Implementation and scalability of a digital intervention to reduce depressive symptoms in people with diabetes, hypertension or both in Brazil and Peru: a qualitative study of health system's stakeholders' perspectives

A mixed-methods, theory-driven assessment of the sustainability of a multi-sectoral preventive intervention for South Asian Americans at risk for cardiovascular disease

BACKGROUND

South Asian Americans bear a high burden of atherosclerotic cardiovascular disease (ASCVD), but little is known about the sustainability of evidence-based interventions (EBI) to prevent ASCVD in this population. Using community-based participatory research, we previously developed and implemented the South Asian Healthy Lifestyle Intervention (SAHELI), a culturally-adapted EBI targeting diet, physical activity, and stress management. In this study, we use the Integrated Sustainability Framework to investigate multisectoral partners' perceptions of organizational factors influencing SAHELI sustainability and strategies for ensuring sustainability.

METHODS

From 2022 to 2023, we conducted a mixed-methods study (quant- > QUAL) with 17 SAHELI partners in the Chicago area. Partners' settings included: community organization, school district, public health department, and healthcare system. Descriptive statistics summarized quantitative results. Two coders used a hybrid thematic analysis approach to identify qualitative themes. Qualitative and quantitative data were integrated and analyzed using mixed methods.

RESULTS

Surveys (score range 1-5: higher scores indicate facilitators; lower scores indicate barriers) indicated SAHELI sustainability facilitators to be its "responsiveness to community values and needs" (mean = 4.9). Barriers were "financial support" (mean = 3.5), "infrastructure/capacity to support sustainment" (mean = 4.2), and "implementation leadership" (mean = 4.3). Qualitative findings confirmed quantitative findings that SAHELI provided culturally-tailored cardiovascular health education responsive to the needs of the South Asian American community, increased attention to health issues, and transformed perceptions of research among community members. Qualitative findings expanded upon quantitative findings, showing that the organizational fit of SAHELI was a facilitator to sustainability while competing priorities were barriers for partners from the public health department and health system. Partners from the public health department and health system discussed challenges in offering culturally-tailored programming exclusively for one targeted population. Sustainability strategies envisioned by partners included: transitioning SAHELI to a program delivered by community members; integrating components of SAHELI into other programs; and expanding SAHELI to other populations. Modifications made to SAHELI (i.e., virtual instead of in-person delivery) had both positive and negative implications for sustainability.

DISCUSSION

This study identifies common sustainability barriers and facilitators across different sectors, as well as those specific to certain settings. Aligning health equity interventions with community needs and values, organizational activities, and local context and resources is critical for sustainability. Challenges also arise from balancing the needs of specific populations against providing programming for broader audiences.

Digital footprints as a new translational approach for mental health care: a commentary

There is a crisis in mental health care, with more people suffering from psychiatric disorders than resources that are available for treatment, even though spending is substantial. Millions who suffer from addiction, psychosis, depression and suicidality are either untreated or inadequately treated and organized psychiatry is unable to reach them. Possibly as reflection of under-treatment of psychiatric disorders, the rates of suicide have risen: from 1999 through 2014, the age-adjusted suicide rate in the US increased 24%, from 10.5 to 13.0 per 100,000. Assessment of psychiatric symptoms in ongoing outpatient settings is costly, inadequate and unable to detect clinical changes over time. One's digital phenotype is assessed through footprints left over as result of our interface with technology, including automated assessments of quantity and quality of social media activity, patterns and speed of device usage, and physiological data that is automatically collected, such as location, quantity and type of movement, heart rate, and sleep patterns. The use of digital footprints has been advocated for large-scale data collection that can facilitate psychiatric research in naturalistic settings. We highlight recent papers in Discover Mental Health addressing digital approaches to mental health and we also advance here the concept that digital footprints are ready for clinical use. However, before that happens there needs to be discussion on the appropriate boundaries between care that is driven by signals from digital footprints and the rights to privacy and self-determination.

Participants’ and Nurses’ Experiences With a Digital Intervention for Patients With Depressive Symptoms and Comorbid Hypertension or Diabetes in Peru: Qualitative Post–Randomized Controlled Trial Study

Background

Depression is one of the most prevalent mental disorders and a leading cause of disability, disproportionately affecting specific groups, such as patients with noncommunicable diseases. Over the past decade, digital interventions have been developed to provide treatment for these patients. CONEMO (Emotional Control in Spanish) is an 18-session psychoeducational digital intervention delivered through a smartphone app and minimally supported by a nurse. CONEMO demonstrated effectiveness in reducing depressive symptoms through a randomized controlled trial (RCT) among patients with diabetes, hypertension, or both, in Lima, Peru. However, in addition to clinical outcomes, it is important to explore users’ experiences, satisfaction, and perceptions of usability and acceptability, which can affect their engagement with the intervention.

Objective

This study aimed to explore the RCT participants’ experiences with CONEMO in Peru, complemented with information provided by the nurses who monitored them.

Methods

In 2018, semistructured interviews were conducted with a sample of 29 (13.4%) patients from the 217 patients who participated in the CONEMO intervention in Peru and the 3 hired nurses who supported its delivery. Interviewees were selected at random based on their adherence to the digital intervention (0-5, 10-14, and 15-18 sessions completed), to include different points of view. Content analysis was conducted to analyze the interviews.

Results

Participants’ mean age was 64.4 (SD 8.5) years, and 79% (23/29) of them were women. Most of the interviewed participants (21/29, 72%) stated that CONEMO fulfilled their expectations and identified positive changes in their physical and mental health after using it. Some of these improvements were related to their thoughts and feelings (eg, think differently, be more optimistic, and feel calmer), whereas others were related to their routines (eg, go out more and improve health-related habits). Most participants (19/29, 66%) reported not having previous experience with using smartphones, and despite experiencing some initial difficulties, they managed to use CONEMO. The most valued features of the app were the videos and activities proposed for the participant to perform. Most participants (27/29, 93%) had a good opinion about the study nurses and reported feeling supported by them. A few participants provided suggestions to improve the intervention, which included adding more videos, making the sessions’ text simple, extending the length of the intervention, and improving the training session with long explanations.

Conclusions

The findings of this qualitative study provide further support and contextualize the positive results found in the CONEMO RCT, including insights into the key features that made the intervention effective and engaging. The participants’ experience with the smartphone and CONEMO app reveal that it is feasible to be used by people with little knowledge of technology. In addition, the study identified suggestions to improve the CONEMO intervention for its future scale-up.

Trial Registration

ClinicalTrials.gov NCT03026426; https://clinicaltrials.gov/ct2/show/NCT03026426