Impact of an acceptance facilitating intervention on diabetes patients' acceptance of Internet-based interventions for depression: a randomized controlled trial

Enhancing the acceptance of smart sensing in psychotherapy patients: findings from a randomized controlled trial

Objective

Smart sensing has the potential to make psychotherapeutic treatments more effective. It involves the passive analysis and collection of data generated by digital devices. However, acceptance of smart sensing among psychotherapy patients remains unclear. Based on the unified theory of acceptance and use of technology (UTAUT), this study investigated (1) the acceptance toward smart sensing in a sample of psychotherapy patients (2) the effectiveness of an acceptance facilitating intervention (AFI) and (3) the determinants of acceptance.

Methods

Patients (N = 116) were randomly assigned to a control group (CG) or intervention group (IG). The IG received a video AFI on smart sensing, and the CG a control video. An online questionnaire was used to assess acceptance of smart sensing, performance expectancy, effort expectancy, facilitating conditions and social influence. The intervention effects of the AFI on acceptance were investigated. The determinants of acceptance were analyzed with structural equation modeling (SEM).

Results

The IG showed a moderate level of acceptance (M = 3.16, SD = 0.97), while the CG showed a low level (M = 2.76, SD = 1.0). The increase in acceptance showed a moderate effect in the intervention group (p < .05, d = 0.4). For the IG, performance expectancy (M = 3.92, SD = 0.7), effort expectancy (M = 3.90, SD = 0.98) as well as facilitating conditions (M = 3.91, SD = 0.93) achieved high levels. Performance expectancy (γ = 0.63, p < .001) and effort expectancy (γ = 0.36, p < .001) were identified as the core determinants of acceptance explaining 71.1% of its variance. The fit indices supported the model's validity (CFI = .95, TLI = .93, RMSEA = .08).

Discussion

The low acceptance in the CG suggests that enhancing the acceptance should be considered, potentially increasing the use and adherence to the technology. The current AFI was effective in doing so and is thus a promising approach. The IG also showed significantly higher performance expectancy and social influence and, in general, a strong expression of the UTAUT factors. The results support the applicability of the UTAUT in the context of smart sensing in a clinical sample, as the included predictors were able to explain a great amount of the variance of acceptance.

Evaluation of the e-Mental Health Intervention Make It Training From Patients' Perspectives: Qualitative Analysis Within the Reduct Trial

BACKGROUND

Make It Training is an e-mental health intervention designed for individuals with cancer that aims to reduce psychological distress and improve disease-related coping and quality of life.

OBJECTIVE

This study evaluated the experienced usefulness and usability of the web-based Make It Training intervention using a qualitative approach.

METHODS

In this study, semistructured interviews were conducted with participants at different cancer stages and with different cancer entities. All participants had previously taken part in the Reduct trial, a randomized controlled trial that assessed the efficacy of the Make It Training intervention. The data were coded deductively by 2 independent researchers and analyzed iteratively using thematic codebook analysis.

RESULTS

Analysis of experienced usefulness resulted in 4 themes (developing coping strategies to reduce psychological distress, improvement in quality of life, Make It Training vs traditional psychotherapy, and integration into daily life) with 11 subthemes. Analysis of experienced usability resulted in 3 themes (efficiency and accessibility, user-friendliness, and recommendations to design the Make It Training intervention to be more appealing) with 6 subthemes. Make It Training was evaluated as a user-friendly intervention helpful for developing functional coping strategies to reduce psychological distress and improve quality of life. The consensus regarding Make It Training was that it was described as a daily companion that integrates well into daily life and that it has the potential to be routinely implemented within oncological health care either as a stand-alone intervention or in addition to psychotherapy.

CONCLUSIONS

e-Mental health interventions such as Make It Training can target both the prevention of mental health issues and health promotion. Moreover, they offer a cost-efficient and low-threshold option to receive psycho-oncological support.

Acceptance of a Web-Based Intervention in Individuals Who Committed Sexual Offenses Against Children: Cross-Sectional Study

BACKGROUND

Individuals who have committed sexual offenses against children often have difficulties finding treatment, despite its potential effectiveness. Although the development of web-based interventions could enhance therapeutic supply, up to now the acceptance thereof among this target group is unknown.

OBJECTIVE

For the first time, this study assesses the acceptance of a web-based intervention among individuals who committed sexual offenses against children and analyzes variables that predict acceptance. Following the Unified Theory of Acceptance and Use of Technology (UTAUT), it is assumed that acceptance of web-based interventions in individuals who have committed sexual offenses against children follows the same mechanisms as for individuals in general psychiatry.

