Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial

BACKGROUND

High consumption of sugar-sweetened beverages (SSB) is a global health concern. Additionally, sugar-sweetened beverage (SSB) consumption is disproportionately high among adolescents and adults in rural Appalachia. The primary study objective is to determine the intervention effects of Kids SIPsmartER on students' SSB consumption. Secondary objectives focus on caregivers' SSB consumption and secondary student and caregiver outcomes [e.g, body mass index (BMI), quality of life (QOL)].

METHODS

This Type 1 hybrid, cluster randomized controlled trial includes 12 Appalachian middle schools (6 randomized to Kids SIPsmartER and 6 to control). Kids SIPsmartER is a 6-month, 12 lesson, multi-level, school-based, behavior and health literacy program aimed at reducing SSB among 7th grade middle school students. The program also incorporates a two-way text message strategy for caregivers. In this primary prevention intervention, all 7th grade students and their caregivers from participating schools were eligible to participate, regardless of baseline SSB consumption. Validated instruments were used to assess SSB behaviors and QOL. Height and weight were objectively measured in students and self-reported by caregivers. Analyses included modified two-part models with time fixed effects that controlled for relevant demographics and included school cluster robust standard errors.

RESULTS

Of the 526 students and 220 caregivers, mean (SD) ages were 12.7 (0.5) and 40.6 (6.7) years, respectively. Students were 55% female. Caregivers were mostly female (95%) and White (93%); 25% had a high school education or less and 33% had an annual household income less than $50,000. Regardless of SSB intake at baseline and relative to control participants, SSB significantly decreased among students [-7.2 ounces/day (95% CI = -10.7, -3.7); p < 0.001, effect size (ES) = 0.35] and caregivers [-6.3 ounces/day (95% CI = -11.3, -1.3); p = 0.014, ES = 0.33]. Among students (42%) and caregivers (28%) who consumed > 24 SSB ounces/day at baseline (i.e., high consumers), the ES increased to 0.45 and 0.95, respectively. There were no significant effects for student or caregiver QOL indicators or objectively measured student BMI; however, caregiver self-reported BMI significantly decreased in the intervention versus control schools (p = 0.001).

CONCLUSIONS

Kids SIPsmartER was effective at reducing SSB consumption among students and their caregivers in the rural, medically underserved Appalachian region. Importantly, SSB effects were even stronger among students and caregivers who were high consumers at baseline.

TRIAL REGISTRATION

Clincialtrials.gov: NCT03740113. Registered 14 November 2018- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03740113 .

The effects of a sleep-focused smartphone application on insomnia and depressive symptoms: a randomised controlled trial and mediation analysis

BACKGROUND

Rates of depression are increasing among adolescents. A novel way to reduce depression is by improving sleep. We evaluated whether an app-based intervention for insomnia improved sleep and depression, and whether changes in insomnia mediated changes in depression.

METHODS

We conducted a 2-arm single-blind randomised controlled trial at the Black Dog Institute in Australia. Adolescents 12-16 years experiencing insomnia symptoms were randomly allocated to receive Sleep Ninja, an app-delivered cognitive behavioural therapy program for insomnia, or to an active control group involving weekly text message sleep tips. Assessments took place at baseline, 6 weeks (post-intervention) and 14 weeks (post-baseline). Co-primary outcomes were symptoms of insomnia and depression at post-intervention (primary endpoint). Intent-to-treat analyses were conducted. The trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12619001462178.

RESULTS

Between October 25, 2019, and September 6, 2020, 264 participants were randomised to receive Sleep Ninja (n = 131) or to the control group (n = 133). Relative to the control group, those allocated to the intervention reported a greater reduction in insomnia symptoms at 6 weeks (95% CI: -2.96 to -0.41, d = .41) and 14 weeks (95% CI: -3.34 to -0.19, d = .39), and a greater reduction in depression symptoms at 6 weeks (95% CI: -3.46 to -0.56, d = .28) but not 14 weeks (p < 1). Change in insomnia mediated change in depression. No adverse events were reported.

CONCLUSIONS

An app-delivered program for insomnia could be a practical, non-stigmatising and scalable way to reduce symptoms of insomnia and depression among adolescents experiencing difficulties getting enough good quality sleep.

The Electronic Surviving Cancer Competently Intervention Program-a Psychosocial Digital Health Intervention for English- and Spanish-Speaking Parents of Children With Cancer: Protocol for Randomized Controlled Trial

BACKGROUND

The psychosocial needs and risks of children with cancer and their families are well-documented including increased risk of parental distress, posttraumatic stress, and anxiety. There is a critical need to provide evidence-based psychosocial care to parents and caregivers of children with cancer. Digital health interventions are important to address many barriers to in-person intervention delivery but are not widely used in pediatric psychosocial cancer care. The COVID-19 pandemic has reinforced the need for flexible, acceptable, and accessible psychosocial digital health interventions. The Electronic Surviving Cancer Competently Intervention Program (eSCCIP) is an innovative digital health intervention for parents and caregivers of children with cancer, delivered through a combination of self-guided web-based content and supplemented by 3 telehealth follow-up sessions with a trained telehealth guide. A Spanish language adaptation of eSCCIP, El Programa Electronico de Intervencion para Superar Cancer Competentemente (eSCCIP-SP), has been developed. The self-guided web-based cores of eSCCIP/eSCCIP-SP are a mix of didactic video content, multifamily video discussion groups featuring parents of children with cancer, and hands-on web-based activities.

OBJECTIVE

The objective of this study is to test eSCCIP/eSCCIP-SP in a multisite randomized controlled trial, compared to an internet-based education control condition consisting of information specifically focused on concerns relevant to parents and caregivers of children with cancer.

METHODS

Using a randomized controlled clinical trial design, 350 eligible parents and caregivers of children with cancer will be randomly assigned to the intervention (eSCCIP/eSCCIP-SP) or an education control condition. Data will be collected at 3 time points: preintervention (prior to randomization), immediately post intervention (after 6 weeks), and at a 3-month follow-up (from baseline). Participants randomized to either condition will receive study material (eSCCIP/eSCCIP-SP intervention or education control website) in English or Spanish, based on the primary language spoken in the home and participant preference.

RESULTS

The primary study end point is a reduction in acute distress from baseline to postintervention, with secondary end points focused on reductions in symptoms of posttraumatic stress and anxiety, and improvements in coping self-efficacy and cognitive coping. An additional exploratory aim will be focused on implementation strategies and potential costs and cost-savings of eSCCIP/eSCCIP-SP, laying the groundwork for future trials focused on dissemination and implementation, stepped-care models, and intervention refinement.

CONCLUSIONS

This trial will provide necessary data to evaluate the efficacy of eSCCIP/eSCCIP-SP. This intervention has the potential to be an easily scalable and highly impactful psychosocial treatment option for parents and caregivers of children with cancer.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05294302; https://clinicaltrials.gov/ct2/show/NCT05294302.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46339.

Development of a Digital Behavioral Intervention to Reduce the Consumption of Sugar-Sweetened Beverages Among Rural Appalachian Adults: Multiphased, Human-Centered Design Approach

BACKGROUND

To avoid the low engagement and limited efficacy of digital behavioral health interventions, robust human-centered design (HCD) processes are needed.

