Therapist-delivered Internet psychotherapy for depression in primary care: a randomised controlled trial

BACKGROUND

Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care.

METHODS

In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578.

FINDINGS

113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023).

INTERPRETATION

CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT.

FUNDING

BUPA Foundation.

Peer assistance reaches its 25th year

This column traces the history of the efforts of the American Association of Nurse Anesthetists to provide assistance to members struggling with addiction. The work of the Ad Hoc Committee on Chemical Dependency, the Peer Assistance Advisors, Anesthetists in Recovery, the Council on Public Interest in Anesthesia, and the Wellness Program are examined.

EFFECTS OF THE NEW FATHERS NETWORK ON FIRST-TIME FATHERS' PARENTING SELF-EFFICACY AND PARENTING SATISFACTION DURING THE TRANSITION TO PARENTHOOD

The effectiveness of an Internet-based intervention, the New Fathers Network, was tested in improving first-time fathers' parenting self-efficacy and parenting satisfaction during the first 8 weeks following their infants' birth as compared with no intervention (Comparison Group). Parenting self-efficacy and satisfaction scores for the Intervention Group significantly improved from 4 to 8 weeks; parenting self-efficacy and satisfaction scores for the Comparison Group to which no intervention was given did not change significantly. Participants were primarily satisfied with the New Fathers Network.

XML technologies for the Omaha System: a data model, a Java tool and several case studies supporting home healthcare

The eXtensible markup language (XML) is a metalanguage which is useful to represent and exchange data between heterogeneous systems. XML may enable healthcare practitioners to document, monitor, evaluate, and archive medical information and services into distributed computer environments. Therefore, the most recent proposals on electronic health records (EHRs) are usually based on XML documents. Since none of the existing nomenclatures were specifically developed for use in automated clinical information systems, but were adapted to such use, numerous current EHRs are organized as a sequence of events, each represented through codes taken from international classification systems. In nursing, a hierarchically organized problem-solving approach is followed, which hardly couples with the sequential organization of such EHRs. Therefore, the paper presents an XML data model for the Omaha System taxonomy, which is one of the most important international nomenclatures used in the home healthcare nursing context. Such a data model represents the formal definition of EHRs specifically developed for nursing practice. Furthermore, the paper delineates a Java application prototype which is able to manage such documents, shows the possibility to transform such documents into readable web pages, and reports several case studies, one currently managed by the home care service of a Health Center in Central Italy.

A care revolution. Interview by Lynne Pearce

With the increased longevity of the population, demands on health care are sure to increase. Some technological solutions can help.

Improving infection control competency through an online learning course

BACKGROUND

While most staff are aware of the basics of infection prevention and control, this can be eroded over time. In addition, it is difficult to keep up with emerging best practices.

AIM

To develop an online course to improve infection prevention and control competency and access to training.

METHOD

Surveys were conducted with 76 healthcare professionals, most of whom were nurses, before and after the course.

RESULTS

Participants made significant increases in competency scores, and satisfaction with the course was high.

DISCUSSION

A number of barriers to online learning in the workplace were identified. Organisational support in terms of protected training time, computers and internet access are essential.

CONCLUSION

Online learning can be an effective way for nurses to learn or refresh their skills and knowledge but needs employer support to be successful.

Computer-tailored health interventions delivered over the Web: review and analysis of key components

OBJECTIVE

This systematic review explores how computer-tailored, behavioral interventions implemented and delivered via the Web have been operationalized in a variety of settings.

METHODS

Computer-tailored, online behavioral intervention studies published from 1996 to early 2007 were selected and reviewed by two independent coders.

RESULTS

Of 503 studies screened, 30 satisfied the selection criteria. The level of sophistication of these interventions varied from immediate risk/health assessment, tailored web content to full-blown customized health programs. The most common variables for tailoring content were health behaviors and stages of change. Message tailoring was achieved through a combination mechanisms including: feedback, personalization and adaptation.

CONCLUSIONS

Tailored, self-guided health interventions delivered via the Web to date have involved a great diversity of features and formats. While some programs have been relatively brief and simple, others have involved complex, theory-based tailoring with iterative assessment, tools for development of self-regulatory skills, and various mechanisms for providing feedback.