METHODS

This cross-sectional study is based on the data from an ongoing clinical trial (@myTabu) evaluating the effectiveness of a web-based intervention in individuals who committed sexual offenses against children (N=113). Acceptance level was measured using a questionnaire based on the UTAUT and modified for the target group. Furthermore, predictors of acceptance from the UTAUT (performance expectancy, effort expectancy, and social influence [SI]), attitudes toward web-based interventions, and internet anxiety were assessed at baseline.

RESULTS

Most participants (61.1%, 69/113), reported high acceptance, while 36.3% (41/113) of them indicated moderate acceptance, and 2.7% (3/113) of them expressed low acceptance. In a linear regression model, the predictors explained 41.2% of the variance (F11,101=9.055; P=.01). Attitudes toward web-based interventions (B=0.398, 95% CI 0.16-0.64; P=.001) and SI (B=0.183, 95% CI 0.03-0.38; P=.04) significantly predicted acceptance. Post hoc explorative analysis showed that the participants' belief that people close to them would recommend the use of a web-based intervention is a predictor of acceptance. In contrast, the belief that their community supervisor would recommend the use thereof was not predictive in this respect.

CONCLUSIONS

For the participants of this study, we identified high acceptance of web-based interventions for the majority of participants. SI and the participants' attitudes toward web-based interventions were important in predicting acceptance.

TRIAL REGISTRATION

German Clinical Trial Registration (DRKS, Deutsches Register Klinischer Studien) DRKS 00021256; https://drks.de/search/de/trial/DRKS00021256.

Understanding the use intention and influencing factors of telerehabilitation in people with rehabilitation needs: a cross-sectional survey

Objective

This study aimed to investigate the use intention and influencing factors of telerehabilitation in people with rehabilitation needs.

Methods

This cross-sectional survey recruited a total of 183 participants with rehabilitation needs from May 2022 to December 2022. Sociodemographic and medical data were collected by a structured questionnaire. The factors influencing the use intention of telerehabilitation were measured by the extended Unified Theory of Acceptance and Use of Technology (UTAUT) model. Multiple hierarchical regression analyses were performed.

Results

A total of 150 valid questionnaires were included for analysis. The results indicated that the use intention of telerehabilitation was overall high in people with rehabilitation needs. Health condition (β = -0.21, p = 0.03), performance expectancy (β = 0.21, p = 0.01), facilitating conditions (β = 0.25, p = 0.03), perceived trust (β = 0.25, p < 0.01), and self-efficacy (β = 0.19, p = 0.04) were significant factors influencing the use intention of telerehabilitation.

Conclusion

Overall, the use intention of telerehabilitation is high in individuals with rehabilitation needs. Health conditions, performance expectancy, facilitating conditions, perceived trust, and self-efficacy are important factors influencing the use intention of telerehabilitation in individuals with rehabilitation needs.

Acceptance of smart sensing: a barrier to implementation-results from a randomized controlled trial

Background

Accurate and timely diagnostics are essential for effective mental healthcare. Given a resource- and time-limited mental healthcare system, novel digital and scalable diagnostic approaches such as smart sensing, which utilizes digital markers collected via sensors from digital devices, are explored. While the predictive accuracy of smart sensing is promising, its acceptance remains unclear. Based on the unified theory of acceptance and use of technology, the present study investigated (1) the effectiveness of an acceptance facilitating intervention (AFI), (2) the determinants of acceptance, and (3) the acceptance of adults toward smart sensing.

Methods

The participants (N = 202) were randomly assigned to a control group (CG) or intervention group (IG). The IG received a video AFI on smart sensing, and the CG a video on mindfulness. A reliable online questionnaire was used to assess acceptance, performance expectancy, effort expectancy, facilitating conditions, social influence, and trust. The self-reported interest in using and the installation of a smart sensing app were assessed as behavioral outcomes. The intervention effects were investigated in acceptance using t-tests for observed data and latent structural equation modeling (SEM) with full information maximum likelihood to handle missing data. The behavioral outcomes were analyzed with logistic regression. The determinants of acceptance were analyzed with SEM. The root mean square error of approximation (RMSEA) and standardized root mean square residual (SRMR) were used to evaluate the model fit.