OBJECTIVE

The primary objective of this study was to describe a flexible, step-by-step HCD process to develop digital behavioral health interventions by illustrating iSIPsmarter as an example. iSIPsmarter is a digital intervention for reducing the consumption of sugar-sweetened beverages (SSBs) that comprises 6 internet-based cores metered out over time to deliver the program content, an integrated SMS text message strategy to engage users in reporting SSB behaviors, and an electronic cellular-enabled scale for in-home weighing. The secondary objective is to illustrate the key components and characteristics of iSIPsmarter that resulted from the HCD process.

METHODS

The methods were guided by the Model for Internet Interventions and by best practices in HCD and instructional design processes (eg, rapid prototype development and think-aloud protocol). The 3-phased (ie, contextual, prototype testing, end user testing phases) process followed in this study included a series of 13 semistructured one-on-one interviews with 7 advisory team participants from the targeted Appalachian user group. The interviews were content coded by 2 researchers and then deductively coded to the suggested areas of digital behavioral health interventions.

RESULTS

The participants provided rich perspectives pertaining to iSIPsmarter's appearance, behavioral prescriptions, burdens, content, delivery, message, participation, and assessment. These inputs included requests for built-in flexibility to account for varying internet and SMS text message accessibility among users; ideas to resolve the issues and problems encountered when using the prototypes, including those related to navigation and comprehension of content; ideas to enhance personalized feedback to support motivation and goal setting for SSB consumption and weight; and feedback to refine the development of realistic and relatable vignettes. The participants were able to interact with multiple prototype drafts, allowing researchers to capture and incorporate feedback related to the iSIPsmarter dashboard, daily SSB and weight diaries, action planning, core content, interactions, and vignettes.

CONCLUSIONS

Using scientific models and established processes is critical for building robust and efficacious interventions. By applying an existing model and HCD and instructional design processes, we were able to identify assumptions and address the key areas of the iSIPsmarter intervention that were hypothesized to support users' engagement and promote behavior change. As evidenced by the rich feedback received from the advisory team members and the resulting iSIPsmarter product, the HCD methodology was instrumental in the development process. Although the final iSIPsmarter content is specific to improving SSB consumption behaviors among adults in rural areas, the intent is that this HCD process will have wide applications in the development of digital behavioral health interventions across multiple geographic and behavioral contexts.

Intervention for Sleep and Pain in Youth (ISPY-RCT): protocol for a two-phase randomized controlled trial of sequenced cognitive-behavioral therapy for insomnia and pain management in adolescents with migraine

BACKGROUND

Migraine is a major pediatric health problem impacting 10-12% of youth. About 1 in 3 youth with migraine are diagnosed with insomnia. Sleep and migraine share a cyclical relationship, and data indicate that insomnia symptoms increase migraine severity. CBT for insomnia (CBT-I) has demonstrated efficacy for improving insomnia in adults with migraine and other pain conditions; however, effects in youth have not been evaluated. Moreover, in adults, there is some indication that CBT-I may lead to changes in pain after there are sustained improvements in sleep, but this has never been empirically tested. Cognitive-behavioral therapy for pain management (CBT-Pain) is an established treatment approach for youth with migraine, leading to reductions in headache frequency and disability. In the proposed study, we will address these gaps in knowledge by using an innovative two-phase trial design to (1) test the efficacy of Internet-delivered CBT-I intervention for youth with migraine and comorbid insomnia compared to Internet-delivered sleep education for modifying sleep and (2) investigate how changes in sleep may modify the response to Internet-delivered CBT-Pain intervention.

METHODS

We will study a cohort of 180 adolescents, ages 11-17 years, with migraine (with or without aura, chronic migraine) and comorbid insomnia. In phase 1, youth will be randomly assigned to receive Internet-delivered CBT-I intervention or Internet sleep education control. In phase 2, all youth will receive Internet-delivered CBT-Pain intervention. Assessments will occur at baseline, immediately after phase 1 intervention, immediately after phase 2 intervention, and 6 months post-intervention. We will use a comprehensive multidimensional assessment of sleep and headache including self-report questionnaires, ambulatory actigraphy monitoring, and 14-day daily diaries.

DISCUSSION

Given the high prevalence of insomnia in adolescents with migraine, an extension of CBT-I intervention to this population will address an important gap in clinical practice and in conceptual understanding of the relationship between sleep and migraine. By testing a separate CBT-I intervention, we will be able to apply this treatment in the future to other pediatric populations (e.g., cancer, arthritis) who commonly experience comorbid insomnia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04936321. Registered on June 23, 2021.

0441 Treating Insomnia Disorder in Black Women: Results from an Internet-Based, Randomized Clinical Trial of a Culturally Tailored Intervention

Introduction

Black women are at high risk for insomnia. Despite considerable interest in addressing sleep health disparities, there is very limited research investigating the efficacy of gold standard treatment (cognitive-behavioral therapy for insomnia; CBT-I) among this minority population. Further, we are not aware of any data studying whether a culturally tailored intervention would improve treatment efficacy and/or engagement among Black women.

Methods

We conducted a randomized clinical trial within a national, longitudinal cohort study (Black Women’s Health Study; BWHS). BWHS participants with elevated insomnia symptoms were randomized to receive: (1) automated Internet-delivered CBT-I (Sleep Healthy Using the Internet; SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education about sleep (PE). Primary outcomes were insomnia severity (Insomnia Severity Index; ISI) and treatment engagement (completion of the intervention). We hypothesized that both SHUTi and SHUTi-BWHS would lead to significantly decreased insomnia severity compared to PE, and that SHUTi-BWHS participants would be more likely to complete the intervention.

Results

Three-hundred and thirty-three Black women (mean age=59.3 years) were enrolled in the trial. Those randomized to receive either SHUTi or SHUTi-BWHS had greater reductions in ISI scores at 6-month follow-up (-10.0 and -9.3 points, respectively) compared to PE (-3.6 points). More participants randomized to SHUTi-BWHS completed the intervention compared to those randomized to SHUTi (78.2% vs 64.8%; p&lt;.01). Participants who completed either SHUTi or SHUTi-BWHS showed greater reductions in insomnia severity compared to non-completers (-10.4 vs -6.2 points; p&lt;.01).

Conclusion

Both SHUTi and SHUTi-BWHS improved sleep outcomes more than an active control. The culturally tailored SHUTi-BWHS program was more effective at engaging participants with the program as a greater proportion completed the full intervention, which was associated with greater improvements in sleep outcomes. These compelling data demonstrate that offering a culturally adapted program is a possible path in efforts to address the sleep health disparities facing Black Americans.

Support (If Any)

This trial was funded by Patient-Centered Outcomes Research Institute grant AD-2017C1-6314. National Cancer Institute grant U01 CA164974 supports the BWHS infrastructure.

Moderators of the Effects of mySmartSkin, a Web-Based Intervention to Promote Skin Self-examination and Sun Protection Among Individuals Diagnosed With Melanoma

BACKGROUND

Identifying the characteristics of persons who benefit more from behavioral interventions can help health care providers decide which individuals should be offered particular interventions because this is the subgroup of persons who are more likely to derive greater benefit from the intervention and refine the underlying constructs of the model guiding the intervention.

PURPOSE

This study evaluated possible demographic, medical, knowledge and attitudinal, and psychosocial variables that may moderate the impact of an online intervention, called mySmartSkin (MSS), on engagement in skin self-examination (SSE) and sun protection behaviors among melanoma survivors.

METHODS

Participants completed a baseline survey and were then randomized to the MSS condition or usual care. Follow-up surveys were completed by participants at 8-, 24-, and 48-week postrandomization.

