Informing the dosing of interventions in randomized trials

The role of art knowledge training on aesthetic judgements and executive functions

The study of how we develop art knowledge can provide valuable insights into the underlying cognitive systems that support expertise and knowledge transfer to new contexts. An important and largely unanswered question is whether art knowledge training impacts subsequent judgements of artworks and executive functions. Across three pre-registered experiments (N > 630 total), which used a training intervention and Bayesian regression modelling, we explore whether art knowledge training impacts subsequent judgements of artworks and executive functions. Experiments 1 and 2 revealed an effect of art training on aesthetic judgements for trained but not untrained artworks. These training effects were generalized to unseen artworks produced by the same artist (Experiment 1) or another artist with a similar style (Experiment 2), but not to different art styles. Experiment 2 also showed that with larger training 'doses' (>16 minutes), the generalization effects are stronger. Experiment 3 showed invariance of the attentional network to art training versus non-art training, suggesting similar sensitivity of executive functions to different types of training. This work shines new light on the cognitive systems that support learning and generalization of learning to new contexts. Likewise, from an applied perspective, it emphasizes that learning and generalization can occur rapidly with a relatively short (approx. 16 minutes) training video.

Linking Adherence to Effectiveness in Family-Based Adolescent ADHD Academic Training and Medication Decision-Making Protocols

OBJECTIVE

Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA) and Medication Integration Protocol (MIP) are two family-based behavioral protocols designed to promote family solutions to academic problems and medication decision-making. Building on a randomized control trial examining these protocols, the current study examined how protocol dose, an indicator of treatment adherence, was associated with treatment outcomes.

METHOD

The sample consisted of 145 adolescent clients (M age = 14.8, 72% male, 42% White, 37% Hispanic, 15% Black) and 49 community and hospital-based therapists (82% female, 63% White, 29% Hispanic). Latent growth curve models examined how therapist reports of minutes adolescents and their caregivers received CASH-AA and MIP predicted levels and change in inattentive and hyperactive symptoms (MINI-International Neuropsychiatric Interview); co-occurring symptoms (Youth Self Report/Child Behavior Checklist); homework problems (Homework Problems Checklist); and medication compliance at baseline, 3, 6, and 12-month follow-ups.

RESULTS

MIP minutes were prospectively associated with lower caregiver-reported inattentive and hyperactive symptoms, adolescent- and caregiver-reported externalizing symptoms and caregiver-reported homework problems at the 12-month follow-up (ẞ range = -.16 to -.39, p < .05), as well as faster decline in caregiver-reported inattentive symptoms (ẞ = -.29, p < .001). CASH-AA minutes were associated with greater caregiver-reported inattentive symptoms (ẞ = .11, p = .049) at 12-month follow-up and slower declines in homework problems (ẞ = -.39, p < .001). Neither MIP nor CASH-AA minutes were associated with internalizing symptoms or medication use.

CONCLUSIONS

Findings further support MIP as an effective behavioral protocol for adolescent ADHD and indicate the need for increasing MIP implementation efforts in community settings.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

OBJECTIVE

Adults with serious mental illness have high rates of tobacco use disorder and underuse pharmacotherapy for tobacco cessation. In a previous randomized controlled trial, participants receiving community health worker (CHW) support and education for their primary care providers (PCPs) had higher tobacco abstinence rates at 2 years, partly because of increased initiation of tobacco-cessation pharmacotherapy. The authors aimed to determine the association between CHW-participant engagement and tobacco abstinence outcomes.

METHODS

The authors conducted a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of the number and duration of CHW visits, number of smoking-cessation group sessions attended, and number of CHW-attended PCP visits on initiation of tobacco-cessation pharmacotherapy and tobacco abstinence were modeled via logistic regression. Interviews with 12 CHWs, 17 patient participants, and 17 PCPs were analyzed thematically.

RESULTS

Year 2 tobacco abstinence was significantly associated with CHW visit number (OR=1.85, 95% CI=1.29-2.66), visit duration (OR=1.51, 95% CI=1.00-2.28), and number of group sessions attended (OR=1.85, 95% CI=1.33-2.58); effects on pharmacotherapy initiation were similar. One to three CHW visits per month across 2 years were optimal for achieving abstinence. Interviews identified CHW-patient engagement facilitators (i.e., trust, goal accountability, skills reinforcement, assistance in overcoming barriers to treatment access, and adherence). Training and supervision facilitated CHW effectiveness; barriers included PCPs' and care teams' limited understanding of the CHW role.

CONCLUSIONS

Greater CHW-participant engagement, within feasible dose ranges, was associated with tobacco abstinence among adults with serious mental illness. Implementation of CHW interventions may benefit from further CHW training and integration within clinical teams.

Hyped-up or meditate: A scoping review of mindfulness-based group interventions for adolescents with attention deficit hyperactivity disorder

The objective of this scoping review is to evaluate the effectiveness of mindfulness training in improving functioning in adolescents (aged 12-19 years) diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). Previous research has demonstrated that psychological interventions improve functioning in a myriad of domains for individuals diagnosed with ADHD, such as attention training, interpersonal relationships, and social skills. Mindfulness-based interventions (MBI) are indicated as an intervention in attention training. It maybe argued that group based MBI programmes should begin early, for children and adolescents at a time that is critical in their development. Methods and reporting are in line with the PRISMA extension for scoping reviews, the protocol is preregistered in the (Open Science Framework register). The study outcomes included attention, impulsivity, and relationships of adolescents with ADHD. Findings demonstrated preliminary evidence for the use of group-based mindfulness interventions with adolescents continues to be nascent. Although studies reported positive results, the evidence of its effectiveness for adolescents with ADHD is inconclusive, due to limited studies available and the limitations of the study design. This scoping review provides a panorama of MBI for ADHD adolescents.

Perispinal etanercept stroke trial design: PESTO and beyond

INTRODUCTION

Perispinal etanercept (PSE) is an innovative treatment designed to improve stroke recovery by addressing chronic post-stroke neuroinflammation. Basic science evidence, randomized clinical trial (RCT) evidence and 14 years of favorable clinical experience support the use of PSE to treat chronic stroke. This article provides guidance for the design of future PSE RCTs in accordance with current FDA recommendations.

AREAS COVERED

Scientific background and essential elements of PSE RCT design.

EXPERT OPINION

Intimate familiarity with PSE, its novel method of drug delivery, and the characteristics of ideal enriched study populations are necessary for those designing future PSE stroke trials. The design elements needed to enable a PSE RCT to generate valid results include a suitable research question; a homogeneous study population selected using a prospective enrichment strategy; a primary outcome measure responsive to the neurological improvements that result from PSE; trialists with expertise in perispinal delivery; optimal etanercept dosing; and steps taken to minimize the number of placebo responders. RCTs failing to incorporate these elements, such as the PESTO trial, are incapable of reaching reliable conclusions regarding PSE efficacy. SF-36 has not been validated in PSE trials and is unsuitable for use as a primary outcome measure in PSE RCTs.