Results

The intervention did not affect the acceptance (p = 0.357), interest (OR = 0.75, 95% CI: 0.42-1.32, p = 0.314), or installation rate (OR = 0.29, 95% CI: 0.01-2.35, p = 0.294). The performance expectancy (γ = 0.45, p < 0.001), trust (γ = 0.24, p = 0.002), and social influence (γ = 0.32, p = 0.008) were identified as the core determinants of acceptance explaining 68% of its variance. The SEM model fit was excellent (RMSEA = 0.06, SRMR = 0.05). The overall acceptance was M = 10.9 (SD = 3.73), with 35.41% of the participants showing a low, 47.92% a moderate, and 10.41% a high acceptance.

Discussion

The present AFI was not effective. The low to moderate acceptance of smart sensing poses a major barrier to its implementation. The performance expectancy, social influence, and trust should be targeted as the core factors of acceptance. Further studies are needed to identify effective ways to foster the acceptance of smart sensing and to develop successful implementation strategies.

Clinical Trial Registration

identifier 10.17605/OSF.IO/GJTPH.

Breast Cancer Survivors' Attitudes toward eMental Health: A Cross-Sectional Study

BACKGROUND

Breast cancer survivors' (BCS) attitudes toward eMental Health (eMH) are largely unknown, and adoption predictors and their interrelationships remain unclear. This study aimed to explore BCS' attitudes toward eMH and investigate associated variables.

METHODS

A cross-sectional study involving 336 Portuguese BCS was conducted. Attitudes toward eMH, depression and anxiety symptoms, health-related quality of life, and sociodemographic, clinical, and internet-related variables were assessed using validated questionnaires. Spearman-ranked correlations, χ2, and multiple regression analyses were computed to explore associations between attitudes and collected variables.

RESULTS

BCS held a neutral stance toward eMH. In models adjusted for age and education, positive attitudes were statistically significantly associated with increased depressive symptoms and worse emotional, cognitive, and body image functioning. Social network use, online health information and mental healthcare seeking, higher self-reported knowledge of eMH, and previous use of remote healthcare were positively associated with better attitudes toward eMH.

CONCLUSIONS

eMH programs targeting BCS seem to be a promising strategy for providing supportive psychosocial care to BCS. However, increasing awareness about eMH efficacy and security may be necessary to improve its acceptance and use among BCS. Additional research is necessary to understand how BCS' unmet care needs, and specifically their psychological distress severity, may impact BCS' acceptance and use of eMH.

Factors Influencing Community Participation in Internet Interventions Compared With Research Trials: Observational Study in a Nationally Representative Adult Cohort

BACKGROUND

Digital mental health (DMH) programs can be effective in treating and preventing mental health problems. However, community engagement with these programs can be poor. Understanding the barriers and enablers of DMH program use may assist in identifying ways to increase the uptake of these programs, which have the potential to provide broad-scale prevention and treatment in the community.

OBJECTIVE

In this study, we aimed to identify and compare factors that may influence participation in DMH programs in practice and research trials, identify any respondent characteristics that are associated with these factors, and assess the relationship between intentions to use DMH programs and actual uptake.

METHODS

Australian adults aged ≥18 years were recruited from market research panels to participate in the study. The sample was representative of the Australian adult population based on age, gender, and location. Participants completed a cross-sectional web-based survey assessing demographic characteristics, mental health symptom measures, attitudes and use of DMH programs in practice and in research studies, and the factors influencing their use in both settings.

RESULTS

Across both research and practice, trust in the organization delivering the service or trial was the top-ranked factor influencing participation, followed by anonymity or privacy and adequate information. There was little variation in rankings across demographic groups, including intentions to use DMH programs or mental health status. Intentions to use DMH programs were a strong predictor of both current (odds ratio 2.50, 99% CI 1.41-4.43; P<.001) and past (odds ratio 2.98, 99% CI 1.71-5.19; P<.001) use behaviors.

CONCLUSIONS

Efforts to increase the uptake of DMH programs or participation in research trials should focus on clearly communicating the following to users: the legitimacy of the organization delivering the program, security and use of participant data, and effectiveness of DMH programs.

Investigating information needs and preferences regarding digital mental health services among medical and psychology students in Germany: A qualitative study

Background

Since 2020, physicians and psychotherapists in Germany can prescribe digital mental health services (dMHSs). However, even future healthcare professionals (HCPs), such as medical and psychology students, remain reluctant to use dMHSs, although they are a risk group for mental health issues themselves. Reasons include scepticism and lacking awareness of dMHSs, which can be addressed by acceptance-facilitating interventions (AFIs) such as information strategies. To date, though, little is known about their information needs.