RESULTS

A greater impact of MSS on SSE was illustrated among participants with more phenotypic skin cancer risk factors and participants reporting lower baseline self-efficacy in conducting SSE. A more favorable response of MSS on sun protection behaviors was shown when initial knowledge about abnormal lesions and sun protection barriers were high. Greater use of MSS and more favorable evaluations of it were also associated with higher intervention response.

CONCLUSIONS

Future studies seeking to improve SSE and sun protection among melanoma survivors might benefit from focusing on survivors who report more skin cancer risk factors, lower self-efficacy in conducting SSE, less knowledge about what abnormal skin lesions look like, more perceived barriers to sun protection behaviors, and less worry about recurrence and cancer-related distress.

Lessons Learned From Clinical Recruitment of Older Adults With MCI for an Internet-Delivered Intervention Study

Clinical research involving participants with mild cognitive impairment (MCI) presents challenges to recruitment that may be further compounded by concerns when delivering a behavioral intervention via the Internet. The purpose of this talk is to describe recruitment adaptations for an Internet-delivered behavioral intervention study with older adults living with MCI and insomnia. Over the course of study recruitment, unforeseen barriers to recruitment were discovered, including fewer older adults with MCI endorsing sleep concerns than expected. The most substantive changes made to improve clinical recruitment were related to eligibility criteria, yielding 50% of the overall sample. Anticipated concerns of older adults with MCI using technology or accessing the Internet were not significant barriers to recruitment. Study findings support Internet-delivered intervention use in this population, which in the context of the COVID-19 pandemic, presents a potentially efficient and effective method for recruiting and delivering behavioral interventions in this difficult-to-enroll population.

Digital cognitive-behavioural therapy for insomnia compared with digital patient education about insomnia in individuals referred to secondary mental health services in Norway: protocol for a multicentre randomised controlled trial

INTRODUCTION

Insomnia is highly prevalent in outpatients receiving treatment for mental disorders. Cognitive-behavioural therapy for insomnia (CBT-I) is a recommended first-line intervention. However, access is limited and most patients with insomnia who are receiving mental healthcare services are treated using medication. This multicentre randomised controlled trial (RCT) examines additional benefits of a digital adaptation of CBT-I (dCBT-I), compared with an online control intervention of patient education about insomnia (PE), in individuals referred to secondary mental health clinics.

METHODS AND ANALYSIS

A parallel group, superiority RCT with a target sample of 800 participants recruited from treatment waiting lists at Norwegian psychiatric services. Individuals awaiting treatment will receive an invitation to the RCT, with potential participants undertaking online screening and consent procedures. Eligible outpatients will be randomised to dCBT-I or PE in a 1:1 ratio. Assessments will be performed at baseline, 9 weeks after completion of baseline assessments (post-intervention assessment), 33 weeks after baseline (6 months after the post-intervention assessment) and 61 weeks after baseline (12 months after the post-intervention assessment). The primary outcome is between-group difference in insomnia severity 9 weeks after baseline. Secondary outcomes include between-group differences in levels of psychopathology, and measures of health and functioning 9 weeks after baseline. Additionally, we will test between-group differences at 6-month and 12-month follow-up, and examine any negative effects of the intervention, any changes in mental health resource use, and/or in functioning and prescription of medications across the duration of the study. Other exploratory analyses are planned.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Regional Committee for Medical and Health Research Ethics in Norway (Ref: 125068). Findings from the RCT will be disseminated via peer-reviewed publications, conference presentations, and advocacy and stakeholder groups. Exploratory analyses, including potential mediators and moderators, will be reported separately from main outcomes.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04621643); Pre-results.

Correlates of sun protection behaviors among melanoma survivors

BACKGROUND

The study objective was to assess potential correlates of sun protection behaviors among melanoma survivors.

METHODS

Participants were 441 melanoma survivors recruited from three health centers and a state cancer registry in the United States. Sun protection behaviors (sunscreen, shade, protective shirts, and hats) were assessed through an online survey, as were potential correlates (demographic, melanoma risk, knowledge and beliefs, psychological and social influence factors). Hierarchical multiple regression analyses were conducted.

RESULTS

Correlates of sun protection behaviors included education, skin cancer risk factors, melanoma knowledge and beliefs, melanoma worry and distress, physician recommendation for sun protection, injunctive norms, and pro-protection beliefs (e.g., perceived barriers, self-efficacy).

CONCLUSIONS

Future efforts to improve sun safety among melanoma survivors may benefit from targeting individuals with lower education levels, and addressing sun protection social influence, barriers, and self-efficacy.

Use of Technology in an Internet-Delivered Intervention for Older Adults With Mild Cognitive Impairment

Internet-based interventions using technology can promote access to treatment and reduce participant burden for sleep disorders. However, preliminary studies examining technology use and compliance in older adults with mild cognitive impairment (MCI) are needed prior to undertaking large-scale interventions. Older adults with MCI were recruited from hospital-based memory and sleep disorders clinics and enrolled in a single-arm intervention pilot study. An Internet-delivered cognitive behavioral therapy for insomnia program collected daily sleep diary data and delivered the automated intervention over nine weeks. Sleep diaries and wrist-worn actigraphs collected sleep data for 14 days, pre- and post-intervention. Descriptive statistics for participant technology use are presented. We have recruited 12 subjects with MCI. Most subjects with MCI accessed the intervention program daily; however, actiwatch compliance varied. Incorporating technology for intervention delivery and data collection in this population is promising, and future work should consider using reminders with wearable technology to increase compliance.

Assessing Digital Health Implementation for a Pediatric Chronic Pain Intervention: Comparing the RE-AIM and BIT Frameworks Against Real-World Trial Data and Recommendations for Future Studies

Background

Digital health interventions have demonstrated efficacy for several conditions including for pediatric chronic pain. However, the process of making interventions available to end users in an efficient and sustained way is challenging and remains a new area of research. To advance this field, comprehensive frameworks have been created.

Objective

The aim of this study is to compare the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) and Behavior Interventions using Technology (BIT) frameworks with data collected from the web-based management of adolescent pain (WebMAP Mobile; WMM) randomized controlled trial (RCT).

Methods

We conducted a hybrid effectiveness-implementation cluster RCT with a stepped wedge design in which the intervention was sequentially implemented in 8 clinics, following a usual care period. Participants were 143 youths (mean age 14.5 years, SD 1.9; 117/143, 81.8% female) with chronic pain, from which 73 were randomized to receive the active intervention. Implementation outcomes were assessed using the RE-AIM and BIT frameworks.

Results

According to the RE-AIM framework, the WMM showed excellent reach, recruiting a sample 19% larger than the size originally planned and consenting 79.0% (143/181) of eligible referred adolescents. Effectiveness was limited, with only global impression of change showing significantly greater improvements in the treatment group; however, greater treatment engagement was associated with greater reductions in pain and disability. Adoption was excellent (all the invited clinics participated and referred patients). Implementation was acceptable, showing good user engagement and moderate adherence and positive attitudes of providers. Costs were similar to planned, with a 7% increase in funds needed to make the WMM publicly available. Maintenance was evidenced by 56 new patients downloading the app during the maintenance period and by all clinics agreeing to continue making referrals and all, but one, making new referrals. According to the BIT, 82% (60/73) of adolescents considered the treatment acceptable. In terms of adoption, 93% (68/73) downloaded the app, and all of them used it after their first log-in. In terms of appropriateness at the user level, 2 participants were unable to download the app. Perceptions of the appearance, navigation, and theme were positive. Providers perceived the WMM as a good fit for their clinic, beneficial, helpful, and resource efficient. In terms of feasibility, no technical issues were reported. In terms of fidelity, 40% (29/73) completed the treatment. Implementation costs were 7% above the budget. With regard to penetration, 56 new users accessed the app during the maintenance period. In terms of sustainability, 88% (7/8) of clinics continued recommending the WMM after the end of the study.