Implementation of Community Health Worker Support for Tobacco Cessation: A Mixed-Methods Study

Objective

Adults with serious mental illness have high tobacco use disorder rates and underutilization of first-line tobacco cessation pharmacotherapy. In a randomized trial, participants offered community health worker (CHW) support and primary care provider (PCP) education had higher tobacco abstinence rates at two years, partly through increased tobacco cessation pharmacotherapy initiation. This study determined the association between participant-CHW engagement and tobacco abstinence outcomes.

Methods

This was a secondary, mixed-methods analysis of 196 participants in the trial's intervention arm. Effects of CHW visit number and duration, CHW co-led smoking cessation group sessions attended, and CHW-attended PCP visit number on tobacco use disorder pharmacotherapy initiation and tobacco abstinence were modeled using logistic regression. Interviews with 12 CHWs, 16 participants, and 17 PCPs were analyzed thematically.

Results

Year-two tobacco abstinence was associated with CHW visit number (OR=1.85, 95% CI=[1.29, 2.66]) and duration (OR=1.85, 95% CI=[1.33, 2.58]) and number of groups attended (OR=1.51, 95% CI=[1.00, 2.28]); effects on pharmacotherapy initiation were similar. 1-3 CHW visits per month over two years was optimal for achieving abstinence. Interviews identified engagement facilitators, including CHWs establishing trust, providing goal accountability, skills reinforcement, and assistance overcoming barriers to treatment access and adherence related to social determinants of health and illness factors. Robust training and supervision facilitated CHW effectiveness. Barriers included PCPs' and care teams' limited understanding of the CHW role.

Conclusions

Feasible CHW engagement was associated with tobacco abstinence in adults with serious mental illness. CHW implementation may benefit from promoting CHW training and integration within clinical teams.

Supporting responsive parenting in real-world implementation: minimal effective dose of the Video Interaction Project

BACKGROUND

The Video Interaction Project (VIP) is a healthcare-based intervention that provides real-time video-feedback of parent-child play and reading interactions to families with children aged 0 to 36 months. Although evidence from randomized controlled trials demonstrates improved early relational health, including responsive parenting, after three to five VIP visits, the minimal effective dose in real-world implementations is unknown. This study aimed to determine the minimal effective dose of VIP during a real-world implementation for changing responsive parenting behaviors.

METHODS

We performed a longitudinal prospective study of 183 dyads at a public hospital pediatric clinic. Responsive parenting behaviors were assessed with an observational checklist utilized as part of standard VIP practice at baseline and two follow-up VIP visits.

RESULTS

Multilevel models adjusted for baseline sociodemographics (child's sex and age, and maternal education) and time between visits showed that responsive parenting behaviors during parent-child reading and play significantly increased after a single VIP visit (Cohen's d = 0.52, p < 0.05) with additional impact following completion of a second visit (cumulative for 2 visits: d = 0.76, p < 0.05).

CONCLUSIONS

A single VIP visit is associated with increased responsive parenting behaviors. Findings support offering VIP widely, regardless of capacity to ensure attendance at multiple visits.

IMPACT

This is the first study showing the minimal effective dose of the Video Interaction Project (VIP) for increasing responsive parenting behaviors. Responsive parenting behaviors increased by over 22% following a single VIP visit, with a cumulative increase of 37% following the second visit compared to baseline. Findings have important implications for implementation and scalability of pediatric-based preventive programs that support early relational health through activities such as reading and play.

Does Mandala Art Improve Psychological Well-Being in Patients? A Systematic Review

Objectives: Psychological disorders and symptoms are common and can significantly impair functioning in some areas in patients. We aimed to investigate the effects of mandala art (MA) on psychological well-being in patients. Design: A systematic review. Methods: We did a systematic review to assess the associations between MA and psychological well-being among patients. A systematic search of PubMed, EMBASE, Web of Science, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trial databases was conducted by independent reviewers from database inception to April 2023. We include randomized controlled trials, quasi-experimental studies, and qualitative studies. Outcome measures included any measurement of subjective and objective psychological well-being outcomes, such as stress, anxiety, depression, distress, mindfulness, hope, resilience, pain, mood, fatigue, and trauma symptoms. Results: Eleven studies of 405 participants were identified in the systematic review. Overall, the included studies provided preliminary evidence to suggest that MA may improve negative symptoms and hope, relieving pain, and reducing some physiological indicators of stress in patients. However, the quality of the existing evidence limited the generalization of results. Conclusions: According to the current evidence, the therapeutic benefits of using mandalas for improving the psychological well-being of patients are uncertain. More well-designed and high-quality studies in the field of MA are needed in the future.

Implementation Fidelity and Theory-Informed Dose Effects of a Teen Pregnancy Prevention Program for Native American Youth

In 2019, Native youth had the highest rate of teen pregnancy of all racial/ethnic groups. "Respecting the Circle of Life" (RCL) is one of the first evidence-based teen pregnancy prevention programs for Native teens and there is interest in replicating the program across tribal communities. To inform replication, it is important to consider process data including quality, fidelity, and dosage as these may all moderate impact of the program. Participants were Native youth aged 11-19 and a trusted adult. This study includes participants randomized to the RCL program only (N = 266). Data sources include independent observations, facilitator self-assessments, attendance logs, and self-report assessments completed by enrolled youth at baseline and 3 months post assessment. Data was compiled and summed by cohort. Dosage was number of minutes participating in activities separated by theoretical constructs. Linear regression models were utilized to assess moderation of the effects of the intervention dosage on outcomes of interest. Eighteen facilitators delivered RCL. One hundred eighteen independent observations and 320 facilitator self-assessments were collected and entered. Findings indicate RCL was implemented with high fidelity and quality (4.40 to 4.82 out of a 5-point Likert scale; 96.6% of planned activities completed). Dosage was high with an average completion of 7 out of 9 lessons. There was no association between theoretical construct dosage and outcomes of interest. Overall, this study indicates RCL was delivered with high fidelity, quality, and dosage in this trial. This paper informs future replication of RCL and provides support for hiring paraprofessionals from the local community as facilitators, delivering the RCL to peer groups of the same age and sex, delivering the RCL with short duration and high frequency, and encouraging youth to attend all RCL lessons, but continue to serve youth who have missed one or more lessons.

Comprehensive geriatric assessment-where are we now, where do we need to be in the context of global ageing?

Comprehensive geriatric assessment (CGA) is the cornerstone of modern geriatric medicine and the framework around which conventional and new models of care for older people are developed. Whilst there are a substantial number of reviews synthesising the evidence on patient and service outcomes from CGA, as an intervention it remains poorly described. There is a lack of detail on how a CGA plan is coordinated, delivered and followed up, especially outside of acute care. This commentary reflects on the authors' experience of extracting data from 57 published studies on CGA. CGA as an intervention is akin to a 'black box' in terms of describing and measuring participants' interactions with CGA activity in terms of time, frequency and amount (dose) received. There is also a lack of detail on how newly established CGA teams become effective, interdisciplinary, high functioning and sustainable teams. The CGA knowledge-do gap persists with a need to draw from complex system theory and implementation science frameworks to better describe the intervention and understand the influence of the organisation and health service within which CGA is operationalised. Equally, the voice of older people, families and staff is critical in the conduct and evaluation of CGA, and how it evolves as a model to meet the growing needs of ageing populations.