Methods

Semi-structured interviews with n = 21 students were conducted between August and September 2021. Students of legal age studying psychology or medicine at a German university could participate. Interview recordings were transcribed verbatim and content-analyzed according to Mayring, using deductive and inductive coding.

Results

Most students reported having little experience with dMHSs. Digital health has barely been raised in their study, even though it was perceived as crucial for personal needs as well as in preparation for their work as HCPs. Students favoured receiving information on and recommendations for dMHSs from their university via, e.g. social media or seminars. Among others, information about data safety, scientific evidence base and application scope were preferred. Additionally, information on costs as well as user reviews seemed to be essential components of information strategies because students were concerned that high costs or low usability would hinder uptake.

Conclusions

The results give first insights on how future HCPs would like to be informed on dMHSs. Future research should focus on systematic variations of AFIs' components mimicking real-world decision scenarios to increase the adoption of dMHSs.

Digitale Phänotypisierung in der Psychologie – ein Quantensprung in der psychologischen Forschung?

Zusammenfassung. Digitale Phänotypisierung stellt einen neuen, leistungsstarken Ansatz zur Realisierung psychodiagnostischer Aufgaben in vielen Bereichen der Psychologie und Medizin dar. Die Grundidee besteht aus der Nutzung digitaler Spuren aus dem Alltag, um deren Vorhersagekraft für verschiedenste Anwendungsmöglichkeiten zu überprüfen und zu nutzen. Voraussetzungen für eine erfolgreiche Umsetzung sind elaborierte Smart Sensing Ansätze sowie Big Data-basierte Extraktions- (Data Mining) und Machine Learning-basierte Analyseverfahren. Erste empirische Studien verdeutlichen das hohe Potential, aber auch die forschungsmethodischen sowie ethischen und rechtlichen Herausforderungen, um über korrelative Zufallsbefunde hinaus belastbare Befunde zu gewinnen. Hierbei müssen rechtliche und ethische Richtlinien sicherstellen, dass die Erkenntnisse in einer für Einzelne und die Gesellschaft als Ganzes wünschenswerten Weise genutzt werden. Für die Psychologie als Lehr- und Forschungsdomäne bieten sich durch Digitale Phänotypisierung vielfältige Möglichkeiten, die zum einen eine gelebte Zusammenarbeit verschiedener Fachbereiche und zum anderen auch curriculare Erweiterungen erfordern. Die vorliegende narrative Übersicht bietet eine theoretische, nicht-technische Einführung in das Forschungsfeld der Digitalen Phänotypisierung, mit ersten empirischen Befunden sowie einer Diskussion der Möglichkeiten und Grenzen sowie notwendigen Handlungsfeldern.

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

BACKGROUND

The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.

OBJECTIVE

This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.

METHODS

Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.

RESULTS

A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.

CONCLUSIONS

Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.

Analyzing the determinants to accept a virtual assistant and use cases among cancer patients: a mixed methods study

Background

Technological progress in artificial intelligence has led to the increasing popularity of virtual assistants, i.e., embodied or disembodied conversational agents that allow chatting with a technical system in a natural language. However, only little comprehensive research is conducted about patients' perceptions and possible applications of virtual assistant in healthcare with cancer patients. This research aims to investigate the key acceptance factors and value-adding use cases of a virtual assistant for patients diagnosed with cancer.

Methods

Qualitative interviews with eight former patients and four doctors of a Dutch radiotherapy institute were conducted to determine what acceptance factors they find most important for a virtual assistant and gain insights into value-adding applications. The unified theory of acceptance and use of technology (UTAUT) was used to structure perceptions and was inductively modified as a result of the interviews. The subsequent research model was triangulated via an online survey with 127 respondents diagnosed with cancer. A structural equation model was used to determine the relevance of acceptance factors. Through a multigroup analysis, differences between sample subgroups were compared.

Results

The interviews found support for all factors of the UTAUT: performance expectancy, effort expectancy, social influence and facilitating conditions. Additionally, self-efficacy, trust, and resistance to change, were added as an extension of the UTAUT. Former patients found a virtual assistant helpful in receiving information about logistic questions, treatment procedures, side effects, or scheduling appointments. The quantitative study found that the constructs performance expectancy (ß = 0.399), effort expectancy (ß = 0.258), social influence (ß = 0.114), and trust (ß = 0.210) significantly influenced behavioral intention to use a virtual assistant, explaining 80% of its variance. Self-efficacy (ß = 0.792) acts as antecedent of effort expectancy. Facilitating conditions and resistance to change were not found to have a significant relationship with user intention.