Conclusions

For the first time, a real-world digital health intervention was used as a proof of concept to test all the domains in the RE-AIM and BIT frameworks, allowing for comparisons.

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2018.10.003

Prevalence and correlates of skin self-examination practices among cutaneous malignant melanoma survivors

Melanoma patients are at elevated risk for recurrence of the primary cancer as well as second primary melanomas. Regular skin self-examination (SSE) is recommended as part of follow-up surveillance. In this study, we examined SSE performance and comprehensiveness as well as knowledge and attitudinal correlates of SSE performance and comprehensiveness. Four hundred forty-one melanoma survivors completed measures of SSE performance as well as knowledge and attitudes about SSE and melanoma. Approximately two-thirds of the sample reported having conducted an SSE in the past two months; the average number of body parts examined was 10.64 (out of 15 maximum). Only 7.5% of the sample checked all 15 body parts. Greater worry about recurrence, fewer barriers to SSE, more planning for when to conduct SSE, and more confidence in the ability to conduct SSE and recognize a suspicious growth were associated with both SSE performance and greater SSE comprehensiveness. Physician influence was positively associated with SSE performance. Survivor education efforts may benefit from reminding survivors to check hard-to-see and sensitive areas, develop a plan for how to ask for assistance in conducting exams, as well as use mirrors to see hard-to-reach areas. Addressing perceived SSE barriers, fostering SSE planning, and improving SSE self-efficacy may be important foci for intervention efforts to enhance SSE performance and comprehensiveness.

1204 Analyzing User Journey Data In Digital Health: Predicting Dropout From A Digital CBT-I Intervention

Introduction

Intervention dropout is an important factor for the evaluation and implementation of digital therapeutics, including in insomnia. Large amounts of individualized data (logins, questionnaires, EMA data) in these interventions can combine to create user journeys - the data generated by the path an individual takes to navigate the digital therapeutic. User journeys can provide insight about how likely users are to drop out of an intervention on an individual level and lead to increased prediction performance. Thus, the goal of this study is to provide a step-by-step guide for the analysis of user journeys and utilize this guide to predict intervention dropout, illustrated with an example from a data in a RCT of digital therapeutic for chronic insomnia, for which outcomes have previously been published.

Methods

Analysis of user journeys includes data transformation, feature engineering, and statistical model analysis, using machine learning techniques. A framework is established to leverage user journeys to predict various behaviors. For this study, the framework was applied to predict dropouts of 151 participants from a fully automated web-based program (SHUTi) that delivered cognitive behavioral therapy for insomnia. For this task, support vector machines, logistic regression with regularization, and boosted decision trees were applied at different points in 9-week intervention. These techniques were evaluated based on their predictive performance.

Results

After model evaluation, a decision tree ensemble achieved AUC values ranging between 0.6-0.9 based on application of machine earning techniques. Various handcrafted and theory-driven features (e.g., time to complete certain intervention steps, time to get out of bed after arising, and days since last system interaction contributed to prediction performance.

Conclusion

Results indicate that utilizing a user journey framework and analysis can predict intervention dropout. Further, handcrafted theory-driven features can increase prediction performance. This prediction of dropout could lead to an enhanced clinical decision-making in digital therapeutics.

Support

The original study evaluating the efficacy of this intervention has been reported elsewhere and was funded by grant R01 MH86758 from the National Institute of Mental Health.

"Diabetes Just Tends to Take Over Everything": Experiences of Support and Barriers to Diabetes Management for Pregnancy in Women With Type 1 Diabetes

To optimize clinical outcomes, women with type 1 diabetes are advised to consistently achieve blood glucose levels in their target range before becoming pregnant. However, following this recommendation can be clinically and psychologically challenging for patients. We explored women's experiences of pregnancy-related diabetes management and any barriers and support systems affecting their self-management. Fifteen semi-structured telephone interviews were conducted with a nationwide sample. Interviews focused on women's perceptions of barriers hindering pregnancy-related diabetes management and support systems facilitating their self-management. Audio recordings were analyzed using inductive thematic analysis. Results indicated significant impairment of psychological health and overall quality of life in women with type 1 diabetes who were pregnant or planning pregnancy. Most participants reported a lack of support and empathetic engagement from their health care team, which affected their clinical management. Guilt and concerns about high blood glucose levels, constant pressure to meet glucose targets, and difficult interactions with health care professionals were a few of the primary themes with regard to barriers to optimal management. Patient-centered programs that provide effective clinical and psychosocial support for women who are preparing for pregnancy with preexisting diabetes are urgently needed so that these women feel adequately supported and empowered to undertake pregnancy.

Adjunctive Internet-delivered cognitive behavioural therapy for insomnia in men with depression: A randomised controlled trial

OBJECTIVE

Internet-delivered cognitive behavioural therapy for insomnia is efficacious for insomnia, and post hoc analyses suggest mood improvements. We undertook the first clinical trial evaluating the efficacy of Internet-delivered cognitive behavioural therapy for insomnia on depressive symptoms as an adjunct to guideline-based treatment of depressive disorders.

METHODS

Older men undergoing psychiatrist-coordinated treatment for major depressive disorder or dysthymia and who had significant insomnia symptoms were randomised to either adjunctive Internet-delivered cognitive behavioural therapy for insomnia (Sleep Healthy Using The Internet) or online sleep psychoeducation. The primary outcome was change in depressive symptoms (Centre for Epidemiological Studies Depression scale) from baseline to week 12 (post intervention). Secondary outcomes were insomnia and anxiety symptoms.

RESULTS

In all, 87 men were randomised (Internet-delivered cognitive behavioural therapy for insomnia = 45; psychoeducation = 42). The mean observed Centre for Epidemiological Studies Depression scale changes by week 12 were 8.2 (standard deviation = 11.5) and 3.9 (standard deviation = 12.8) for Internet-delivered cognitive behavioural therapy for insomnia and psychoeducation, respectively. The adjunctive effect size of 0.35 in favour of Sleep Healthy Using The Internet programme was not statistically significant (group × time difference in the Mixed effect Model Repeat Measurement analysis difference 4.3; 95% confidence interval = [-1.2, 9.8]; p = 0.15). There was a statistically significant effect on insomnia symptoms (group × time p = 0.02, difference 2.7; 95% confidence interval = [0.2, 5.3]; effect size = 0.62). There were no differences in insomnia or depression at 6 months or differential effects on anxiety at any time point. There were no reported adverse trial-related events in the intervention arm.

CONCLUSION

Adjunctive Internet-delivered cognitive behavioural therapy for insomnia for older men being treated for depression can improve insomnia in the short term, without apparent harm. The short-term depressive symptom effect size in this pilot trial was comparable to other adjunctive interventions and may warrant a larger, definitive trial.