Phone-Delivered Intervention to Improve HIV Care for Young People Living With HIV: Trial to Inform Implementation and Utility

BACKGROUND

Phone-delivered counseling has demonstrated improved health outcomes for people living with HIV. However, counseling is hampered by a lack of guidance on the frequency and duration of intervention in relation to clinical benefits. The added benefits of bidirectional (ie, interactive) vs. unidirectional (ie, passive) text messages to augment counseling are also unknown. We conducted a clinical trial of adaptive phone counseling along with either bidirectional or unidirectional text messaging for people living with HIV.

METHODS

A community sample of 425 young people (aged 16-36 years) living with HIV in Georgia, USA, received weekly phone counseling sessions with the number of sessions determined by the participant and their counselor. Participants were subsequently randomized to either (1) weekly bidirectional text messages with their counselor or (2) weekly automated unidirectional text message reminders. Participants were followed for 16 months to assess 3 primary outcomes: antiretroviral therapy (ART) adherence, HIV care engagement, and HIV suppression.

RESULTS

Participants demonstrated improved clinical outcomes over the follow-up period, with 74% of those who were not taking ART initiating treatment, 65% of those on ART improving adherence, and 47% who had detectable viral loads at baseline attaining viral suppression. The number of sessions completed predicted improved ART adherence, greater care engagement, and HIV suppression over follow-ups. Bidirectional text messages impacted care engagement by moderating the effects of counseling sessions on HIV suppression.

CONCLUSIONS

Phone counseling augmented by bidirectional text messages has the potential to improve HIV care for young adults living with HIV.

The effect of a multi-component behavior change technique intervention on medication adherence among individuals on primary prevention statin therapy: a dose-finding protocol

BACKGROUND

In the USA, the primary cause of death and morbidity continues to be cardiovascular disease (CVD). Numerous trials have shown that statin medication reduces the likelihood of CVD events; it is a cornerstone of CVD prevention. However, studies have also indicated that up to 60% of the estimated 26.8 million Americans prescribed primary prevention statin treatment are nonadherent during the first year. Multi-component behavioral change technique (BCT) therapies have shown moderate promise in improving medication adherence as well as other positive health behaviors (such as physical activity). However, no research has looked at the duration of multi-component BCT intervention needed to result in a clinically significant improvement in statin adherence behaviors. This study aims to determine the necessary dose of a multi-component BCT intervention (defined as duration in weeks) to promote adherence to statin medication among those on primary prevention statin treatment by utilizing the modified time-to-event continuous reassessment method (TiTE-CRM).

METHODS AND DESIGN

The study will utilize the modified TiTE-CRM in 42 participants, recruited in 14 cohorts of 3 participants each. The goal of this analysis is to identify the minimum effective dose (MED) of a multi-behavior change technique (BCT) intervention required to increase adherence to statins by 20% between baseline and follow-up periods. Using the TiTE-CRM method, the dose of the behavior intervention in weeks will be assigned to each cohort based on the performance of the prior cohort. At the end of the study, the intervention dose that has been found to be associated with a 20% increase in statin adherence among 80% of participants assigned to that dose will be identified as the MED.

DISCUSSION

If successful, the current trial will provide additional guidance to researchers and clinicians seeking to increase statin medication adherence using a BCT intervention by identifying the dose (i.e., the duration) of an intervention required to meaningfully increase adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05273736. Registered on March 10, 2022. https://www.

CLINICALTRIALS

gov/ct2/show/NCT05273736.

Rethinking how and when to report descriptions of behavior change content within interventions: a case study of an ongoing physical activity trial (ready steady 3.0)

Specifications of what and how much health behavior change (BC) content within research interventions are needed to advance BC science, its implementation, and dissemination. We analyzed the types and dosages of the smallest potentially active BC ingredients and associated behavioral prescriptions intended to be delivered in an ongoing physical activity optimization trial for older adults (Ready Steady 3.0 [RS3]). We defined BC types as behavior change techniques (BCT) and behavioral prescriptions. Our protocol integrated the BCT Taxonomy coding procedures with BCT roles (primary or secondary) and, when relevant, linkages to behavioral prescriptions. Primary BCTs targeted theoretical mechanisms of action, whereas secondary BCTs supported primary BCT delivery. Behavioral prescriptions represented what participants were encouraged to do with each primary BCT in RS3 (ascertain, practice, implement). We assessed dosage parameters of duration, frequency, and amount in each BCT and prescription. Results provided a catalog of in-depth, multidimensional content specifications with 12 primary BCTs, each supported by 2-7 secondary BCTs, with dosages ranging from 2 to 8 weeks, 1 to 8 contacts, and 5 to 451 minutes. Minutes spent on behavioral prescriptions varied: ascertain (1 to 41), practice (5 to 315), and implement (0 to 38). Results can be organized and summarized in varied ways (e.g., by content component) to strengthen future assessments of RS3 fidelity and intervention refinement. Results highlight potential benefits of this early, integrated approach to analyzing BC content and frames questions about how such information might be incorporated and disseminated with reporting research outcomes.

Measuring the dosage of brief and skill-targeted social-emotional learning (SEL) activities in humanitarian settings

Introduction

In humanitarian settings, social-emotional learning (SEL) programs for children are often delivered using a field-feasible approach where the programs are more easily deployable and adaptable in the field, require minimal training, and depend less on the strict sequence and structure of the program components to elicit the intended treatment effect. However, evidence is lacking on what aspects of this implementation approach enable the SEL programming to be more beneficial to children's SEL development.

Method

In this study, we propose and evaluate measures for three dimensions of dosage (quantity, duration, and temporal pattern) of two sets of brief and skill-targeted SEL activities (Mindfulness and Brain Games) implemented in 20 primary schools in two low-income chiefdoms of Sierra Leone.

Results

We find preliminary evidence of predictive validity that these dosage measures could predict children's attendance and classroom adaptive behavior.

Discussion

This study is the first to develop procedures to measure the dimensions of dosage of brief SEL activities in humanitarian settings. Our findings illuminate the need for future research on optimizing the dosage and implementation design of SEL programming using brief SEL activities.

A qualitative evaluation of a clinic versus home exercise rehabilitation program for adults with multiple sclerosis: The tele-exercise and multiple sclerosis (TEAMS) study

BACKGROUND

Substantial evidence supports therapeutic exercise for improving health and function in people with multiple sclerosis (MS). However, few studies have considered the patients' perspective.

OBJECTIVE

This study explored perspectives of adults with MS following participation in a 3-month clinic- and home-based exercise rehabilitation program.

METHODS

Twenty participants with MS were interviewed using a semi-structured interview guide on the design and implementation processes of the exercise programs as well as any perceived facilitators or barriers to exercise. Data analysis was conducted using a thematic analysis approach to generate themes from the transcribed interviews.

RESULTS

Key facilitators of exercise for people with MS included perceived improvements in physical health and function, activity participation, and psychosocial health. Mismatched level of exercise with their stage of post-diagnosis and/or functional ability and limited human interaction emerged as barriers to exercise.

