical time troubleshooting technology instead of discussing health matters, and lack of time to check and review constant streams of data these digital tools can produce. In this 'From Research to Clinical Practice' piece, we focus on how a new care team member, the digital navigator, can help overcome these barriers through conducting evidence-based app evaluation to help in selecting the right apps, troubleshooting technology outside of visits to improve the therapeutic alliance during, and finally summarizing digital data to facilitate clinical care that focus on actionable data.

What influences evidence-based treatment sustainment after implementation support ends? A mixed method study of the adolescent-community reinforcement approach

BACKGROUND

Little is known about clinician perspectives regarding the factors that support or hinder the long-term delivery (i.e., sustainment) of evidence-based treatments in community-based treatment settings.

METHODS

Clinical staff from 82 community-based treatment organizations that received federal grant funding to support the delivery of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment for adolescent substance use, were asked to participate in interviews focused on understanding their perspectives about the sustainment of A-CRA. Qualitative themes were identified using inductive and deductive approaches. Then the themes were dichotomized (present/absent) so that quantitative comparisons could be made between staff from organizations that sustained and did not sustain delivery of A-CRA. Administrative data about each organization in relation to federal funding support and their primary focus was also examined to explore whether these characteristics were associated with A-CRA sustainment.

RESULTS

Staff (n = 134) representing 78 organizations participated in the interviews. Staff from organizations that had received multiple federal grants to support the delivery of A-CRA and whose primary focus was substance use rather than other conditions (mental health or primary care) were more likely to report sustaining A-CRA. Staff from sustaining organizations were more likely to report positive grant experiences and success with maintaining both organizational and external support in comparison to staff from non-sustaining organizations. Staff from non-sustaining organizations were more likely to report barriers to sustaining A-CRA, including more challenges with intervention delivery, and lack of internal support and external funding.

CONCLUSIONS

Our findings lend empirical support for implementation theories in that multiple factors appear to be associated with long-term delivery of an evidence-based treatment. Although A-CRA was generally perceived positively by staff from both organizations that sustained A-CRA and organizations that did not sustain A-CRA, inner setting factors (e.g., structural policies, leadership support and staff retention) along with outer setting factors (e.g., external funding support) were reported as key to A-CRA sustainment.

Cognitive-Behavioral Therapy in the Digital Age: Presidential Address

Our field has come a long way in establishing cognitive-behavioral therapy as the empirically supported treatment of choice for a wide range of mental and behavioral health problems. Nevertheless, most individuals with mental disorders do not receive any care at all, and those who do often have difficulty accessing care that is consistently high in quality. Addressing these issues is complex and costly and thus progress has been slow. We are entering an exciting stage in which emerging technologies might offer novel solutions to the treatment gap. This paper discusses a number of technology-enabled solutions to our field's challenges, including Internet-based and smartphone-based cognitive-behavioral therapy. Nevertheless, we must remain attentive to potential pitfalls of these emerging technologies. The paper incorporates suggestions for how the field may approach these potential pitfalls and provides a vision for how we might develop powerful, scalable, precisely timed, personalized interventions to enhance global mental health.

The utility and impact of the addiction comprehensive health enhancement support system (ACHESS) on substance abuse treatment adherence among youth in an intensive outpatient program

Youth experiencing substance use disorders often are susceptible to relapse because traditional support systems can be expensive, geographically dispersed, operated on limited schedules and lacking in peer support. The continuity of care offered via the digital Addiction Comprehensive Health Enhancement Support System (ACHESS) system holds promise in preventing relapse because of its portability and capability to foster virtually anytime/anywhere, cost-effective access to supportive interventions. The aim of this mixed-methods study was to evaluate the utility and impact of ACHESS on treatment adherence among youth with substance use disorders in an intensive outpatient program in the US Midwest. Data on 28 clients using ACHESS during 2016-17 were compared to retrospective data on 28 carefully-matched others treated without ACHESS during 2014-16. Fifty-four percent of the study group successfully completed treatment as opposed to 42.9% of those in the comparison group. Staff focus group findings highlighted how some features of ACHESS were effectively integrated into the care model and appeared to positively impact outcomes, while other elements of the application offered little utility. We suggest further study of ACHESS among larger samples of youth with substance use disorders in intensive outpatient programs to assess its efficacy in supporting adherence to treatment.