Online recruitment of a non-help-seeking sample for an internet intervention: Lessons learned in an alcohol-exposed pregnancy risk reduction study

BACKGROUND

Recruiting a hidden population, such as the population of women at risk for alcohol-exposed pregnancy (AEP) who binge drink and are at risk of an unintended pregnancy, is challenging as this population is not typically seeking help or part of an identifiable group. We sought to identify affordable and efficient methods of recruitment for hidden populations.

METHODS

Several popular online social media and advertising sites were identified. Cities with high rates of binge drinking among women were targeted. We placed advertisements and study notices using Facebook, Twitter, Craigslist, University postings, and ClinicalTrials.gov.

RESULTS

For this study, 75 women at risk for AEP were recruited from across the U.S. within 7 months. Online advertising for study participants on Craigslist resulted in enrollment of the majority 51 (68%) of the study participants. While Craigslist advertising could be tailored to specific locations with high rates of binge drinking among women, there were challenges to using Craigslist. These included automated deletion due to repeated postings and mention of sexual behavior or drinking, requiring increased efforts and resources by the study team. Several strategies were developed to optimize advertising on Craigslist. Approximately 100 h of staff time valued at $2500 was needed over the 7-month recruitment period.

DISCUSSION

Despite challenges, the target sample of women at risk for AEP was recruited in the 7 month recruitment period using online advertising methods. We recommend that researchers consider online classified advertisements when recruiting from non-help seeking populations. By taking advantage of national data to target specific risk factors, and by tailoring advertising efforts, it is possible to efficiently and affordably recruit a non-treatment seeking sample.

Online insomnia treatment and the reduction of anxiety symptoms as a secondary outcome in a randomised controlled trial: The role of cognitive-behavioural factors

OBJECTIVE

Insomnia and anxiety commonly co-occur, yet the mechanisms underlying this remain unclear. The current paper describes the impact of an Internet-based intervention for insomnia on anxiety, and explores the influence of two cognitive-behavioural constructs - dysfunctional beliefs about sleep and sleep-threat monitoring.

METHODS

A large-scale, 9-week, two-arm randomised controlled trial ( N = 1149) of community-dwelling Australian adults with insomnia and elevated yet subclinical depression symptoms was conducted, comparing a cognitive behavioural therapy-based online intervention for insomnia (Sleep Healthy Using The Internet) with an attention-matched online control intervention (HealthWatch). Symptoms of anxiety were assessed at pretest, posttest, and 6-month follow-up. Dysfunctional beliefs about sleep and sleep threat monitoring were assessed only at pretest.

RESULTS

Sleep Healthy Using The Internet led to a greater reduction in anxiety symptoms at both posttest ( t_724.27 = -6.77, p < 0.001) and at 6-month follow-up ( t_700.67 = -4.27, p < 0.001) than HealthWatch. At posttest and follow-up, this effect was found to moderated by sleep-threat monitoring ( t_713.69 = -2.39, p < 0.05 and t_694.77 = -2.98, p < 0.01 respectively) but not by dysfunctional beliefs about sleep at either posttest or follow-up ( t_717.53 = -0.61, p = 0.55 and t_683.79 = 0.22, p = 0.83 respectively). Participants in the Sleep Healthy Using The Internet condition with higher levels of sleep-threat monitoring showed a greater reduction in anxiety than those with lower levels from pretest to posttest, ( t_724.27 = -6.77, p < 0.001) and through to 6-month follow-up ( t_700.67 = -4.27, p < 0.001). This result remained after controlling for baseline anxiety levels.

CONCLUSION

The findings suggest that online cognitive behavioral therapy interventions for insomnia are beneficial for reducing anxiety regardless of people's beliefs about their sleep and insomnia, and this is particularly the case for those with high sleep-threat monitoring. This study also provides further evidence for cognitive models of insomnia.

A hierarchical clustering approach to identify repeated enrollments in web survey data

INTRODUCTION

Online surveys are a valuable tool for social science research, but the perceived anonymity provided by online administration may lead to problematic behaviors from study participants. Particularly, if a study offers incentives, some participants may attempt to enroll multiple times. We propose a method to identify clusters of non-independent enrollments in a web-based study, motivated by an analysis of survey data which tests the effectiveness of an online skin-cancer risk reduction program.

METHODS

To identify groups of enrollments, we used a hierarchical clustering algorithm based on the Euclidean distance matrix formed by participant responses to a series of Likert-type eligibility questions. We then systematically identified clusters that are unusual in terms of both size and similarity, by repeatedly simulating datasets from the empirical distribution of responses under the assumption of independent enrollments. By performing the clustering algorithm on the simulated datasets, we determined the distribution of cluster size and similarity under independence, which is then used to identify groups of outliers in the observed data. Next, we assessed 12 other quality indicators, including previously proposed and study-specific measures. We summarized the quality measures by cluster membership, and compared the cluster groupings to those found when using the quality indicators with latent class modeling.

RESULTS AND CONCLUSIONS

When we excluded the clustered enrollments and/or lower-quality latent classes from the analysis of study outcomes, the estimates of the intervention effect were larger. This demonstrates how including repeat or low quality participants can introduce bias into a web-based study. As much as is possible, web-based surveys should be designed to verify participant quality. Our method can be used to verify survey quality and identify problematic groups of enrollments when necessary.

Overcoming insomnia: protocol for a large-scale randomised controlled trial of online cognitive behaviour therapy for insomnia compared with online patient education about sleep

INTRODUCTION

Insomnia is a major public health concern. While cognitive behaviour therapy for insomnia (CBT-I) is acknowledged as the best available intervention, there are unanswered questions about its wider dissemination, socioeconomic benefits and its impact on health resource utilisation. The aim of this randomised controlled trial (RCT) is to investigate the effectiveness of a fully automated online version of CBT-I compared with online patient education about sleep (PE). Outcome measures comprise changes in symptoms of insomnia, time off work due to sick leave as well as medication and health resource utilisation. Also, we will examine (i) putative mediators of the effects of CBT-I on insomnia severity and (ii) selected potential psycho-bio-social moderators of the effects of the interventions.

METHODS AND ANALYSIS

A parallel-group RCT will be conducted in a target sample of about 1500 adults recruited across Norway. Participants will complete an online screening and consent process. Those who meet eligibility criteria will be randomised to receive direct access to fully automated online CBT-I or to an online PE programme. The primary outcome is change in insomnia severity immediately postintervention; secondary outcomes are change in daytime functioning and other sleep measures postintervention and at 6-month and 24-month follow-up. Objective data from national registries will be obtained at two time points (1 year and 2 years post-treatment), allowing a mirror image study of preintervention and postintervention rates of sick leave, and of medication and healthcare utilisation by condition.

ETHICS AND DISSEMINATION

The study protocol was approved by the Regional Committee for Medical and Health Research Ethics in South East Norway (2015/134). Findings from the RCT will be disseminated in peer-reviewed publications and conference presentations. Exploratory analyses of potential mediators and moderators will be reported separately. User-friendly outputs will be disseminated to patient advocacy and other relevant organisations.

TRIAL REGISTRATION NUMBER

NCT02558647; Pre-results.

A Pilot RCT of an Internet Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy

BACKGROUND

Preventing alcohol-exposed pregnancies (AEPs) could reduce the incidence of fetal alcohol spectrum disorders. Previous face-to-face interventions significantly reduced risk for AEP, but a scalable intervention is needed to reach more women at risk.