CONCLUSIONS

Participation in the exercise program was a positive experience for people with MS. Despite the provision of a high level of adaptation and tailored exercise plan and delivery, self-directed exercise continued to present challenges for people with MS. Additionally, the importance of seeking cost-effective ways to maintain motivational support was implicit in participant responses. The findings provided an improved understanding of personal experiences and exercise perspectives that can inform future intervention strategies aimed at promoting sustained exercise participation.

Idiopathic sudden sensorineural hearing loss: A critique on corticosteroid therapy

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a condition affecting 5-30 per 100,000 individuals with the potential to significantly reduce one's quality of life. The true incidence of this condition is not known because it often goes undiagnosed and/or recovers within a few days. ISSNHL is defined as a ≥30 dB loss of hearing over 3 consecutive audiometric octaves within 3 days with no known cause. The disorder is typically unilateral and most of the cases spontaneously recover to functional hearing within 30 days. High frequency losses, ageing, and vertigo are associated with a poorer prognosis. Multiple causes of ISSNHL have been postulated and the most common are vascular obstruction, viral infection, or labyrinthine membrane breaks. Corticosteroids are the standard treatment option but this practice is not without opposition. Post mortem analyses of temporal bones of ISSNHL cases have been inconclusive. This report analyzed ISSNHL studies administering corticosteroids that met strict inclusion criteria and identified a number of methodologic shortcomings that compromise the interpretation of results. We discuss the issues and conclude that the data do not support present treatment practices. The current status on ISSNHL calls for a multi-institutional, randomized, double-blind trial with validated outcome measures to provide science-based treatment guidance.

The influence of mindfulness-based interventions on the academic performance of students measured by their GPA. A systematic review and meta-analysis

Objective: Mindfulness-based interventions are increasingly used in health, economic and educational systems. There are numerous studies demonstrating the effectiveness of mindfulness-based interventions in the educational sectors (primary, secondary, and tertiary). This systematic review and meta-analysis assessed the current state of research on the effectiveness of mindfulness-based interventions on the academic performance of students as measured by their grade point average (GPA). Methods: Literature search was conducted in Psychology and Behavioral Sciences Collection, PsycARTICLES, PubMed, and Google Scholar through March 2022. The inclusion criteria were: (1) the use of GPA as a measure of students' academic performance, (2) a sample that was subjected to a mindfulness-based intervention without medical indication, (3) the student status of the subjects. Meta-analysis was conducted using a random effects model with the generic inverse variance method. Results: The search included a total of 759 studies, of which six randomized controlled trials met the inclusion criteria. In these trials, significant group differences for GPA were found with effect sizes ranging from d = 0.16-1.62 yielding a significant overall effect of d = 0.42 (95% CI: 0.15-0.69) and a low magnitude of heterogeneity of I 2 = 37%. Discussion: In conclusion, the first results of this emerging research field seem promising. However, the exact mechanisms of action are still unclear.

The Effect of Positive Intervention Dosing Frequency: Fixed Intervals May Decrease More Depression than Flexible Ones

Positive interventions (PIs) that are based on the theory of positive psychology have proven to be effective in improving well-being and alleviating depression. However, little research has explored the effect of dosing intervals on experimental effects. As such, this study designed strength-based PIs using cognitive reframing theory and compared flexible and fixed dosing intervals to find out which one could more effectively reduce depression with equal total amounts of dosing. The 8-item Center for Epidemiological Studies Depression Scale (8-item CES-D) and the Positive reframing scale (PRS) were adopted as research instruments. A total of 193 Taiwanese college students were recruited as the research sample and they were randomly assigned to experimental Group A (fixed dosing intervals), experimental Group B (flexible dosing intervals), and the Control Group. The research participants received 17-day interventions with follow-up tests administered in the seventh week of the experiment. Ultimately, 157 participants completed the experiment. According to the ANCOVA results, participants in experimental Group A showed significantly lower degrees of depression than those in the Control Group in both post-test and follow-up stages and displayed greater effect size in the follow-up stage than in the post-test stage. The results indicated that the design of fixed dosing intervals enabled the participants to effectively integrate reflections on reframing learned during PIs into their life. On the contrary, participants in experimental Group B exhibited no significant difference in the degree of depression from those in the Control Group during either the post-test or follow-up stage and manifested poorer effects in the follow-up stage than in the post-test stage. These results demonstrated that fixed dosing intervals achieved better effects than flexible dosing intervals. Participants receiving fixed dosing intervals could more effectively execute cognitive reframing and showed longer-lasting experimental effects, whereas participants using the design of flexible dosing intervals were more prone to forget to implement PIs and attain less positive effects as a result.

Person-specific dose-finding for a digital messaging intervention to promote physical activity

OBJECTIVE

Digital messaging is an established method for promoting physical activity. Systematic approaches for dose-finding have not been widely used in behavioral intervention development. We apply system identification tools from control systems engineering to estimate dynamical models and inform decision rules for digital messaging intervention to promote physical activity.

METHOD

Insufficiently active emerging and young adults (n = 45) wore an activity monitor that recorded minute-level step counts and heart rate and received 0-6 digital messages daily on their smartphone for 6 months. Messages were drawn from 3 content libraries (move more, sit less, inspirational quotes). Location recordings via location services in the user's smartphone were used to lookup weather indices at the time and place of message delivery. Following system identification, responses to each message type were simulated under different conditions. Response features were extracted to summarize dynamic processes.

RESULTS

A generic model based on composite data was conservative and did not capture the heterogeneous responses evident in person-specific models. No messages were uniformly ineffective but responses to specific message content in different contexts varied between people. Exterior temperature at the time of message receipt moderated the size of some message effects.

CONCLUSIONS

A generic model of message effects on physical activity can provide the initial evidence for context-sensitive decision rules in a just-in-time adaptive intervention, but it is likely to be error-prone and inefficient. As individual data accumulates, person-specific models should be estimated to optimize treatment and evolve as people are exposed to new environments and accumulate new experiences. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A pilot clinical trial of a self-management intervention in patients with a left ventricular assist device

Self-management is a health behavior known to predict treatment outcomes in patients with multiple co-morbidities and/or chronic conditions. However, the self-management process and outcomes in the left-ventricular assist device (LVAD) population are understudied. This pilot randomized control trial (RCT) evaluated the feasibility of a novel "smartphone app-directed and nurse-supported self-management intervention" in patients implanted with durable LVADs. Assessments included behavioral (self-efficacy and adherence), clinical (complications), and healthcare utilization (unplanned clinic, emergency room (ER) visits, and re-hospitalization) outcomes, completed at baseline (pre-hospital discharge) and months 1, 3, and 6 post-hospital discharge. Intervention patients (n = 14) had favorable patterns/trends of results across study outcomes than control patients (n = 16). Notably, intervention patients had much lower complications and healthcare utilization rates than controls. For example, intervention patients had 2 (14.3%) driveline infections in 6 months while control patients had 3 (19.0%). Additionally, at month 3, intervention patients had 0% ER visits versus 36% of control patients. At month 6, the mean cumulative number of re-hospitalizations for the control group was higher (0.9 ± 0.93) than intervention (0.3 ± 0.61) group. Despite the small sample size and limitations of feasibility/pilot studies, our outcomes data appeared to favor the novel intervention. Lessons learned from this study suggest the intervention should be implemented for 6 months post-hospital discharge. Further research is needed including large and rigorous multi-center RCTs to generate knowledge explaining the mechanism of the effect of self-management on LVAD treatment outcomes.