Augmenting Mental Health in Primary Care: A 1-Year Study of Deploying Smartphone Apps in a Multi-site Primary Care/Behavioral Health Integration Program

Background: Integrating behavioral health (BH) services into primary care is an evidence-based intervention that can increase access to care, improve patient outcomes, and decrease costs. Digital technology, including smartphone apps, has the potential to augment and extend the reach of these integrated behavioral health services through self-management support impacting lifestyle behaviors. To date, the feasibility and acceptability of using mental health mobile apps within an integrated primary care setting has not yet been explored as part of routine clinical care. Objectives: The objectives of this study were to (a) test the feasibility of using mental health applications to augment integrated primary care services; (b) solicit feedback from patients and providers to guide implementation, and (c) develop a mental health apps toolkit for system-wide dissemination. Methods: Cambridge Health Alliance (CHA) is a safety-net healthcare system that includes three community hospitals and 12 Primary Care (PC) clinics serving nearly 150,000 ethnically and socioeconomically diverse patients around Boston. To select and disseminate mental health apps, a four-phase implementation was undertaken: (1) Evaluation of mental health mobile applications (2) Development of an apps toolkit with stakeholder input, (3) Conducting initial pilot at six primary care locations, and (4) Rolling out the app toolkit across 12 primary care sites and conducting 1-year follow-up survey. Results: Among BH providers, 24 (75%) responded to the follow-up survey and 19 (83%) indicated they use apps as part of their clinical care. Anxiety was the most common condition for which app use was recommended by providers, and 10 (42%) expressed interest in further developing their knowledge of mental health apps. Among patients, 35 (65%) of participants provided feedback; 23 (66%) reported the tools to be helpful, especially for managing stress and anxiety. Conclusions: Our findings indicate mental health apps are applicable and relevant to patients within integrated primary care settings in safety-net health systems. Behavioral health providers perceive the clinical value of using these tools as part of patient care, but require training to increase their comfort-level and confidence applying these tools with patients. To increase provider and patient engagement, mobile apps must be accessible, simple, intuitive and directly relevant to patients' treatment needs.

Health-related internet use among opioid treatment patients

The Internet and smartphones have become commonplace and can be effective in overcoming traditional barriers to accessing health information about substance use disorders (SUD), and their prevention or treatment. Little is known, however, about specific factors that may influence the use of these technologies among socioeconomically disadvantaged populations with SUDs. This study characterized the use of digital technologies and the Internet among individuals receiving treatment for opioid use disorder, focusing on identifying predictors of Internet use for health-related purposes. Participants came from an urban opioid replacement therapy program and completed a face-to-face survey on Internet and technology use. We examined the association between online health information seeking and technology acceptance variables, including perceived usefulness, effort expectancy, social influence, and facilitating conditions (e.g., availability of devices/services and technical support). Participants (N = 178, ages 18–64) endorsed high rates of current smartphone ownership (94%) and everyday Internet use (67%). 88% of participants reported searching online for information about health or medical topics in the past 3 months. Predictors of Internet use for health-related purposes were higher technology acceptance for mobile Internet use, younger age, current employment, and less bodily pain. Our results demonstrate high acceptance and use of mobile technology and the Internet among this sample of socioeconomically disadvantaged individuals with SUDs. However, these findings also highlight the importance of identifying barriers that disadvantaged groups face in using mobile technologies when designing technology-based interventions for this population.

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94% of those surveyed with an opioid use disorder owned a smartphone.

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67% used the Internet everyday, and 88% searched the Internet for health information.

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Technology acceptance and bodily pain predicted online health information seeking.

Factors Affecting User Acceptance in Overuse of Smartphones in Mobile Health Services: An Empirical Study Testing a Modified Integrated Model in South Korea