PRACTICE IMPLICATIONS

Our ability to fully optimize the use of computer-assisted tailoring will depend on the development of empirically based guidelines for tailoring across populations, health foci, health behaviors and situations. Further outcome research is needed to enhance our understanding of how and under what conditions computer-tailoring leads to positive health outcomes in online behavioral interventions.

Child mental health: an e-learning resource for student CYP nurses

This paper outlines a small action research work-based study. Its aim was to ascertain the content of an e-learning resource designed to help student children and young people's (CYP) nurses promote young children's mental health. Recent policy stresses the importance of this area of health promotion. The setting for the study was a higher education institution and the data collection methods were a focus group and semi-structured interviews.The key stakeholders involved in the study were four student CYP nurses, a child health programme leader, a child health lecturer, a child and adolescent mental health lecturer and an e-learning expert.The results suggest that attachment theory, assessment framework and Bronfenbrenner's ecology model should be included in the learning resource in order to promote a holistic approach toward young children's mental health promotion. Further research is required into what training is required for student CYP nurses regarding child mental health and how CYP nurses can be prepared for their role in skill-mixed health visiting teams.

Consumer health informatics: from genomics to population health

Innovations in health information technology have ushered in a new era of health care. The use of emerging information and communication technology to improve or enable health and health care is the central focus of consumer health informatics (CHI). Traditionally, CHI interventions to promote health and well-being have targeted the individual or family. Advances in genomic health and the emergence of public health informatics call for broadening the scope of CHI. The authors discuss CHI from the point-of-view of the consumer (e.g., from individuals to policy makers) and the level of health data from the subcellular (e.g., genetic or protein structures) to population (e.g., geographically-referenced information).

Towards Web-based representation and processing of health information

BACKGROUND

There is great concern within health surveillance, on how to grapple with environmental degradation, rapid urbanization, population mobility and growth. The Internet has emerged as an efficient way to share health information, enabling users to access and understand data at their fingertips. Increasingly complex problems in the health field require increasingly sophisticated computer software, distributed computing power, and standardized data sharing. To address this need, Web-based mapping is now emerging as an important tool to enable health practitioners, policy makers, and the public to understand spatial health risks, population health trends and vulnerabilities. Today several web-based health applications generate dynamic maps; however, for people to fully interpret the maps they need data source description and the method used in the data analysis or statistical modeling. For the representation of health information through Web-mapping applications, there still lacks a standard format to accommodate all fixed (such as location) and variable (such as age, gender, health outcome, etc) indicators in the representation of health information. Furthermore, net-centric computing has not been adequately applied to support flexible health data processing and mapping online.

RESULTS

The authors of this study designed a HEalth Representation XML (HERXML) schema that consists of the semantic (e.g., health activity description, the data sources description, the statistical methodology used for analysis), geometric, and cartographical representations of health data. A case study has been carried on the development of web application and services within the Canadian Geospatial Data Infrastructure (CGDI) framework for community health programs of the New Brunswick Lung Association. This study facilitated the online processing, mapping and sharing of health information, with the use of HERXML and Open Geospatial Consortium (OGC) services. It brought a new solution in better health data representation and initial exploration of the Web-based processing of health information.

CONCLUSION

The designed HERXML has been proven to be an appropriate solution in supporting the Web representation of health information. It can be used by health practitioners, policy makers, and the public in disease etiology, health planning, health resource management, health promotion and health education. The utilization of Web-based processing services in this study provides a flexible way for users to select and use certain processing functions for health data processing and mapping via the Web. This research provides easy access to geospatial and health data in understanding the trends of diseases, and promotes the growth and enrichment of the CGDI in the public health sector.

Evaluation of different delivery modes of an interactive e-learning programme for teaching cultural diversity

OBJECTIVE

UK medical schools find it challenging to provide standardised teaching to expanding year intakes. In addition, developing and implementing diversity training can cause difficulties. This paper describes the evaluation of an interactive e-learning programme to raise awareness and understanding of communication difficulties in diversity consultations.

METHODS

The programme was part of an undergraduate portfolio-based community module. Three hundred and two students were assigned to one of three delivery methods--a large group setting, small groups with a facilitator, and as part of distance learning while on community placement. The evaluation included analysis of their coursework marks, a self-completed evaluation questionnaire, and small group discussions.