"I Want a Program That Looks at My Whole Life." A Focus Group Study on the Ideal Components for an mHealth Weight Management Program for African American Women

BACKGROUND

The high rate of obesity, ownership of smartphones, and online search for nutrition and dieting information among African American women (AAW) provide a unique opportunity to develop cost-effective, accessible, and acceptable mHealth weight management programs for them. Furthermore, they should participate in the development and evaluation of these programs.

OBJECTIVE

To explore ideal components of a culturally relevant mHealth weight management program for AAW and to examine how these components may vary by age group.

DESIGN

Twelve focus group triads were conducted with AAW in north central Florida. The framework method was used to manage, organize, synthesize, and analyze data themes by age groups: 18 to 29 (young), 30 to 50 (middle age), and 51+ (older).

PARTICIPANTS/SETTING

Thirty-six smartphone owners who expressed a desire to lose weight were recruited through several community partnerships.

RESULTS

Based on body mass index (BMI), young women were classified as overweight (BMI 26.23 ± 6.7), middle-aged women as obese (BMI30.72 ± 8.31), and older women as obese (BMI 31.03 ± 5.67). Most searched online for dieting information within the past 12 months. Five overarching themes for designing mHealth weight management programs were identified: (1) holistic program that goes beyond dieting; (2) social media integration for support and sense of community; (3) self-monitoring app; (4) two-way text messaging; and (5) programs of varying lengths and meaningful incentives.

CONCLUSION

AAW were receptive to mHealth weight management programs, which may be appealing during and after the COVID-19 pandemic. Holistic programs of 4 to 6 weeks that addressed stress eating, had a social media component, and included a few educational texts per week may be appealing to AAW.

Self-care research: How to grow the evidence base? (reprint)

BACKGROUND AND OBJECTIVE

The number of studies in the area of self-care is growing and international researchers are increasingly developing self-care interventions to improve outcomes of individual patients and communities. However, growth of the evidence is still slow due to challenges with designing and testing self-care interventions. In this article we address major methodological challenges with regard to the definition of self-care, use of theory, and research design, intended to provide guidance to researchers in this field.

METHOD

During the inaugural conference of the International Center for Self-Care Research held in Rome, Italy in June 2019 we identified important issues in existing self-care research. Discussion and literature review lead to eight recommendation for future self-care research.

RESULTS

In preparation, begin with a theoretically sound definition of self-care. In planning the intervention, build on and extend previous studies. Use theory to develop self-care interventions and consider translational models to guide development, evaluation and implementation of complex self-care interventions. Employ a study design that fits the current phase and objectives of the research and measure self-care and related factors carefully. In reporting, describe the sample and setting sufficiently so that others can draw conclusions about generalizability and applicability to their practice and patient population. In interpretation, describe how the intervention is assumed to work (causal assumptions) and its key components.

CONCLUSION

Our review of existing self-care research clearly illustrates that the recommendations we provide are needed if we are to substantially grow the evidence base supporting self-care. Embracing a core set of principles will allow us to build on each other's work. Tweetable abstract: A core set of methodological principles is needed to substantially grow the evidence base supporting self-care.

The effectiveness of a men-only supportive expressive group therapy intervention for psychosocial health outcomes in gastrointestinal cancer patients: a 6-month longitudinal study

BACKGROUND

An increasing number of gastrointestinal cancer (GI) patients suffer from side effects of cancer treatment that can affect their mood states and quality of life. Despite its demonstrated effectiveness in female cancer patients, Supportive Expressive Group Therapy (SEGT) has not been tested in male cancer patients. The current study sought to examine the longitudinal effects of a professionally-led, men-only SEGT on mood states, coping, and quality of life (QoL) in male GI cancer patients.

METHODS

A sample of male GI cancer patients (n = 31), at different stages of cancer treatment, was recruited from an ongoing, men-only biweekly GI cancer SEGT. Data were collected at baseline (before or near the beginning of group attendance) and at three months and six months follow-up. All study outcomes were patient-reported and included socio-demographic data as well as validated questionnaires: Profile of Mood States (POMS) for mood states, Functional Assessment of Cancer Therapy-General (FACT-G) for QoL, and Ways of Coping-Cancer Version (WOC) for coping. Linear mixed models were used to examine the change in outcomes over time. Effect sizes were estimated using Cohen's d.

RESULTS

The Anxiety (p = .04; d = 0.70), Depression (p = .03; d = 0.93) and Anger (p = .04; d = 1.28) subscales of the POMS decreased between baseline and six months. Participants also reported improvements in coping through Distancing (distancing oneself from negative thoughts, being more accepting of the situation, and looking for positives) of the WOC (p = .04; d = 0.4) between baseline and six months. There was no change in any of the FACT subscales (QoL) over time.

CONCLUSIONS

This is the first study to investigate the effects of a SEGT intervention in male cancer patients. Participation in the intervention was associated with improved mood states and coping in male GI cancer patients; however, there was no change in measures of QoL.

The Impact of Social Support on Treatment Participation and Completion in a Disability Prevention Intervention for Older Adults

Objectives: This study evaluates the role of emotional and instrumental social support on treatment participation and completion using the Positive Minds-Strong Bodies (PMSB) disability prevention program. Methods: Data from a multisite randomized controlled trial of the PMSB program for older adults (≥60 years) with physical impairment and mild to severe depression and/or anxiety were used. Participants were randomly assigned to receive 10 sessions of cognitive behavior therapy (CBT) plus 36 sessions of group exercise or usual care. Results: Adjusting for covariates, higher levels of emotional social support at baseline were associated with increased odds of completing the recommended number of CBT sessions (6 or more, OR = 2.58, p = .030), attending 5.56 more exercise sessions (p = .006), and increased odds of completing the recommended exercise sessions (25 or more, OR = 2.37, p = .047). Discussion: Emotional social support appears to increase dosage in a disability prevention program.

Promoting Higher Quality Teacher-Child Relationships: The INSIGHTS Intervention in Rural Schools

Children’s relationships with teachers in kindergarten are crucial for academic and social success. Research shows that teacher–child relationships are predicated, in part, on children’s temperament. The “INSIGHTS into Children’s Temperament” intervention was intended to improve children’s and teachers’ understanding of their and others’ temperament, and has been shown to improve children’s social skills and self-regulation in urban, under-resourced schools. The current study is part of a replication of the effects of INSIGHTS with a sample in rural schools. The purpose was to test the effectiveness of INSIGHTS for promoting positive relationships between teachers and children in kindergarten. Two cohorts of kindergarten students (N = 127) and teachers (N = 30) were randomized into INSIGHTS or control conditions by school. Teachers reported on the quality of the teacher–child relationship before and after the INSIGHTS intervention (Time 1 and 2) using the Student–Teacher Relationship Scale: Short Form and provided a rating of children’s temperament with the Teacher School-Age Temperament Inventory at Time 1. Data were analyzed with hierarchical linear modeling. Two significant findings emerged. First, INSIGHTS promoted more closeness between teachers and children, regardless of temperament. Second, the INSIGHTS intervention was protective against the development of conflictual teacher–child relationships for children with negative reactivity.