Smartphones have become crucial in people's everyday lives, including in the medical field. However, as people become close to their smartphones, this leads easily to overuse. Overuse leads to fatigue due to lack of sleep, depressive symptoms, and social relationship failure, and in the case of adolescents, it hinders academic achievement. Self-control solutions are needed, and effective tools can be developed through behavioral analysis. Therefore, the aim of this study was to investigate the determinants of users' intentions to use m-Health for smartphone overuse interventions. A research model was based on TAM and UTAUT, which were modified to be applied to the case of smartphone overuse. The studied population consisted of 400 randomly selected smartphone users aged from 19 to 60 years in South Korea. Structural equation modeling was conducted between variables to test the hypotheses using a 95% confidence interval. Perceived ease of use had a very strong direct positive association with perceived usefulness, and perceived usefulness had a very strong direct positive association with behavioral intention to use. Resistance to change had a direct positive association with behavioral intention to use and, lastly, social norm had a very strong direct positive association with behavioral intention to use. The findings that perceived ease of use influenced perceived usefulness, that perceived usefulness influenced behavioral intention to use, and social norm influenced behavioral intention to use were in accordance with prior related research. Other results that were not consistent with previous research imply that these are unique behavioral findings regarding smartphone overuse. This research identifies the critical factors that need to be considered when implementing systems or solutions in the future for tackling the issue of smartphone overuse.

Factors Influencing Sustained Engagement with ECG Self-Monitoring: Perspectives from Patients and Health Care Providers

BACKGROUND

Patient-generated health data (PGHD) collected digitally with mobile health (mHealth) technology has garnered recent excitement for its potential to improve precision management of chronic conditions such as atrial fibrillation (AF), a common cardiac arrhythmia. However, sustained engagement is a major barrier to collection of PGHD. Little is known about barriers to sustained engagement or strategies to intervene upon engagement through application design.

OBJECTIVE

This article investigates individual patient differences in sustained engagement among individuals with a history of AF who are self-monitoring using mHealth technology.

METHODS

This qualitative study involved patients, health care providers, and research coordinators previously involved in a randomized, controlled trial involving electrocardiogram (ECG) self-monitoring of AF. Patients were adults with a history of AF randomized to the intervention arm of this trial who self-monitored using ECG mHealth technology for 6 months. Semistructured interviews and focus groups were conducted separately with health care providers and research coordinators, engaged patients, and unengaged patients. A validated model of sustained engagement, an adapted unified theory of acceptance and use of technology (UTAUT), guided data collection, and analysis through directed content analysis.

RESULTS

We interviewed 13 patients (7 engaged, 6 unengaged), 6 providers, and 2 research coordinators. In addition to finding differences between engaged and unengaged patients within each predictor in the adapted UTAUT model (perceived ease of use, perceived usefulness, facilitating conditions), four additional factors were identified as being related to sustained engagement in this population. These are: (1) internal motivation to manage health, (2) relationship with health care provider, (3) supportive environments, and (4) feedback and guidance.

CONCLUSION

Although it required some modification, the adapted UTAUT model was useful in understanding of the parameters of sustained engagement. The findings of this study provide initial requirement specifications for the design of applications that engage patients in this unique population of adults with AF.

Feasibility and Effects of Digital Interventions to Support People in Recovery From Substance Use Disorders: Systematic Review

Background

The development and evaluation of digital interventions aimed at preventing or treating substance use–related problems and disorders is a rapidly growing field. Previous reviews of such interventions reveal a large and complex picture with regard to targeted users, use, and efficacy.

Objective

The objective of this review was to investigate the feasibility and effects of interventions developed specifically for digital platforms. These interventions are focused on supporting people in recovery from substance use disorders by helping them achieve their substance use goals and develop a more satisfying life situation.

Methods

The review is based on a systematic search in MEDLINE, Embase, PsycInfo, and Cochrane Library databases. Of the 1149 identified articles, 722 were excluded as obviously not relevant. Of the remaining articles, 21 were found to be previous reviews, 269 were on interventions aimed at reducing hazardous alcohol or cannabis use, and 94 were on digitized versions of standard treatment methods. The remaining 43 articles were all read in full and systematically scored by both authors.

Results

The 43 articles cover 28 unique interventions, of which 33 have been published after 2013. The interventions are aimed at different target groups (defined by age, substance, or comorbidity). Based on the number of features or modules, the interventions can be categorized as simple or complex. Fourteen of the 18 simple interventions and 9 of the 10 complex interventions have been studied with quantitative controlled methodologies. Thirteen of the 18 simple interventions are integrated in other treatment or support systems, mainly delivered as mobile phone apps, while 6 of the 10 complex interventions are designed as stand-alone interventions, most often delivered on a platform combining desktop/Web and mobile phone technologies. The interventions were generally easy to implement, but in most cases the implementation of the complex interventions was found to be dependent on sustained organizational support. Between 70% and 90% of the participants found the interventions to be useful and easy to use. The rates of sustained use were also generally high, except for simple interventions with an open internet-based recruitment and some information and education modules of the complex interventions. Across all interventions, slightly more than half (55%) of the studies with control groups generated positive findings on 1 or more substance use outcomes, with 57% of the interventions also found to be efficacious in 1 or more studies. In the positive studies, effects were typically in the small to moderate range, with a few studies yielding larger effects. Largely due to the inclusion of stronger control conditions, studies of simple interventions were less likely to produce positive effects.