METHODS

This study compared a 6 Core automated, interactive, and tailored Internet intervention, the Contraception and Alcohol Risk Reduction Internet Intervention (CARRII), to a static patient education (PE) website for its effect on AEP risk. Participants were recruited online to a pilot randomized clinical trial (RCT) with baseline, 9 weeks posttreatment, and 6-month (6-M) follow-up assessments. Seventy-one women completed online questionnaires and telephone interviews and were randomized to CARRII (n = 36) or PE (n = 35). Primary outcomes were rates of risky drinking, unprotected sex episodes, and AEP risk, collected from online prospective diaries.

RESULTS

CARRII participants showed significant reductions in rate of unprotected sex from pretreatment (88.9%) to posttreatment (70.6%) (p < 0.04) and to 6-M follow-up (51.5%) (p = 0.001); rate of risky drinking from pretreatment (75.0%) to posttreatment (50.0%) (p < 0.02), but insignificant change from pretreatment to 6-M follow-up (57.6%) (p < 0.09); and rate of AEP risk from pretreatment (66.7%) to posttreatment (32.4%) (p = 0.001) and to 6-M follow-up (30.3%) (p = 0.005). PE participants demonstrated no significant changes on all 3 variables across all time points. Intent-to-treat group-by-time tests were not significant, but power was limited by missing diaries. Over 72% of CARRII participants completed all 6 Cores. Exploratory analyses suggest that higher program utilization is related to change.

CONCLUSIONS

These data show that CARRII was acceptable, feasible, promising to reduce AEP risk, and merits further testing in a fully powered RCT.

Longitudinal change in parent and child functioning after internet-delivered cognitive-behavioral therapy for chronic pain

Theoretical models of pediatric chronic pain propose longitudinal associations between children's pain experiences and parent and family factors. A large body of cross-sectional research supports these models, demonstrating that greater parent distress and maladaptive parenting behaviors are associated with greater child disability. Family-based cognitive-behavioral therapy interventions have been developed for youth with chronic pain which aim to improve child disability and reduce maladaptive parenting behaviors. However, little is known about temporal, longitudinal associations between parent and child functioning in this population. In the present study, we conducted a secondary analysis of data from 138 families of youth with chronic pain aged 11 to 17 years old who received family-based cognitive-behavioral therapy delivered through the Internet as part of a randomized controlled trial. Measures of child disability, parent protective behavior, and parent distress were obtained at pretreatment, immediate posttreatment, 6-month follow-up, and 12-month follow-up. Latent growth modeling indicated that child disability, parent protective behavior, and parent distress improved with treatment over the 12-month study period. Latent growth modeling for parallel processes indicated that higher parent distress at pretreatment predicted less improvement in child disability over 12 months. No other predictive paths between parent and child functioning were significant. These findings indicate that parent distress may increase the risk of poor response to psychological pain treatment among youth with chronic pain. At present, parent distress is not routinely targeted in psychological interventions for pediatric chronic pain. Research is needed to determine optimal strategies for targeting parent and family factors in the treatment of pediatric chronic pain.

A study protocol for a randomised controlled trial of an interactive web-based intervention: CancerCope

INTRODUCTION

Approximately 35% of patients with cancer experience clinically significant distress, and unmet psychological supportive care needs are prevalent. This study describes the protocol for a randomised controlled trial (RCT) to assess the efficacy and cost-effectiveness of an internet-based psychological intervention for distressed patients with cancer.

METHODS AND ANALYSIS

In phase I, the intervention was developed on an interactive web platform and pilot tested for acceptability using a qualitative methodology with 21 patients with cancer. Phase II is an RCT underway with patients with or at risk of elevated psychological distress comparing: (1) static patient education website with (2) individualised web-delivered cognitive behavioural intervention (CancerCope). Participants were recruited through the Queensland Cancer Registry and Cancer Council Helpline and met the following inclusion criteria: (1) recently diagnosed with cancer; (2) able to read and speak English; (3) no previous history of head injury, dementia or psychiatric illness; (4) no other concurrent cancer; (5) phone and internet access; (5) scored ≥4 on the Distress Thermometer. Participants are assessed at four time points: baseline/recruitment and 2, 6 and 12 months after recruitment and intervention commencement. Of the 163 participants recruited, 50% met caseness for distress. The area of highest unmet supportive care needs were psychological followed by physical and daily living needs. Primary outcomes are psychological and cancer-specific distress and unmet psychological supportive care needs. Secondary outcomes are positive adjustment, quality of life and cost-effectiveness.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Griffith University Human Research Ethics Committee (Approval: PSY/70/13/HREC) and the Metro South Human Research Ethics Committee (HREC/13/QPAH/601). All participants provide informed consent prior to taking part in the study. Once completed, this study will provide recommendations about the efficacy of web-based cognitive behavioural interventions to facilitate better psychosocial adjustment for people with cancer.

TRIAL REGISTRATION NUMBER

ANZCTR (ACTRN12613001026718).

A smartphone "app"-delivered randomized factorial trial targeting physical activity in adults

Rapid technological development has challenged researchers developing mobile moderate-to-vigorous physical activity (MVPA) interventions. This 12-week randomized factorial intervention aimed to determine the individual and combined impact of a self-monitoring smartphone-app (tracking, feedback, education) and two theory-based modules (goal-setting, points-based feedback) on MVPA, key psychosocial outcomes, and application usage. Adults (N = 116; M _age  = 41.38 ± 7.57) received (1) a basic self-monitoring app, (2) the basic app plus goal setting, (3) the basic app plus points-based feedback, or (4) the basic app plus both modules. All individuals increased MVPA by more than 11 daily minutes. Those with points-based feedback demonstrated still higher levels of MVPA and more favorable psychosocial and app usage outcomes across the intervention. Those with access to in-app goal setting had higher levels of app usage relative to those without the component. It is imperative that effective digital intervention "ingredients" are identified, and these findings provide early evidence to this effect. Trial Registration clinicaltrials.gov identifier NCT02592590.

Technology Use Among Patients in a Nonurban Southern U.S. HIV Clinic in 2015

BACKGROUND

Behavioral interventions can be delivered over the Internet, but nonurban subpopulations living with HIV may still have inadequate Internet access to make this feasible.

METHODS

We report on a survey conducted in 2015 among 150 patients receiving care at a university-based Infectious Disease Clinic serving a nonurban and rural population in central Virginia. Our aim was to determine the rate of computer, tablet, and smartphone usage, as well as Internet access, to inform the delivery of a novel intervention using Internet and mobile technology.

RESULTS

The participants' mean age was 46; 111 patients used computers, 101 used smartphones, and 41 used tablets. The results showed that 87% of patients had Internet access. Of those, 49 reported daily Internet use, while 18% reported weekly Internet use, and 33% reported less frequent Internet use.

CONCLUSIONS

The survey study data suggest that Internet access among nonurban and rural patients with HIV is adequate to support trials testing Internet-delivered interventions. It is time to develop and deliver Internet interventions tailored for this often isolated subpopulation.

MindSpot Clinic: An Accessible, Efficient, and Effective Online Treatment Service for Anxiety and Depression

OBJECTIVE

The main objective of this study was to report the feasibility of delivering online cognitive-behavioral therapy (iCBT) treatments for anxiety and depression in a national public mental health service.

METHODS

A prospective noncontrolled cohort study was conducted of all patients who began assessment or treatment at the MindSpot Clinic from January through December 2013. Clinic services were used by a representative cross-section of the Australian population. Mean age at assessment was 36.4±13.0 years, and age range was 18-86 years. Patients completed one of four online courses over eight weeks, during which they received weekly support from a therapist via telephone or secure e-mail. Primary outcome measures were the nine-item Patient Health Questionnaire (PHQ-9) and the seven-item Generalized Anxiety Disorder scale (GAD-7) administered at posttreatment and three months posttreatment.