Smartphone-Delivered Progressive Muscle Relaxation for the Treatment of Migraine in Primary Care: A Randomized Controlled Trial

OBJECTIVE

Scalable, accessible forms of behavioral therapy for migraine prevention are needed. We assessed the feasibility and acceptability of progressive muscle relaxation (PMR) delivered by a smartphone application (app) in the Primary Care setting.

METHODS

This pilot study was a non-blinded, randomized, parallel-arm controlled trial of adults with migraine and 4+ headache days/month. Eligible participants spoke English and owned a smartphone. All participants were given the RELAXaHEAD app which includes an electronic headache diary. Participants were randomized to receive 1 of the 2 versions of the app-one with PMR and the other without PMR. The primary outcomes were measures of feasibility (adherence to the intervention and diary entries during the 90-day interval) and acceptability (satisfaction levels). We conducted exploratory analyses to determine whether there was a change in Migraine Disability Assessment Scale (MIDAS) scores or a change in headache days.

RESULTS

Of 139 participants (77 PMR, 62 control), 116 (83%) were female, mean age was 41.7 ± 12.8 years. Most patients 108/139 (78%) had moderate-severe disability. Using a 1-5 Likert scale, participants found the app easy to use (mean 4.2 ± 0.7) and stated that they would be happy to engage in the PMR intervention again (mean 4.3 ± 0.6). For the first 6 weeks, participants practiced PMR 2-4 days/week. Mean per session duration was 11.1 ± 8.3 minutes. Relative to the diary-only group, the PMR group showed a greater non-significant decline in mean MIDAS scores (-8.7 vs -22.7, P = .100) corresponding to a small-moderate mean effect size (Cohen's d = 0.38).

CONCLUSION

Smartphone-delivered PMR may be an acceptable, accessible form of therapy for migraine. Mean effects show a small-moderate mean effect size in disability scores.

Perspective of Dose and Response for Individualized Physical Exercise and Training Prescription

Physical interventions are used to increase physical (sports) performance and considered as effective low-cost strategies in the fields of healthcare, disease or injury prevention, and medical treatment. In general, a considerable amount of evidence buttress the application of physical interventions in various fields as it has been demonstrated to contribute to the maintenance and recovery of physical performance, cognitive function, and overall state of health. To implement physical interventions effectively, it is essential to provide an appropriate exercise and training prescription. Exercise and training prescription are key for "dose" specification and for the individualization (personalizing) of physical exercise and training, precisely adjusted and controlled like medication. Since the physiological response to physical interventions is demonstrably individual and dependent on many influencing factors, individualization is an emerging approach aiming to maximize the efficiency of an intervention by accounting for the interindividual heterogeneity. The present brief viewpoint article aims to distinguish and to redefine between the terms dose and response in order to improve the understanding of practitioners, the methodology of study protocols, and to relate future findings to the actual biological (interindividual) variability of acute and chronic responses.

A Discussion on Different Approaches for Prescribing Physical Interventions - Four Roads Lead to Rome, but Which One Should We Choose?

It is well recognized that regular physical exercise has positive effects on physical and mental health. To use the beneficial health effects of physical exercise, there are worldwide movements encouraging health care providers to include physical exercise in their care and treatments strategies. However, a crucial point in administering the "exercise polypill" is the dosing and, in turn, the prescription of the physical intervention (PI). In this perspective article, we discuss the advantages and disadvantages of different approaches to prescribe PI. In this context, we also highlight outstanding questions and potential areas of opportunity for further investigations.

Dose-Response Matters! - A Perspective on the Exercise Prescription in Exercise-Cognition Research

In general, it is well recognized that both acute physical exercises and regular physical training influence brain plasticity and cognitive functions positively. However, growing evidence shows that the same physical exercises induce very heterogeneous outcomes across individuals. In an attempt to better understand this interindividual heterogeneity in response to acute and regular physical exercising, most research, so far, has focused on non-modifiable factors such as sex and different genotypes, while relatively little attention has been paid to exercise prescription as a modifiable factor. With an adapted exercise prescription, dosage can be made comparable across individuals, a procedure that is necessary to better understand the dose-response relationship in exercise-cognition research. This improved understanding of dose-response relationships could help to design more efficient physical training approaches against, for instance, cognitive decline.

Dose-response research in digital health interventions: Concepts, considerations, and challenges

To optimize digital health interventions, intervention creators must determine what intervention dose will produce the most substantial health behavior change-the dose-response relationship-while minimizing harms or burden. In this article we present important concepts, considerations, and challenges in studying dose-response relationships in digital health interventions. We propose that interventions make three types of prescriptions: (1) intervention action prescriptions, prescriptions to receive content from the intervention, such as to read text or listen to audio; (2) participant action prescriptions, prescriptions to produce and provide content to the intervention, such as to send text messages or post intervention-requested photos on social media; and (3) behavioral target action prescriptions, prescriptions to engage in behaviors outside the intervention, such as changing food intake or meditating. Each type of prescription has both an intended dose (i.e., what the intervention actually prescribes) and an enacted dose (i.e., what portion of the intended dose is actually completed by the participant). Dose parameters of duration, frequency, and amount can be applied to each prescription type. We consider adaptive interventions and interventions with ad libitum prescriptions as examples of tailored doses. Researchers can experimentally manipulate the intended dose to determine the dose-response relationship. The enacted dose cannot be directly manipulated; however, we consider the applicability of "controlled concentration" research design to the study of enacted dose. We consider challenges in dose-response research in digital health interventions, including characterizing amount with self-paced activities and combining doses across modality. The presented concepts and considerations may help contribute to the optimization of digital health interventions. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

When is Enough, Enough? How the Absence of Dose-Determination Trials Impedes Implementation of HIV Behavioral Interventions

Carefully controlled clinical trials have determined that theory-based behavioral interventions delivered by adherence nurses, professional and paraprofessional counselors, and case managers improve ART adherence and viral suppression. However, there are no studies that empirically inform how much intervention is needed for which patient populations and at what cost. This Editorial raises the issue of how a lack of intervention dosing limits interpretation of trial results and impedes implementation, therefore calling for behavioral intervention dose-finding studies.