Conclusions

The digital interventions included in this review are in general feasible but are not consistently effective in helping people in recovery from substance use disorder reduce their substance use or achieving other recovery goals.

Assessing long-term sustainment of clinic participation in NIATx200: Results and a new methodological approach

BACKGROUND

Sustainability frameworks differentiate between sustainability capacity and sustainment of organizational change. Multiple studies have examined sustainability capacity. Methodological approaches to assess long-term sustainment have not been explored. This study addresses this gap by describing the development of a long-term sustainment methodology and evaluating its application utilizing data from substance abuse clinics participating in a quality improvement collaborative.

METHODS

The study involved clinics (n = 121) in three states (MI, NY and WA) participating in the 2007-2009 NIATx200 quality improvement (QI) intervention. It extended the primary analysis to focus on clinics' long-term sustainment of wait time, retention and admission improvements. Long-term sustainment was defined as two years post end of the active implementation period (Calendar Years 2010 and 2011). The analysis defined case exclusion criteria and spline "knot" time intervals; allowed for C_p statistic use to address clinic data volatility; established the structure of sustainment plots and explored differences between NIATx implementation strategies.

RESULTS

Example spline and sustain plots highlight the application of the long-term sustainment methodology for NIATx200 clinics. In clinics with available longitudinal outcome data, 40.8% (n = 31 of 76 clinics) sustained improvements in wait time, 26.7% (n = 20 of 75 clinics) in retention, and 28.1% (n = 32 of 114 clinics) for admissions. Clinic assignment to a NIATx200 implementation strategy did not significantly influence a clinics' long-term sustainment except for lower wait time changes in the interest circle interventions. Thirty clinics (24.8%) sustained improvements for two outcomes and six clinics (5.0%) did so for all three outcomes. The clinics that sustained multiple outcome improvements were assigned to the interest circle (n = 12), learning session (n = 10), combination (n = 8), and coaching (n = 6) implementation strategies. Guidance for applying the long-term sustainment methodology in other quality improvement settings is described.

CONCLUSIONS

Research about sustainability capacity and sustainment of change has become increasingly important in dissemination and implementation research. Assessment of long-term sustainment in a multi-organizational quality improvement collaborative (QIC) is needed to identify when program drift and intervention decay occurs. If "cut-points" indicate when effects diminish, specific sustainability modules could be developed and introduced within the structure of a QIC to improve organizational long-term sustainment. Coaches and change teams could be trained to focus on organizational change sustainment and strengthen the likelihood of institutionalization. ClinicalTrials.gov Identifier: NCT00934141 Registered July 6, 2009. Retrospectively registered.

A Newly Designed Mobile-Based Computerized Cognitive Addiction Therapy App for the Improvement of Cognition Impairments and Risk Decision Making in Methamphetamine Use Disorder: Randomized Controlled Trial

Background

Cognitive rehabilitation therapy has been found to improve cognitive deficits and impulse control problems in methamphetamine use disorder (MUD). However, there is limited research regarding this therapy’s feasibility when using mobile-based health technologies in supporting recovery from MUD in China.

Objective

The main aim of this study was to test whether 4 weeks of a newly designed computerized cognitive addiction therapy (CCAT) app can improve cognitive impairments, eliminate drug-related attention bias, and attenuate risk decision-making behaviors in participants with MUD.

Methods

Forty MUD participants were assigned randomly to either the CCAT group (n=20), who received 4 weeks of CCAT plus regular detoxification treatment as usual, or the control group (n=20), who only received the regular detoxification treatment as usual, in drug rehabilitation centers in Shanghai. The CCAT was designed by combine methamphetamine use-related picture stimuli with cognitive training with the aim of improving cognitive function and eliminating drug-related attention bias. The CogState Battery, Delay Discounting Task (DDT), Iowa Gambling Task (IGT), and Balloon Analog Risk Task (BART) were administered face-to-face to all participants before and after CCAT interventions.