RESULTS

Two hundred and twenty-three students took part in the evaluation. They were able to apply the concepts they learnt to clinical examples from their own experiences. Type of delivery did not affect coursework marks, but students tended to prefer the e-learning as part of a distance learning package. They offered helpful suggestions to improve its complexity and range.

CONCLUSION

The acceptability and utility of this e-learning module both in face to face teaching and remote placement has been demonstrated, and evaluation by the students has provided valuable information for its further development.

PRACTICE IMPLICATIONS

All medical schools should include some diversity training, and further research should concentrate on the effects of this type of learning on longer term outcomes such as attitude and performance tests. Such tools could reduce demands on staff time in facilitation of small groupwork, and their cost effectiveness could be increased by making them available to other medical schools.

Charity websites: resources for professionals

Many charities now provide websites with useful information for health and social care professionals. Several of these websites have dedicated areas with information and other resources for practitioners, as well as materials that can be downloaded for clients. This article outlines some of the more comprehensive websites for practitioners from health, medical and children's charities in the UK.

Older members perform better in an internet-based behavioral weight loss program compared to younger members

BACKGROUND

New technology offers increased opportunities for weight control. However, it is not clear whether older people with less computer training can make use of this tool. Our objective was to examine how members above the age of 65 years performed in an internet-based behavioral weight loss program, compared to younger members.

METHODS

Data from members (n = 23,233) of an internet-based behavioral weight loss program were analyzed. We restricted our study to active participants accessing the weight club, during a 6-month period (n = 4,440). The number of logins, food intake, and weight records were examined. Participants were divided into age tertiles separately for men and women. The oldest tertile was further subdivided into two groups: above and below the age of 65 years.

RESULTS

Participants aged 65 or older were more likely to remain active in the weight club for at least 6 months compared to younger age groups. They had the highest frequency of recordings of food intake and current weight. Among women, those older than 65 years had on average the highest percentage of weight loss (5.6 kg, 6.8%). Men above 65 years of age had the highest number of logins, on average 161 times during the 6-month period.

CONCLUSION

Older participants are performing equally well or even better in an internet-based behavioral weight loss program than younger participants. Internet-based programs could be a promising and attractive option for older adults requiring assistance in losing weight.

Participation in online patient support groups endorses patients' empowerment

OBJECTIVE

Although much has been expected of the empowering effect of taking part in online patient support groups, there is no direct evidence thus far for the effects of participation on patient empowerment. Hence our exploring to what extent patients feel empowered by their participation in online support groups, and which processes that occur in these groups are related to the empowering outcomes.

METHODS

An online questionnaire was completed by 528 individuals who were active in online groups for patients with breast cancer, fibromyalgia and arthritis.

RESULTS

The respondents felt empowered in several ways by their participation. The empowering outcomes that were experienced to the strongest degree were 'being better informed' and 'enhanced social well-being'. No significant differences in empowering outcomes between diagnostic groups were found. The empowering outcomes could only be predicted in a modest way by the processes that took place in the online support groups.

CONCLUSION

This study indicates that participation in online support groups can make a valuable contribution to the empowerment of patients.

PRACTICE IMPLICATIONS

Health care providers should acquaint their patients with the existence of online support groups and with the benefits that participation in these groups can offer.

Strategies for success in online learning

The nursing and nursing faculty shortages have created a greater need for effective online learning strategies. Today's learners require the flexibility offered by online learning, but only when well grounded in sound teaching-learning principles. This article describes strategies for online learning designed to keep the needs of today's learners in mind. These strategies are focused on the resolution of technology problems as well as the learning process.

Translating research into practice: a German sickness fund supporting patient participation

OBJECTIVE

To demonstrate how a German sickness fund like the Techniker Krankenkasse (TK) tries to translate evidence from research in the field of shared decision-making (SDM) into practice.

METHODS

This article outlines three different initiatives of the TK, supporting patient participation in every day life: information tools, continuous interactive case management, and web-based interactive patient dialogue. These three activities are supposed to show a stepwise development- and introduction-process which is designed to include patient feedback at all stages of progress. Wherever available, empirical data is added to the description of the initiatives. This data contains information about how many people use a special service offered and how useful or satisfying the service is in the users' eyes.

RESULTS

The examples given show that a single sickness fund is able to support patient participation with different kinds of initiatives.