Conclusions

Performance and effort expectancy are the leading determinants of virtual assistant acceptance. The latter is dependent on a patient’s self-efficacy. Therefore, including patients during the development and introduction of a VA in cancer treatment is important. The high relevance of trust indicates the need for a reliable, secure service that should be promoted as such. Social influence suggests using doctors in endorsing the VA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08189-7.

Effects of a video intervention on physicians' acceptance of pain apps: a randomised controlled trial

OBJECTIVES

The aim of our study was to determine and enhance physicians' acceptance, performance expectancy and credibility of health apps for chronic pain patients. We further investigated predictors of acceptance.

DESIGN

Randomised experimental trial with a parallel-group repeated measures design.

SETTING AND PARTICIPANTS

248 physicians working in various, mainly outpatient settings in Germany.

INTERVENTION AND OUTCOME

Physicians were randomly assigned to either an experimental group (short video about health apps) or a control group (short video about chronic pain). Primary outcome measure was acceptance. Performance expectancy and credibility of health apps were secondary outcomes. In addition, we assessed 101 medical students to evaluate the effectiveness of the video intervention in young professionals.

RESULTS

In general, physicians' acceptance of health apps for chronic pain patients was moderate (M=9.51, SD=3.53, scale ranges from 3 to 15). All primary and secondary outcomes were enhanced by the video intervention: A repeated-measures analysis of variance yielded a significant interaction effect for acceptance (F(1, 246)=15.28, p=0.01), performance expectancy (F(1, 246)=6.10, p=0.01) and credibility (F(1, 246)=25.61, p<0.001). The same pattern of results was evident among medical students. Linear regression analysis revealed credibility (β=0.34, p<0.001) and performance expectancy (β=0.30, p<0.001) as the two strongest factors influencing acceptance, followed by scepticism (β=-0.18, p<0.001) and intuitive appeal (β=0.11, p=0.03).

CONCLUSIONS AND RECOMMENDATIONS

Physicians' acceptance of health apps was moderate, and was strengthened by a 3 min video. Besides performance expectancy, credibility seems to be a promising factor associated with acceptance. Future research should focus on ways to implement acceptability-increasing interventions into routine care.

Digital interventions to address mental health needs in colleges: Perspectives of student stakeholders

Objective

The need for clinical services in U.S. colleges exceeds the supply. Digital Mental health Interventions (DMHIs) are a potential solution, but successful implementation depends on stakeholder acceptance. This study investigated the relevance of DMHIs from students' perspectives.

Methods

In 2020-2021, an online cross-sectional survey using mixed methods was conducted with 479 students at 23 colleges and universities. Respondents reported views and use of standard mental health services and DMHIs and rated the priority of various DMHIs to be offered through campus services. Qualitative data included open-ended responses.

Findings

Among respondents, 91% reported having experienced mental health problems, of which 91% reported barriers to receiving mental health services. Students highlighted therapy and counseling as desired and saw flexible access to services as important. With respect to DMHIs, respondents had the most experience with physical health apps (46%), mental health questionnaires (41%), and mental well-being apps (39%). Most were unaware of or had not used apps or self-help programs for mental health problems. Students were most likely to report the following DMHIs as high priorities: a crisis text line (76%), telehealth (66%), websites for connecting to services (62%), and text/messaging with counselors (62%). They considered a self-help program with coach support to be convenient but some also perceived such services to be possibly less effective than in-person therapy.

Conclusions

Students welcome DMHIs on campus and indicate preference for mental health services that include human support. The findings, with particular focus on characteristics of the DMHIs prioritized, and students' awareness and perceptions of scalable DMHIs emphasized by policymakers, should inform schools looking to implement DMHIs.