Results

Forty male patients were recruited. The mean age was 32.70 (SD 5.27) years in the CCAT group and mean 35.05 (SD 8.02) years in the control group. Compared to the control group, CCAT improved working memory in the CCAT group (P=.01). Group×time interactions were observed among DDT, IGT, and BART tasks, with rates of discounting delayed rewards, IGT, and BART scores (P<.001) being reduced among those who received CCAT, whereas no changes were found in the control group.

Conclusions

The newly designed CCAT can help to improve cognitive impairment and impulsive control in MUD. Further study is needed to understand the underlying brain mechanisms of the cognitive therapy.

Trial Registration

ClinicalTrials.gov NCT03318081; https://clinicaltrials.gov/ct2/show/NCT03318081 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT03318081)

Factors Determining the Success and Failure of eHealth Interventions: Systematic Review of the Literature

Background

eHealth has an enormous potential to improve healthcare cost, effectiveness, and quality of care. However, there seems to be a gap between the foreseen benefits of research and clinical reality.

Objective

Our objective was to systematically review the factors influencing the outcome of eHealth interventions in terms of success and failure.

Methods

We searched the PubMed database for original peer-reviewed studies on implemented eHealth tools that reported on the factors for the success or failure, or both, of the intervention. We conducted the systematic review by following the patient, intervention, comparison, and outcome framework, with 2 of the authors independently reviewing the abstract and full text of the articles. We collected data using standardized forms that reflected the categorization model used in the qualitative analysis of the outcomes reported in the included articles.

Results

Among the 903 identified articles, a total of 221 studies complied with the inclusion criteria. The studies were heterogeneous by country, type of eHealth intervention, method of implementation, and reporting perspectives. The article frequency analysis did not show a significant discrepancy between the number of reports on failure (392/844, 46.5%) and on success (452/844, 53.6%). The qualitative analysis identified 27 categories that represented the factors for success or failure of eHealth interventions. A quantitative analysis of the results revealed the category quality of healthcare (n=55) as the most mentioned as contributing to the success of eHealth interventions, and the category costs (n=42) as the most mentioned as contributing to failure. For the category with the highest unique article frequency, workflow (n=51), we conducted a full-text review. The analysis of the 23 articles that met the inclusion criteria identified 6 barriers related to workflow: workload (n=12), role definition (n=7), undermining of face-to-face communication (n=6), workflow disruption (n=6), alignment with clinical processes (n=2), and staff turnover (n=1).

Conclusions

The reviewed literature suggested that, to increase the likelihood of success of eHealth interventions, future research must ensure a positive impact in the quality of care, with particular attention given to improved diagnosis, clinical management, and patient-centered care. There is a critical need to perform in-depth studies of the workflow(s) that the intervention will support and to perceive the clinical processes involved.

Feasibility of a Mobile Phone App to Support Recovery From Addiction in China: Secondary Analysis of a Pilot Study

Background

Mobile health technologies have been found to improve the self-management of chronic diseases. However, there is limited research regarding their feasibility in supporting recovery from substance use disorders (SUDs) in China.

Objective

The objective of this study was to examine the feasibility of a mobile phone-based ecological momentary assessment (EMA) app by testing the concordance of drug use assessed by the EMA, urine testing, and a life experience timeline (LET) assessment.

Methods

A total of 75 participants dependent on heroin or amphetamine-type stimulant (ATS) in Shanghai were recruited to participate in a 4-week pilot study. Of the participants, 50 (67% [50/75]) were randomly assigned to the experimental group and 25 (33% [25/75]) were assigned to the control group. The experimental group used mobile health (mHealth) based EMA technology to assess their daily drug use in natural environments and received 2 short health messages each day, whereas the control group only received 2 short health messages each day from the app. Urine tests and LET assessments were conducted each week and a post-intervention survey was administered to both groups. The correlations among the EMA, the LET assessment, and the urine test were investigated.

Results

The mean age of the participants was 41.6 (SD 8.0) years, and 71% (53/75) were male. During the 4 weeks of observation, 690 daily EMA survey data were recorded, with a response rate of 49.29% (690/1400). With respect to drug use, the percent of agreement between the EMA and the LET was 66.7%, 79.2%, 72.4%, and 85.8%, respectively, for each of the 4 weeks, whereas the percent of agreement between the EMA and the urine test was 51.2%, 65.1%, 61.9%, and 71.5%, respectively. The post-intervention survey indicated that 46% (32/70) of the participants preferred face-to-face interviews rather than the mHealth app.