Smartphone-based migraine behavioral therapy: a single-arm study with assessment of mental health predictors

Progressive muscle relaxation (PMR) is an under-utilized Level A evidence-based treatment for migraine prevention. We studied the feasibility and acceptability of smartphone application (app)-based PMR for migraine in a neurology setting, explored whether app-based PMR might reduce headache (HA) days, and examined potential predictors of app and/or PMR use. In this single-arm pilot study, adults with ICHD3 migraine, 4+ HA days/month, a smartphone, and no prior behavioral migraine therapy in the past year were asked to complete a daily HA diary and do PMR for 20 min/day for 90 days. Outcomes were: adherence to PMR (no. and duration of audio plays) and frequency of diary use. Predictors in the models were baseline demographics, HA-specific variables, baseline PROMIS (patient-reported outcomes measurement information system) depression and anxiety scores, presence of overlapping pain conditions studied and app satisfaction scores at time of enrollment. Fifty-one patients enrolled (94% female). Mean age was 39 ± 13 years. The majority (63%) had severe migraine disability at baseline (MIDAS). PMR was played 22 ± 21 days on average. Mean/session duration was 11 ± 7 min. About half (47%) of uses were 1+ time/week and 35% of uses were 2+ times/week. There was a decline in use/week. On average, high users (PMR 2+ days/week in the first month) had 4 fewer days of reported HAs in month 2 vs. month 1, whereas low PMR users (PMR < 2 days/week in the first month) had only 2 fewer HA days in month 2. PROMIS depression score was negatively associated with the log odds of using the diary at least once (vs. no activity) in a week (OR = 0.70, 95% CI = [0.55, 0.85]) and of doing the PMR at least once in a week (OR = 0.77, 95% CI = [0.68, 0.91]). PROMIS anxiety was positively associated with using the diary at least once every week (OR = 1.33, 95% CI = [1.09, 1.73]) and with doing the PMR at least once every week (OR = 1.14 [95% CI = [1.02, 1.31]). In conclusion, about half of participants used smartphone-based PMR intervention based upon a brief, initial introduction to the app. App use was associated with reduction in HA days. Higher depression scores were negatively associated with diary and PMR use, whereas higher anxiety scores were positively associated.

The dose of behavioral interventions to prevent and treat childhood obesity: a systematic review and meta-regression

BACKGROUND

A better understanding of the optimal "dose" of behavioral interventions to affect change in weight-related outcomes is a critical topic for childhood obesity intervention research. The objective of this review was to quantify the relationship between dose and outcome in behavioral trials targeting childhood obesity to guide future intervention development.

METHODS

A systematic review and meta-regression included randomized controlled trials published between 1990 and June 2017 that tested a behavioral intervention for obesity among children 2-18 years old. Searches were conducted among PubMed (Web-based), Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), PsycINFO (Ovid platform) and EMBASE (Ovid Platform). Two coders independently reviewed and abstracted each included study. Dose was extracted as intended intervention duration, number of sessions, and length of sessions. Standardized effect sizes were calculated from change in weight-related outcome (e.g., BMI-Z score).

RESULTS

Of the 258 studies identified, 133 had sufficient data to be included in the meta-regression. Average intended total contact (# sessions x length of sessions) was 27.7 (SD 32.2) hours and average duration was 26.0 (SD 23.4) weeks. When controlling for study covariates, a random-effects meta-regression revealed no significant association between contact hours, intended duration or their interaction and effect size.

CONCLUSIONS

This systematic review identified wide variation in the dose of behavioral interventions to prevent and treat pediatric obesity, but was unable to detect a clear relationship between dose and weight-related outcomes. There is insufficient evidence to provide quantitative guidance for future intervention development. One limitation of this review was the ability to uniformly quantify dose due to a wide range of reporting strategies. Future trials should report dose intended, delivered, and received to facilitate quantitative evaluation of optimal dose.

TRIAL REGISTRATIONS

The protocol was registered on PROSPERO (Registration # CRD42016036124 ).

Experiences in implementation and publication of operations research interventions: gaps and a way forward

INTRODUCTION

According to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research.

DISCUSSION

Interventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes.

CONCLUSIONS

Interventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.

The BestFIT trial: A SMART approach to developing individualized weight loss treatments

Behavioral weight loss programs help people achieve clinically meaningful weight losses (8-10% of starting body weight). Despite data showing that only half of participants achieve this goal, a "one size fits all" approach is normative. This weight loss intervention science gap calls for adaptive interventions that provide the "right treatment at the right time for the right person." Sequential Multiple Assignment Randomized Trials (SMART), use experimental design principles to answer questions for building adaptive interventions including whether, how, or when to alter treatment intensity, type, or delivery. This paper describes the rationale and design of the BestFIT study, a SMART designed to evaluate the optimal timing for intervening with sub-optimal responders to weight loss treatment and relative efficacy of two treatments that address self-regulation challenges which impede weight loss: 1) augmenting treatment with portion-controlled meals (PCM) which decrease the need for self-regulation; and 2) switching to acceptance-based behavior treatment (ABT) which boosts capacity for self-regulation. The primary aim is to evaluate the benefit of changing treatment with PCM versus ABT. The secondary aim is to evaluate the best time to intervene with sub-optimal responders. BestFIT results will lead to the empirically-supported construction of an adaptive intervention that will optimize weight loss outcomes and associated health benefits.

Treatment Burden and Treatment Fatigue as Barriers to Health

Effective management of chronic diseases involves sustained changes in health behavior, which often requires substantial effort and patient burden. As treatment burden is associated with reduced adherence across several chronic conditions, its assessment and treatment are important clinical priorities. The balance between patient demands and capacity (e.g., coping resources) may be indexed by patients' subjective experience of treatment fatigue. We present a modified workload-capacity model that incorporates evidence that treatment fatigue may 1) be caused by increased workload due to treatment burden (e.g., intensity, complications) and 2) undermine adherence. Emerging technology-based interventions may be well-suited to reduce treatment burden, prevent treatment fatigue, and increase treatment adherence.

Approaches for informing optimal dose of behavioral interventions

BACKGROUND

There is little guidance about to how select dose parameter values when designing behavioral interventions.

PURPOSE

The purpose of this study is to present approaches to inform intervention duration, frequency, and amount when (1) the investigator has no a priori expectation and is seeking a descriptive approach for identifying and narrowing the universe of dose values or (2) the investigator has an a priori expectation and is seeking validation of this expectation using an inferential approach.

METHODS

Strengths and weaknesses of various approaches are described and illustrated with examples.

RESULTS

Descriptive approaches include retrospective analysis of data from randomized trials, assessment of perceived optimal dose via prospective surveys or interviews of key stakeholders, and assessment of target patient behavior via prospective, longitudinal, observational studies. Inferential approaches include nonrandomized, early-phase trials and randomized designs.

CONCLUSIONS

By utilizing these approaches, researchers may more efficiently apply resources to identify the optimal values of dose parameters for behavioral interventions.

Community-based case management effectiveness in populations that abuse substances

BACKGROUND

The number of persons who are substance abusing has been increasing globally. A majority of them remain in their communities, untreated. Empirical studies have shown some positive impacts of case management on substance abuse. However, studies that systematically synthesize the effectiveness of community-based case management with populations that abuse substances are limited.

AIM

To review evidence of the impact of case management in improving treatment of substance abuse among adults in community settings.