Culturally adapting internet- and mobile-based health promotion interventions might not be worth the effort: a systematic review and meta-analysis

Health promotion interventions offer great potential in advocating a healthy lifestyle and the prevention of diseases. Some barriers to communicating health promotion to people of certain cultural groups might be overcome via the internet- and mobile-based interventions (IMI). This systematic review and meta-analysis aims to explore the effectiveness of culturally adapted IMI for health promotion interventions among culturally diverse populations. We systematically searched on Cochrane Central Register of Controlled Trials (CENTRAL), EbscoHost/MEDLINE, Ovid/Embase, EbscoHost/PsychINFO, and Web of Science databases in October 2020. Out of 9438 records, 13 randomized controlled trials (RCT) investigating culturally adapted health promotion IMI addressing healthy eating, physical activity, alcohol consumption, sexual health behavior, and smoking cessation included. From the included studies 10,747 participants were eligible. Culturally adapted IMI proved to be non-superior over active control conditions in short- (g = 0.10, [95% CI −0.19 to 0.40]) and long-term (g = 0.20, [95% CI −0.11 to 0.51]) in promoting health behavior. However, culturally adapted IMI for physical activity (k = 3, N = 296) compared to active controls yielded a beneficial effect in long-term (g = 0.48, [95%CI 0.25 to 0.71]). Adapting health promotion IMI to the cultural context of different cultural populations seems not yet to be recommendable given the substantial adaption efforts necessary and the mostly non-significant findings. However, these findings need to be seen as preliminary given the limited number of included trials with varying methodological rigor and the partly substantial between-trial heterogeneity pointing in the direction of potentially useful culturally adapted IMI which now need to be disentangled from the less promising approaches.

PROSPERO registration number: 42020152939

Adding Affordances and Communication Efficacy to the Technology Acceptance Model to Study the Messaging Features of Online Patient Portals among Young Adults

The use of messaging features within online patient portals could be beneficial to patients, but many patients do not utilize these features. Furthermore, it remains uncertain the reasons why patients may (or may not) use messaging features to communicate with a care provider. This study proposes and tests an extended Technology Acceptance Model (TAM), which incorporated perceived affordances (editability and persistence) and communication efficacy. An online survey was conducted with a sample of 525 young adults. Results showed that the editability affordance was conducted with perceived usefulness, while communication efficacy was associated with perceived ease of use of messaging. Editability and communication efficacy also were positively associated intention to use online patient portal messaging features, whereas persistence was negatively associated. Results suggest practitioners should emphasize editability and communication efficacy to increase patient intentions to use messaging features to communicate with a care provider.

Effectiveness and Moderators of an Internet-Based Mobile-Supported Stress Management Intervention as a Universal Prevention Approach: Randomized Controlled Trial

Background

Emerging evidence indicates the effectiveness of internet-based mobile-supported stress management interventions (iSMIs) in highly stressed employees. It is yet unclear, however, whether iSMIs are also effective without a preselection process in a universal prevention approach, which more closely resembles routine occupational health care. Moreover, evidence for whom iSMIs might be suitable and for whom not is scarce.

Objective

The aim of this study was to evaluate the iSMI GET.ON Stress in a universal prevention approach without baseline inclusion criteria and to examine the moderators of the intervention effects.

Methods

A total of 396 employees were randomly assigned to the intervention group or the 6-month waiting list control group. The iSMI consisted of 7 sessions and 1 booster session and offered no therapeutic guidance. Self-report data were assessed at baseline, 7 weeks, and at 6 months following randomization. The primary outcome was perceived stress. Several a priori defined moderators were explored as potential effect modifiers.

Results

Participants in the intervention group reported significantly lower perceived stress at posttreatment (d=0.71, 95% CI 0.51-0.91) and at 6-month follow-up (d=0.61, 95% CI 0.41-0.81) compared to those in the waiting list control group. Significant differences with medium-to-large effect sizes were found for all mental health and most work-related outcomes. Resilience (at 7 weeks, P=.04; at 6 months, P=.01), agreeableness (at 7 weeks, P=.01), psychological strain (at 6 months, P=.04), and self-regulation (at 6 months, P=.04) moderated the intervention effects.

Conclusions

This study indicates that iSMIs can be effective in a broad range of employees with no need for preselection to achieve substantial effects. The subgroups that might not profit had extreme values on the respective measures and represented only a very small proportion of the investigated sample, thereby indicating the broad applicability of GET.ON Stress.