Conclusions

This study demonstrated poor agreement between the EMA data and the LET and found that the acceptance of mHealth among individuals with SUDs in China was not positive. Hence, greater efforts are needed to improve the feasibility of mHealth in China.

mHealth for the Detection and Intervention in Adolescent and Young Adult Substance Use Disorder

Purpose of review

The goal of this review is to highlight recent research in mHealth based approaches to the detection and treatment of substance use disorders in adolescents and young adults.

Recent findings

The main methods for mHealth based detection include mobile phone based self-report tools, GPS tracking, and wearable sensors. Wearables can be used to detect physiologic changes (e.g., heart rate, electrodermal activity) or biochemical contents of analytes (i.e. alcohol in sweat) with reasonable accuracy, but larger studies are needed. Detection methods have been combined with interventions based on mindfulness, education, incentives/goals and motivation. Few studies have focused specifically on the young adult population, although those that did indicate high rates of utilization and acceptance.

Summary

Research that explores the pairing of advanced detection methods such as wearables with real time intervention strategies is crucial to realizing the full potential of mHealth in this population.

Mobile Phone Apps for Behavioral Interventions for At-Risk Drinkers in Australia: Literature Review

Background

The mobile technology era has ushered in the use of mobile phone apps for behavioral intervention for at-risk drinkers.

Objective

Our objective was to review recent research relevant to mobile phone apps that can be used for behavioral intervention for at-risk drinkers in Australia.

Methods

The inclusion criteria for this review were articles published in peer-reviewed journals from 2001 to 2017 with use of the search terms “smartphone application,” “alcohol,” “substance,” “behavioural intervention,” “electronic health,” and “mobile health.”

Results

In total, we identified 103 abstracts, screened 90 articles, and assessed 50 full-text articles that fit the inclusion criteria for eligibility. We included 19 articles in this review.

Conclusions

This review highlighted the paucity of evidence-based and empirically validated research into effective mobile phone apps that can be used for behavioral interventions with at-risk drinkers in Australia.

Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare

BACKGROUND

Improvement initiatives offer a valuable mechanism for delivering and testing innovations in healthcare settings. Many of these initiatives deliver meaningful and necessary changes to patient care and outcomes. However, many improvement initiatives fail to sustain to a point where their full benefits can be realised. This has led many researchers and healthcare practitioners to develop frameworks, models and tools to support and monitor sustainability. This work aimed to identify what approaches are available to assess and influence sustainability in healthcare and to describe the different perspectives, applications and constructs within these approaches to guide their future use.

METHODS

A systematic review was carried out following PRISMA guidelines to identify publications that reported approaches to support or influence sustainability in healthcare. Eligibility criteria were defined through an iterative process in which two reviewers independently assessed 20% of articles to test the objectivity of the selection criteria. Data were extracted from the identified articles, and a template analysis was undertaken to identify and assess the sustainability constructs within each reported approach.

RESULTS

The search strategy identified 1748 publications with 227 articles retrieved in full text for full documentary analysis. In total, 62 publications identifying a sustainability approach were included in this review (32 frameworks, 16 models, 8 tools, 4 strategies, 1 checklist and 1 process). Constructs across approaches were compared and 40 individual constructs for sustainability were found. Comparison across approaches demonstrated consistent constructs were seen regardless of proposed interventions, setting or level of application with 6 constructs included in 75% of the approaches. Although similarities were found, no approaches contained the same combination of the constructs nor did any single approach capture all identified constructs. From these results, a consolidated framework for sustainability constructs in healthcare was developed.

CONCLUSIONS

Choosing a sustainability method can pose a challenge because of the diverse approaches reported in the literature. This review provides a valuable resource to researchers, healthcare professionals and improvement practitioners by providing a summary of available sustainability approaches and their characteristics.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD42016040081 in June 2016.

Factors influencing the long-term sustainment of quality improvements made in addiction treatment facilities: a qualitative study

BACKGROUND

A greater understanding of the factors that influence long-term sustainment of quality improvement (QI) initiatives is needed to promote organizational ability to sustain QI practices over time, help improve future interventions, and increase the value of QI investments.