METHODS

The Cochrane processes guided this systematic review. PubMed, CINAHL, PsycINFO, Ovid and the Web of Science were searched to retrieve primary studies published from 2000 to 2013. All randomized controlled trials were considered for review. The methodological quality of the studies was assessed.

RESULTS

The initial unfiltered search identified 506 references. A total of seven randomized controlled trials were selected for review. Findings show that, compared with clinical case management and usual care, community-based case management services significantly improved clients' ability to abstain from drug use, reduced social problems, supported unmet service needs and improved satisfaction. Studies also showed reduced use of healthcare services, but results were mixed.

CONCLUSIONS

There is an evidence base for practicing case management among adults who are substance abusing. In general, studies concluded that case management is an active and assertive method of care coordination for formal substance abuse treatment. Further research is needed to assess case management's cost-effectiveness and the impact of dosage on client outcomes.

IMPLICATIONS FOR NURSING POLICY

Because of the complexity of population health management across settings and over long time frames, evidence-based strategies are required to achieve health improvements. Because it provides continuous and timely care, healthcare leaders and policymakers should consider community-based case management as an important strategy for coordinating the care in populations that are substance abusing.

Introduction to SMART designs for the development of adaptive interventions: with application to weight loss research

The management of many health disorders often entails a sequential, individualized approach whereby treatment is adapted and readapted over time in response to the specific needs and evolving status of the individual. Adaptive interventions provide one way to operationalize the strategies (e.g., continue, augment, switch, step-down) leading to individualized sequences of treatment. Often, a wide variety of critical questions must be answered when developing a high-quality adaptive intervention. Yet, there is often insufficient empirical evidence or theoretical basis to address these questions. The Sequential Multiple Assignment Randomized Trial (SMART)-a type of research design-was developed explicitly for the purpose of building optimal adaptive interventions by providing answers to such questions. Despite increasing popularity, SMARTs remain relatively new to intervention scientists. This manuscript provides an introduction to adaptive interventions and SMARTs. We discuss SMART design considerations, including common primary and secondary aims. For illustration, we discuss the development of an adaptive intervention for optimizing weight loss among adult individuals who are overweight.

Psychosocial interventions for men with prostate cancer

BACKGROUND

As the incidence and prevalence of prostate cancer continue to rise, the number of men needing help and support to assist them in coping with disease and treatment-related symptoms and their psychosocial effects is likely to increase.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for men with prostate cancer in improving quality of life (QoL), self-efficacy and knowledge and in reducing distress, uncertainty and depression.

SEARCH METHODS

We searched for trials using a range of electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO to October 2013, together with handsearching of journals and reference lists.

SELECTION CRITERIA

Randomised controlled trials of psychosocial interventions for men at any stage of prostate cancer. We included psychosocial interventions that explicitly used one or a combination of the following approaches: cognitive behavioural, psychoeducational, supportive and counselling. Interventions had to be delivered or facilitated by trained or lay personnel.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently extracted data and assessed risk of bias. We analysed data using standardised mean differences (SMDs), random-effects models and 95% confidence intervals (CIs).

MAIN RESULTS

Nineteen studies comparing psychosocial interventions versus usual care in a total of 3204 men with prostate cancer were included in this review. All but three of these studies were conducted in the United States.Men in the psychosocial intervention group had a small, statistically significant improvement in the physical component of general health-related quality of life (GHQoL) at end of intervention (1414 participants, SMD 0.12, 95% CI 0.01 to 0.22) based on low-quality evidence. A small improvement in favour of psychosocial interventions (SMD 0.24, 95% CI 0.02 to 0.47) was also seen in the physical component of GHQoL at end of intervention for group-based interventions. No clear evidence of benefit was found for GHQoL scores at end of intervention with individual-based interventions compared with controls. Also, no clear evidence suggested that psychosocial interventions were beneficial in improving the physical component of GHQoL at four to six and at eight to 12 months post-intervention. In addition, no clear evidence showed benefit associated with psychosocial interventions for the mental component of GHQoL at end of intervention (1416 participants, SMD -0.04, 95% CI -0.15 to 0.06) based on moderate-quality evidence. Results for the mental component of GHQoL at four to six and at eight to 12 months post-intervention were compatible with benefit and harm. At end of intervention, cancer-related QoL showed a small improvement following psychosocial interventions (SMD 0.21, 95% CI 0.04 to 0.39), but at eight and 12 months, the effect was compatible with benefit and harm. For prostate cancer-specific and symptom-related QoL, the differences between groups were not significant.No clear evidence indicated that psychosocial interventions were beneficial in improving self-efficacy at end of intervention (337 participants, SMD 0.16, 95% CI -0.05 to 0.38) based on very low-quality evidence in three studies that assessed individual-based interventions. The results for self-efficacy at six to eight and at 12 months post-intervention were compatible with benefit and harm. Men in the psychosocial intervention group had a moderate increase in prostate cancer knowledge at end of intervention (506 participants, SMD 0.51, 95% CI 0.32 to 0.71) based on very low-quality evidence in two studies; this increase was also observed in the subgroups of group-based and individual-based interventions. A small increase in knowledge with psychosocial interventions was noted at three months post-intervention (SMD 0.31, 95% CI 0.04 to 0.58).The results for uncertainty (916 participants, SMD -0.05, 95% CI -0.35 to 0.26) and distress (916 participants, SMD 0.02, 95% CI -0.11 to 0.15) at end of intervention were compatible with both benefit and harm based on very low-quality evidence. No clear evidence suggests that psychosocial interventions were beneficial in reducing uncertainty and distress between groups at six to eight and at 12 months post-intervention. Finally, no clear evidence of benefit is associated with psychosocial interventions for depression at end of intervention (434 participants, SMD -0.18, 95% CI -0.51 to 0.15) based on very low-quality evidence. Individual-based interventions significantly reduced depression when compared with usual care groups. The results for depression at six and at 12 months post-intervention were compatible with benefit and harm.The overall risk of bias in the included studies was unclear or high, primarily as the result of performance bias.No data regarding stage of disease or treatment with androgen deprivation therapy (ADT) were extractable for subgroup analysis. Only one study addressed adverse effects. High attrition could indicate that some participants may not have been comfortable with the interventions.

AUTHORS' CONCLUSIONS

Overall, this review shows that psychosocial interventions may have small, short-term beneficial effects on certain domains of well-being, as measured by the physical component of GHQoL and cancer-related QoL when compared with usual care. Prostate cancer knowledge was also increased. However, this review failed to demonstrate a statistically significant effect on other domains such as symptom-related QoL, self-efficacy, uncertainty, distress or depression. Moreover, when beneficial effects were observed, it remained uncertain whether the magnitude of effect was large enough to be considered clinically important. The quality of evidence for most outcomes was rated as very low according to GRADE, reflecting study limitations, loss to follow-up, study heterogeneity and small sample sizes. We were unable to perform meaningful subgroup analyses based on disease stage or treatment modality. Although some findings of this review are encouraging, they do not provide sufficiently strong evidence to permit meaningful conclusions about the effects of these interventions in men with prostate cancer. Additional well-done and transparently reported research studies are necessary to establish the role of psychosocial interventions in men with prostate cancer.