CONCLUSION

Implementation of SDM will be beneficial for the statutory health insurance and will have a positive influence on political and professional decision processes.

PRACTICE IMPLICATIONS

The TK will continue and intensify its engagement for SDM in the future.

Can people find patient decision aids on the Internet?

OBJECTIVE

To determine if people could find patient decision aids (PtDAs) on the Internet using the most popular general search engines.

METHODS

We chose five medical conditions for which English language PtDAs were available from at least three different developers. The search engines used were: Google (www.google.com), Yahoo! (www.yahoo.com), and MSN (www.msn.com). For each condition and search engine we ran six searches using a combination of search terms. We coded all non-sponsored Web pages that were linked from the first page of the search results.

RESULTS

Most first page results linked to informational Web pages about the condition, only 16% linked to PtDAs. PtDAs were more readily found for the breast cancer surgery decision (our searches found seven of the nine developers). The searches using Yahoo and Google search engines were more likely to find PtDAs. The following combination of search terms: condition, treatment, decision (e.g. breast cancer surgery decision) was most successful across all search engines (29%).

CONCLUSION

While some terms and search engines were more successful, few resulted in direct links to PtDAs.

PRACTICE IMPLICATIONS

Finding PtDAs would be improved with use of standardized labelling, providing patients with specific Web site addresses or access to an independent PtDA clearinghouse.

Using online questionnaires to conduct nursing research

This article explores the concept of using online questionnaires to carry out nursing research. It discusses options for nurses who do not have advanced technical IT skills for electronic distribution of survey questionnaires. The general principles of web distribution are explained, and some approaches are evaluated in terms of current access to technology and its ease of use. The article also offers some practical advice for nurse researchers, and examines the advantages and disadvantages of using this new method of data collection, compared with traditional hard copy.

Web citations in the nursing literature: how accurate are they?

One problem with using Web citations is whether those documents will be available over time. We examined 573 Web citations in articles published in nursing journals and checked their availability (either by direct link or by searching the main site). There was a mean of 3.1 Web citations per article. Most Web citations were to documents that related to clinical practice, for example, clinical guidelines and explanations of clinical conditions and treatments. Of the 573 Web citations, 414 (72.3%) were still available; of those, 229 (55.3%) were able to be accessed by direct link and the other 185 (44.7%) by searching the main Web site. However, 159 (27.7%) of the references were not available, not even by searching the Internet using key terms from the citation. Considering that more than a fourth of the Web citations in this study were no longer available, authors need to be cautious about using the Web as a primary source of information for their publications.

Three years experience with the implementation of a networked electronic medical record in Haiti

Since 2005 we have been developing and implementing an electronic medical record (EMR) that supports both individual and population health care of HIV-infected patients in Haiti. Unreliable electrical power and network infrastructure, cultural differences, variable levels of experience and computer literacy, and the geographic dispersion of the team remain challenges, but the system is now implemented in about 40 sites nationwide providing antiretroviral therapy, and includes records for about 18,600 patients. The need to support country-wide monitoring and evaluation drove early architectural decisions to support linking systems under conditions of network uncertainty. We have found surprising end user acceptance of the system, with the adoption of interactive EMR usage exceeding our expectations and timeline.

Blended learning on medication administration for new nurses: integration of e-learning and face-to-face instruction in the classroom

PURPOSE

This study analyzed the effects of a blended learning program on medication administration by new nurses using a non-equivalent groups design.

METHOD

A medication education program using blended learning (including e-learning) was administered to 26 new nurses, while face-to-face instruction in the classroom was given to 24 new nurses. The following dependent variables were compared: degree of knowledge of medication, self-efficacy of medication administration, medication-administration ability, and satisfaction with the learning program.

RESULTS

The experimental, blended learning group showed a significantly higher level of knowledge of medication and satisfaction with the comprehensiveness of their medication learning, but the self-efficacy of medication administration, medication-administration ability, and other items related to their learning satisfaction did not differ significantly from that in the control group.

CONCLUSION

These results suggest that blended learning integrating e-learning and face-to-face instruction in the classroom is useful for enhancing medication knowledge. An e-learning program can reduce the lecturing time and cost of repeated topics such as medication, suggesting that it can be an effective component in nurse education programs.