METHODS

We approached 83 of 201 executive sponsors or change leaders at addiction treatment organizations that participated in the 2007-2009 NIATx200 QI intervention. We completed semi-structured interviews with 33 individuals between November 2015 and April 2016. NIATx200 goals were to decrease wait time, increase admissions and improve retention in treatment. Interviews sought to understand factors that either facilitated or impeded long-term sustainment of organizational QI practices made during the intervention. We used thematic analysis to organize the data and group patterns of responses. We assessed available quantitative outcome data and intervention engagement data to corroborate qualitative results.

RESULTS

We used narrative analysis to group four important themes related to long-term sustainment of QI practices: (1) finding alignment between business- and client-centered practices; (2) staff engagement early in QI process added legitimacy which facilitated sustainment; (3) commitment to integrating data into monitoring practices and the identification of a data champion; and (4) adequate organizational human resources devoted to sustainment. We found four corollary factors among agencies which did not sustain practices: (1) lack of evidence of impact on business practices led to discontinuation; (2) disengaged staff and lack of organizational capacity during implementation period led to lack of sustainment; (3) no data integration into overall business practices and no identified data champion; and (4) high staff turnover. In addition, we found that many agencies' current use of NIATx methods and tools suggested a legacy effect that might improve quality elsewhere, even absent overall sustainment of original study outcome goals. Available quantitative data on wait-time reduction demonstrated general concordance between agency perceptions of, and evidence for, sustainment 2 years following the end of the intervention. Additional quantitative data suggested that greater engagement during the intervention period showed some association with sustainment.

CONCLUSIONS

Factors identified in QI frameworks as important for short-term sustainment-organizational capacity (e.g. staffing and leadership) and intervention characteristics (e.g. flexibility and fit)-are also important to long-term sustainment.

Accelerating Digital Mental Health Research From Early Design and Creation to Successful Implementation and Sustainment

Mental health problems are common and pose a tremendous societal burden in terms of cost, morbidity, quality of life, and mortality. The great majority of people experience barriers that prevent access to treatment, aggravated by a lack of mental health specialists. Digital mental health is potentially useful in meeting the treatment needs of large numbers of people. A growing number of efficacy trials have shown strong outcomes for digital mental health treatments. Yet despite their positive findings, there are very few examples of successful implementations and many failures. Although the research-to-practice gap is not unique to digital mental health, the inclusion of technology poses unique challenges. We outline some of the reasons for this gap and propose a collection of methods that can result in sustainable digital mental health interventions. These methods draw from human-computer interaction and implementation science and are integrated into an Accelerated Creation-to-Sustainment (ACTS) model. The ACTS model uses an iterative process that includes 2 basic functions (design and evaluate) across 3 general phases (Create, Trial, and Sustain). The ultimate goal in using the ACTS model is to produce a functioning technology-enabled service (TES) that is sustainable in a real-world treatment setting. We emphasize the importance of the service component because evidence from both research and practice has suggested that human touch is a critical ingredient in the most efficacious and used digital mental health treatments. The Create phase results in at least a minimally viable TES and an implementation blueprint. The Trial phase requires evaluation of both effectiveness and implementation while allowing optimization and continuous quality improvement of the TES and implementation plan. Finally, the Sustainment phase involves the withdrawal of research or donor support, while leaving a functioning, continuously improving TES in place. The ACTS model is a step toward bringing implementation and sustainment into the design and evaluation of TESs, public health into clinical research, research into clinics, and treatment into the lives of our patients.

Methodology and Reporting of Mobile Heath and Smartphone Application Studies for Schizophrenia

The increasing prevalence of mobile devices among patients of all demographic groups has the potential to transform the ways we diagnose, monitor, treat, and study mental illness. As new tools and technologies emerge, clinicians and researchers are confronted with an increasing array of options both for clinical assessment, through digital capture of the essential behavioral elements of a condition, and for intervention, through formalized treatments, coaching, and other technology-assisted means of patient communication. And yet, as with any new set of tools for the assessment or treatment of a medical condition, establishing and adhering to reporting guidelines-that is, what works and under what conditions-is an essential component of the translational research process. Here, using the recently published World Health Organization mHealth Evaluation, Reporting and Assessment guidelines for evaluating mobile health applications, we review the methodological strengths and weaknesses of existing studies on smartphones and wearables for schizophrenia. While growing evidence supports the feasibility of using mobile tools in severe mental illness, most studies to date failed to adequately report accessibility, interoperability, costs, scalability, replicability, data security, usability testing, or compliance with national guidelines or regulatory statutes. Future research efforts addressing these specific gaps in the literature will help to advance our understanding and to realize the clinical potential of these new tools of psychiatry.