RESULTS

A total of 10,293 adults who self-identified as having problems with anxiety or depression commenced assessment, and 7,172 completed the assessment and were eligible for analysis. Of these, 2,049 enrolled in a course and 1,471 completed the course, for a course completion rate of 71.8%. Moderate to large noncontrolled effect sizes (Cohen's d=.67-1.66, 95% confidence interval=.08-2.07) were found from assessment to three-month follow-up. At posttreatment and follow-up, reliable recovery ranged from 46.7% to 51.1%, and deterioration ranged from 1.9% to 3.8%. Mean total therapist time per patient was 111.8±61.6 minutes.

CONCLUSIONS

The MindSpot Clinic produced treatment outcomes that were comparable to results from published clinical trials of iCBT. This model of service delivery represents an innovative method of providing accessible, low-cost, effective, and acceptable mental health services to many people who currently are not receiving care.

Development of an Internet Intervention to Address Behaviors Associated with Skin Cancer Risk among Young Adults

PURPOSE

Skin cancer is the most common cancer in the US, and its incidence is increasing. The major risk factor for skin cancer is exposure to ultraviolet radiation (UV). Young adults tend to expose themselves to large amounts of UV and engage in minimal skin protection, which increases their skin cancer risk. Interventions are needed to address risk behaviors among young adults that may lead to skin cancer. The nternet offers a cost-effective way to widely disseminate efficacious interventions. The current paper describes the development of an online skin cancer risk reduction intervention (UV4.me) for young adults.

PROCEDURES

The iterative development process for UV4.me followed best-practice guidelines and included the following activities: individual interviews, focus groups, content development by the expert team, acceptability testing, cognitive interviewing for questionnaires, quality control testing, usability testing, and a pilot randomized controlled trial. Participant acceptability and usability feedback was assessed.

PRINCIPAL RESULTS

The development process produced an evidence-informed intervention that is individually-tailored, interactive, and multimedia in nature based on the Integrative Model of Behavior Prediction, a model for internet interventions, and other best-practice recommendations, expert input, as well as user acceptability and usability feedback gathered before, during, and after development.

MAJOR CONCLUSIONS

Development of an acceptable intervention intended to have a significant public health impact requires a relatively large investment in time, money, expertise, and ongoing user input. Lessons learned and recommendations are discussed. The comprehensive process used may help prepare others interested in creating similar behavioral health interventions.

Establishing guidelines for executing and reporting Internet intervention research

The field of Internet interventions is growing rapidly. New programs are continually being developed to facilitate health and mental health promotion, disease and emotional distress prevention, risk factor management, treatment, and relapse prevention. However, a clear definition of Internet interventions, guidelines for research, and evidence of effectiveness have been slower to follow. This article focuses on the quality standardization of research on Internet-delivered psychological and behavioural interventions. Although the science underpinning Internet interventions is just starting to be established, across research studies there are often conceptual and methodological difficulties. The authors argue that this situation is due to the lack of universally accepted operational guidelines and evaluation methods. Following a critical appraisal of existing codes of conduct and guidelines for Internet-assisted psychological and health interventions, the authors developed a framework of guidelines for Internet intervention research utilizing aspects of facet theory (Guttman & Greenbaum, 1998). The framework of facets, elements, and guidelines of best practice in reporting Internet intervention research was then sent to several leading researchers in the field for their comment and input, so that a consensus framework could be agreed on. The authors outline 12 key facets to be considered when evaluating and reporting Internet intervention studies. Each facet consists of a range of recommended elements, designed as the minimum features for reporting Internet intervention studies. The authors propose that this framework be utilized when designing and reporting Internet intervention research, so results across studies can be replicated, extended, compared, and contrasted with greater ease and clarity.

The GoodNight study--online CBT for insomnia for the indicated prevention of depression: study protocol for a randomised controlled trial

BACKGROUND

Cognitive Behaviour Therapy for Insomnia (CBT-I) delivered through the Internet is effective as a treatment in reducing insomnia in individuals seeking help for insomnia. CBT-I also lowers levels of depression in this group. However, it is not known if targeting insomnia using CBT-I will lower depressive symptoms, and thus reduce the risk of major depressive episode onset, in those specifically at risk for depression. Therefore, this study aims to examine whether Internet delivery of fully automated self-help CBT-I designed to reduce insomnia will prevent depression.

METHOD/DESIGN

A sample of 1,600 community-dwelling adults (aged 18-64), who screen positive for both subclinical levels of depressive symptoms and insomnia, will be recruited via various media and randomised to either a 9-week online insomnia treatment programme, Sleep Healthy Using The internet (SHUTi), or an online attention-matched control group (HealthWatch). The primary outcome variable will be depression symptom levels at the 6-month post-intervention on the Patient Heath Questionnaire-9 (PHQ-9). A secondary outcome will be onset of major depressive episodes assessed at the 6-month post-intervention using 'current' and 'time from intervention' criteria from the Mini International Neuropsychiatric Interview.

DISCUSSION

This trial is the first randomised controlled trial of an Internet-based insomnia intervention as an indicated preventative programme for depression. If effective, online provision of a depression prevention programme will facilitate dissemination.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), Registration number: ACTRN12611000121965.

The challenges and future considerations regarding pregnancy-related outcomes in women with pre-existing diabetes

Ineffective management of blood glucose levels during preconception and pregnancy has been associated with severe maternal and fetal complications in women with pre-existing diabetes. Studies have demonstrated that preconception counseling and pre-pregnancy care can dramatically reduce these risks. However, pregnancy-related outcomes in women with diabetes continue to be less than ideal. This review highlights and discusses a variety of patient, provider, and organizational factors that can contribute to these suboptimal outcomes. Based on the findings of studies reviewed and authors' clinical and research experiences, recommendations have been proposed focusing on various aspects of care provided, including improved accessibility to effective preconception and pregnancy-related care and better organized clinic consultations that are sensitive to women's diabetes and pregnancy needs.

Driving mishaps among individuals with type 1 diabetes: a prospective study

OBJECTIVE

Hypoglycemia-related neuroglycopenia disrupts cognitive-motor functioning, which can impact driving safety. Retrospective studies suggest that drivers with type 1 diabetes experience more collisions and citations than their nondiabetic spouses. We present the first prospective data documenting the occurrence of apparent neuroglycopenia-related driving performance impairments.

RESEARCH DESIGN AND METHODS

We completed the initial screening of 452 drivers from three geographically diverse centers who then reported monthly occurrences of driving "mishaps," including collisions, citations, losing control, automatic driving, someone else taking over driving, and moderate or severe hypoglycemia while driving.

RESULTS

Over 12 months, 52% of the drivers reported at least one hypoglycemia-related driving mishap and 5% reported six or more. These mishaps were related to mileage driven, history of severe hypoglycemia, and use of insulin pump therapy.

CONCLUSIONS

Many individuals with type 1 diabetes report hypoglycemia-related driving events. Clinicians should explore the recent experiences with hypoglycemia while driving and the risk of future events.

