Stage-Based Mobile Intervention for Substance Use Disorders in Primary Care: Development and Test of Acceptability

Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis

In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.

Mobile technology and task shifting to improve access to alcohol treatment services in Mozambique

INTRODUCTION

Unhealthy alcohol use (UAU) is a major public health challenge, particularly in low- and middle-income countries. Mozambique is the fourth poorest country in the world where half of the population lives below the poverty line. UAU is frequent among drinkers in Mozambique; however, resources and infrastructure to treat UAU are very limited. This paper examines how task-shifting and a provider-facing mobile health application are being used to improve access to care. In this paper, the feasibility, acceptability and appropriateness of a provider-facing mobile health application being used under a task-shifting model to identify UAU and provide a four-session brief motivational interviewing intervention are described.

METHOD

The study used a sequential exploratory mixed-methods design with a QUAL → quan structure. First, 15 psychiatric technicians and primary care providers in Mozambique's Nampula Province participated in semi-structured interviews. These interviews were recorded and transcribed. Then, 45 providers completed a 12-item quantitative survey on tablets. Quantitative analysis used descriptive statistic calculation and qualitative analysis used thematic analysis.

RESULTS

Nonspecialized providers found the mobile health app to be acceptable, appropriate, and feasible when delivering a 4-session brief motivational intervention under a task-shifting model. Central benefits of the technology were enhanced standardization and efficiency of sessions as well as feelings of legitimacy when interacting with patients. Main concerns were feasibility of implementing the intervention due to time constraints of workload and internet connectivity issues.

CONCLUSIONS

Provider-facing technology shows promise in supporting task-shifting models that can expand alcohol intervention services and increase access to care in low- and middle-income countries. Providers without specialized training in behavioral health interventions can provide critical services to patients with UAU and provider-facing mobile health applications may help bring such models to scale.

PreView: a Randomized Trial of a Multi-site Intervention in Diverse Primary Care to Increase Rates of Age-Appropriate Cancer Screening

BACKGROUND

Women aged 50-70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50-70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50-70-year-old individuals are due for screening or screening discussion.

METHODS

We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a "Provider Alert." Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion.

RESULTS

A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening.

CONCLUSION

In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView's impact on those who are hesitant or reluctant to undergo screening.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02264782.