Implementation of a Substance Use Recovery Support Mobile Phone App in Community Settings: Qualitative Study of Clinician and Staff Perspectives of Facilitators and Barriers

BACKGROUND

Research supports the effectiveness of technology-based treatment approaches for substance use disorders. These approaches have the potential to broaden the reach of evidence-based care. Yet, there is limited understanding of factors associated with implementation of technology-based care approaches in different service settings.

OBJECTIVES

In this study, we explored provider and staff perceptions of facilitators and barriers to implementation of a mobile phone substance use recovery support app with clients in 4 service settings.

METHODS

Interviews were conducted with leadership and provider stakeholders (N=12) from 4 agencies in the first year of an implementation trial of the mobile phone app. We used the Consolidated Framework for Implementation Research as the conceptual foundation for identifying facilitators and barriers to implementation.

RESULTS

Implementation process facilitators included careful planning of all aspects of implementation before launch, engaging a dedicated team to implement and foster motivation, working collaboratively with the app development team to address technical barriers and adapt the app to meet client and agency needs, and consistently reviewing app usage data to inform progress. Implementation support strategies included training all staff to promote organization awareness about the recovery support app and emphasize its priority as a clinical care tool, encouraging clients to try the technology before committing to use, scaling rollout to clients, setting clear expectations with clients about use of the app, and using peer coaches and consistent client-centered messaging to promote engagement. Perceived compatibility of the mobile phone app with agency and client needs and readiness to implement emerged as salient agency-level implementation facilitators. Facilitating characteristics of the recovery support app itself included evidence of its impact for recovery support, perceived relative advantage of the app over usual care, the ability to adapt the app to improve client use, and its ease of use. The mobile phone itself was a strong motivation for clients to opt in to use the app in settings that provided phones. App access was limited in settings that did not provide phones owing to lack of mobile phone ownership or incompatibility of the app with clients' mobile phones. Individual differences in technology literacy and provider beliefs about substance use care either facilitated or challenged implementation. Awareness of patient needs and resources facilitated implementation, whereas external policies and regulations regarding technology use introduced barriers to implementation.

CONCLUSIONS

The conceptually grounded facilitators and barriers identified in this study can guide systematic targeting of strategies to improve implementation of mobile phone interventions in community treatment settings. Results also inform the design of technology-based therapeutic tools. This study highlights directions for research with regard to implementation of technology-based behavioral health care approaches.

Realising the technological promise of smartphones in addiction research and treatment: An ethical review

BACKGROUND

Smartphone technologies and mHealth applications (or apps) promise unprecedented scope for data collection, treatment intervention, and relapse prevention when used in the field of substance abuse and addiction. This potential also raises new ethical challenges that researchers, clinicians, and software developers must address.

AIMS

This paper aims to identify ethical issues in the current uses of smartphones in addiction research and treatment.

METHODS

A search of three databases (PubMed, Web of Science and PsycInfo) identified 33 studies involving smartphones or mHealth applications for use in the research and treatment of substance abuse and addiction. A content analysis was conducted to identify how smartphones are being used in these fields and to highlight the ethical issues raised by these studies.

RESULTS

Smartphones are being used to collect large amounts of sensitive information, including personal information, geo-location, physiological activity, self-reports of mood and cravings, and the consumption of illicit drugs, alcohol and nicotine. Given that detailed information is being collected about potentially illegal behaviour, we identified the following ethical considerations: protecting user privacy, maximising equity in access, ensuring informed consent, providing participants with adequate clinical resources, communicating clinically relevant results to individuals, and the urgent need to demonstrate evidence of safety and efficacy of the technologies.

CONCLUSIONS

mHealth technology offers the possibility to collect large amounts of valuable personal information that may enhance research and treatment of substance abuse and addiction. To realise this potential researchers, clinicians and app-developers must address these ethical concerns to maximise the benefits and minimise risks of harm to users.