Trial Registration

German Clinical Trials Register DRKS00005699; https://www.drks.de/DRKS00005699

Acceptance towards digital health interventions - Model validation and further development of the Unified Theory of Acceptance and Use of Technology

Internet- and mobile-based interventions (IMI) offer an effective way to complement health care. Acceptance of IMI, a key facilitator of their implementation in routine care, is often low. Based on the Unified Theory of Acceptance and Use of Technology (UTAUT), this study validates and adapts the UTAUT to digital health care. Following a systematic literature search, 10 UTAUT-grounded original studies (N = 1588) assessing patients' and health professionals' acceptance of IMI for different somatic and mental health conditions were included. All included studies assessed Performance Expectancy, Effort Expectancy, Social Influence, Facilitating Conditions and acceptance as well as age, gender, internet experience, and internet anxiety via self-report questionnaires. For the model validation primary data was obtained and analyzed using structural equation modeling. The best fitting model (RMSEA = 0.035, SRMR = 0.029) replicated the basic structure of UTAUT's core predictors of acceptance. Performance Expectancy was the strongest predictor (γ = 0.68, p < .001). Internet anxiety was identified as an additional determinant of acceptance (γ = -0.07, p < .05) and moderated the effects of Social Influence (γ = 0.07, p < .05) and Effort Expectancy (γ = -0.05, p < .05). Age, gender and experience had no moderating effects. Acceptance is a fundamental prerequisite for harnessing the full potential of IMI. The adapted UTAUT provides a powerful model identifying important factors - primarily Performance Expectancy - to increase the acceptance across patient populations and health professionals.

The Acceptance and Use of the e-Health Instrument 'The Personal Health Check' in Four Dutch Municipalities: Lessons Learned

This pilot study assessed the acceptance and use of the e-Health instrument “the Personal Health Check” (PHC) among clients and professionals in primary care settings. By filling in the online PHC instrument, participants were provided insights into their health and lifestyle. When results revealed an increased health risk, participants were advised to undertake additional lab tests measuring blood pressure and haemaglobin levels. Based on the online questionnaire and optional lab tests, participants then received a report that included individually-tailored feedback from the e-Health application about personal health risks and suggestions for health interventions. The PHC was implemented in 2016 in four Dutch municipalities that determined which neighbourhood(s) the PHC targeted and how participants were invited. The Unified Theory of Acceptance and Use of Technology was used as a theoretical framework to address our research questions. Methods used to assess acceptance were: PHC instrument data, data from additional questionnaires completed by PHC participants, focus groups with PHC participants and professionals in primary care, and telephone interviews with non-responders to the invitation to participate in the online PHC. Of the 21,735 invited, 12% participated. Our results showed that participants and professionals in this pilot were predominantly positive about the PHC. Participants reported that they made an effort to apply the PHC lifestyle advice they received. Almost all had the knowledge and resources needed to use the PHC online instrument. Invitations from general practitioners almost doubled participation relative to invitations from the sponsoring municipalities. The overall low response rate, however, suggests that the PHC is unsuitable as a foundation on which to develop local public health policy.

Efficacy of Motivational Interviewing to Improve Utilization of Mental Health Services Among Youths With Chronic Medical Conditions: A Cluster Randomized Clinical Trial

IMPORTANCE

Despite the high prevalence of anxiety and depression in youths with chronic medical conditions (CMCs), physicians encounter substantial barriers in motivating these patients to access mental health care services.

OBJECTIVE

To determine the efficacy of motivational interviewing (MI) training for pediatricians in increasing youths' use of mental health care.

DESIGN, SETTING, AND PARTICIPANTS

The COACH-MI (Chronic Conditions in Adolescents: Implementation and Evaluation of Patient-Centered Collaborative Healthcare-Motivational Interviewing) study was a single-center cluster randomized clinical trial at the University Children's Hospital specialized outpatient clinics in Düsseldorf, Germany. Treating pediatricians were cluster randomized to a 2-day MI workshop or treatment as usual (TAU). Patient recruitment and MI conversations occurred between April 2018 and May 2020 with 6-month follow-up and 1-year rescreening. Participants were youths aged 12 to 20 years with CMCs and comorbid symptoms of anxiety and depression; they were advised by their MI-trained or untrained physicians to access psychological counseling services. Statistical analysis was performed from October 2020 to April 2021.

INTERVENTIONS

MI physicians were trained through a 2-day, certified MI training course; they recommended use of mental health care services during routine clinical appointments.

MAIN OUTCOMES AND MEASURES

The primary outcome of uptake of mental health care services within the 6-month follow-up was analyzed using a logistic mixed model, adjusted for the data's cluster structure. Uptake of mental health services was defined as making at least 1 appointment by the 6-month follow-up.