Blood glucose awareness training delivered over the internet

OBJECTIVE

Blood glucose awareness training (BGAT), a psycho-educational intervention, trains individuals with type 1 diabetes to 1) detect/interpret internal cues to better detect extreme blood glucose levels, e.g., neurogenic and neuroglycopenic symptoms; and 2) interpret external cues to detect current and anticipate future extreme blood glucose levels, e.g., insulin timing/dose and recent self-monitoring of blood glucose results. Although outcome studies using BGAT are significant, limitations include the requirement of eight weekly meetings and limited professionals trained to deliver BGAT.

RESEARCH DESIGN AND METHODS

Due to the limitations mentioned above, BGAT was converted for web-based delivery. The internet allows BGAT delivery to be dynamic, engaging, convenient, and personalized. Efficacy was evaluated using a 2 (BGAThome, n = 20, vs. control, n = 20) x 2 (pre/post) design.

RESULTS

BGAThome was judged as useful and easy to use, was completed by 94% of the participants, and resulted in significant clinical improvements (P < 0.05).

CONCLUSIONS

The internet may be an efficient and effective means of delivering diabetes interventions like BGAT.

Detection of hypoglycemia by children with type 1 diabetes 6 to 11 years of age and their parents: a field study

OBJECTIVES

The objectives of this study were to (1) assess accuracy of hypoglycemia detection in children with type 1 diabetes and their parents, using personal digital assistant technology to collect glucose estimates and meter readings, (2) identify demographic, clinical, and psychological predictors of individual differences in accuracy, and (3) test whether poor hypoglycemia detection is a risk factor for severe hypoglycemia in children.

METHODS

Sixty-one children aged 6 to 11 and their parents completed 70 trials, over 1 month, of a survey programmed on a personal digital assistant, which asked them to rate symptoms, estimate current blood glucose level, and then measure blood glucose level. For the subsequent 6 months, parents reported children's severe hypoglycemia episodes bimonthly.

RESULTS

Both parents and children showed poor ability to recognize high or low blood glucose levels, making clinically significant errors as frequently as clinically accurate estimates. Parents failed to recognize >50% of readings <3 mmol/L (<55 mg/dL) and made potentially dangerous errors such as believing the blood glucose level was high when it was low 17% of the time. Children were significantly more accurate at recognizing their hypoglycemia but still failed to detect >40% of episodes. Higher depression scores for children related to lower accuracy. Children who were less accurate at detecting hypoglycemia subsequently experienced more severe hypoglycemia.

CONCLUSIONS

Ability to recognize hypoglycemia is a significant problem for children with type 1 diabetes and their parents. For children, poor ability to detect low blood glucose levels may be a significant and underappreciated risk factor for severe hypoglycemia. More effort is needed to provide education and training designed to improve hypoglycemia detection in this population.

Prediction of severe hypoglycemia

OBJECTIVE

Prevention of severe hypoglycemia (SH) is premised partially on the ability to accurately anticipate its occurrence. This study prospectively tests methods for predicting SH using blood glucose meter readings.

RESEARCH DESIGN AND METHODS

One hundred adults with type 1 diabetes were followed for 6 months, and 79 insulin-using adults with type 2 diabetes were followed for 4 months. During this time, subjects' routine self-monitored blood glucose (SMBG) readings were stored on and retrieved from memory meters, and participants were queried biweekly about occurrence of SH. Respective demographics for the two groups were age 40.7 and 50.2 years, duration of diabetes 20.0 and 12.2 years, A1C 7.6 and 8.8%, and male sex 43 and 39%, respectively.

RESULTS

Relative risk for SH, quantified by the ratio of an individual's low blood glucose index (LBGI) based on the previous 150 SMBG readings to the LBGI based on recent SMBG readings, increased significantly in the 24 h before SH episodes in individuals with type 1 and type 2 diabetes (t = 10.3, P < 0.0001, and t = 4.2, P < 0.001, respectively). A sliding algorithm detected 58% of imminent (within 24 h) SH episodes in the type 1 diabetic group and 60% of those in the type 2 diabetic group when three SMBG readings were available in the 24 h before an episode. Detection increased to 63 and 75%, respectively, if five SMBG readings were available in the 24 h before an episode.

CONCLUSIONS

SH often follows a specific blood glucose fluctuation pattern that is identifiable from SMBG. Thus, partial prediction of imminent SH is possible, providing a potential tool to trigger self-regulatory prevention of significant hypoglycemia.

Does "stubbornness" have a role in pediatric constipation?

The objective of this study was to determine if children with constipation are more stubborn, both in general and specifically regarding toileting behaviors, than children without constipation. A secondary objective was to determine if constipated children who are more stubborn are less likely to respond to routine therapeutic interventions than less stubborn constipated children. One hundred one children aged 2 to 6 years, who were first-time presenters (never received treatment) to their primary care physician (PCP) with constipation, were compared with 84 nonconstipated control children of similar age range. Comparison measures included general stubbornness and toilet-specific stubbornness (active resistance to participating in appropriate toileting behaviors). Measures of stubbornness were generated from retrospective questionnaires, prospective toileting diaries completed by the parents, and direct experimenter observations. The constipated children were treated by their PCP for 2 months and then reassessed. Constipated children were perceived by their parents to be significantly more stubborn than control children generally and specifically in terms of toileting. Some study evidence suggested that constipated children who continued to have difficulties after 2 months of treatment by their PCPs were perceived by their parents to have significantly more general stubbornness than constipated children who responded to treatment. Parent-perceived toilet-specific stubbornness significantly improved after successful treatment of the constipation by their PCP. The finding that constipated children had more parent-perceived stubbornness than children without constipation is notable because it may play a role in the development and/or maintenance of this bowel dysfunction as well as being an obstacle in treatment compliance.

Using the Internet to teach parents and children about constipation and encopresis

Since 1995, we have maintained a tutorial about chronic childhood constipation and encopresis on our web site. The tutorial is directed at parents and older children and includes a feedback form comprised of six multiple-choice questions and a free-text comment field. Between 1 January 1998 and 30 April 2000, we received 1,142 completed feedback forms. The vast majority of respondents identified themselves as parents or guardians of a child with constipation or encopresis. All respondents felt the tutorial was clear and easy to understand. 98% of respondents felt the tutorial helped them understand why children develop constipation and/or encopresis and 91% of respondents felt the tutorial made them better able to take care of a child suffering from constipation and/or encopresis. More than 99% of respondents felt this type of tutorial was a good way to teach people about health problems. 74% of respondents sent us comments about the tutorial. Most often, the comments expressed thanks for having this information available in clear and understandable language, however a significant number of people inquired about a particular child's difficulties or asked a general question not clearly pertaining to a particular child. The results of this study indicate that many people are searching the Internet for information concerning childhood encopresis and that the World Wide Web can provide families with useful information about this common paediatric problem.

Stability of psychiatric patients' perceptions of their admission experience

The primary aim of this study was to evaluate the stability (i.e., consistency of patients' responses over time) of newly developed scales to measure the admission experience of psychiatric hospitalization. Eighty-four psychiatric patients involuntarily committed to a crisis stabilization unit participated. All participants were admitted under an emergency petition or ex parte order for a psychiatric evaluation. Patients were interviewed soon after admission (M = 3.33 days, SD = 1.86 days). The test-retest interval was 24-48 hours with most (83.3%) re-evaluated at 24 hours. Overall, the measures showed acceptable levels of stability (r's range from .62 to .72). Factors associated with reliable responses were lower overall psychiatric symptom severity, less severe psychotic symptoms, and mentioning the same person as an influence of perceptions about the admission experience at each assessment point.