RESULTS

Among 164 youths with CMCs and conspicuous anxiety or depression screening, 97 (59%) were female, 94 (57%) had MI, and 70 (43%) had TAU; the mean (SD) age was 15.2 (1.9) years. Compared with patients receiving TAU, the difference in mental health care use at 6 months among patients whose physicians had undergone MI training was not statistically significant (odds ratio [OR], 1.96; 95% CI, 0.98-3.92; P = .06). The effect was moderated by the subjective burden of disease (F2,158 = 3.42; P = .04). Counseling with an MI-trained physician also led to lower anxiety symptom scores at 1-year rescreening (F1,130 = 4.11; P = .045). MI training was associated with longer conversations between patients and physicians (30.3 [16.7] minutes vs 16.8 [12.5] minutes; P < .001), and conversation length significantly influenced uptake rates across conditions (OR, 1.03; 95% CI, 1.01-1.06; P = .005).

CONCLUSIONS AND RELEVANCE

In this study, use of MI in specialized pediatric consultations did not increase the use of mental health care services among youths with CMCs but did lead to longer patient-physician conversations and lower anxiety scores at 1 year. Additional research is required to determine whether varying scope and duration of MI training for physicians could encourage youths with CMCs to seek counseling and thus improve integrated care models.

TRIAL REGISTRATION

German Trials Registry: DRKS00014043.

Acceptance of a Smartphone-Based Visual Field Screening Platform for Glaucoma: Pre-Post Study

Background

Glaucoma, the silent thief of sight, is a major cause of blindness worldwide. It is a burden for people in low-income countries, specifically countries where glaucoma-induced blindness accounts for 15% of the total incidence of blindness. More than half the people living with glaucoma in low-income countries are unaware of the disease until it progresses to an advanced stage, resulting in permanent visual impairment.

Objective

This study aims to evaluate the acceptability of the Glaucoma Easy Screener (GES), a low-cost and portable visual field screening platform comprising a smartphone, a stereoscopic virtual reality headset, and a gaming joystick.

Methods

A mixed methods study that included 24 eye care professionals from 4 hospitals in Southwest Ethiopia was conducted to evaluate the acceptability of GES. A pre-post design was used to collect perspectives before and after using the GES by using questionnaires and semistructured interviews. A Wilcoxon signed-rank test was used to determine the significance of any change in the scores of the questionnaire items (two-tailed, 95% CI; α=.05). The questionnaire and interview questions were guided by the Unified Theory of Acceptance and Use of Technology.

Results

Positive results were obtained both before and after use, suggesting the acceptance of mobile health solutions for conducting glaucoma screening by using a low-cost headset with a smartphone and a game controller. There was a significant increase (two-tailed, 95% CI; α=.05) in the average scores of 86% (19/22) of postuse questionnaire items compared with those of preuse questionnaire items. Ophthalmic professionals perceived GES as easy to use and as a tool that enabled the conduct of glaucoma screening tests, especially during outreach to rural areas. However, positive evaluations are contingent on the accuracy of the tool. Moreover, ophthalmologists voiced the need to limit the tool to screening only (ie, not for making diagnoses).

Conclusions

This study supports the feasibility of using a mobile device in combination with a low-cost virtual reality headset and classic controller for glaucoma screening in rural areas. GES has the potential to reduce the burden of irreversible blindness caused by glaucoma. However, further assessment of its sensitivity and specificity is required.

Perceived Benefits, Barriers, and Facilitators of a Digital Patient-Reported Outcomes Tool for Routine Diabetes Care: Protocol for a National, Multicenter, Mixed Methods Implementation Study

BACKGROUND

There is growing evidence that digital patient-reported outcome (PRO) questionnaires and PRO-based decision support tools may help improve the active engagement of people with diabetes in self-care, thereby improving the quality of care. However, many barriers still exist for the real-world effectiveness and implementation of such PRO tools in routine care. Furthermore, limited research has evaluated the acceptability, feasibility, and benefits of such tools across different health care settings.

OBJECTIVE

This study aims to evaluate the acceptability, feasibility, and perceived benefits of the Danish digital PRO diabetes tool in different health care settings in Denmark and to determine the factors affecting its implementation. Furthermore, the study evaluates the psychometric characteristics of the Danish PRO Diabetes Questionnaire and the validity of the scoring algorithms for dialogue support. The objective of this study is to guide the ongoing optimization of the PRO diabetes tool, its implementation, and the design of future randomized controlled effectiveness studies.

METHODS

We designed a multicenter, mixed methods, single-arm acceptability-feasibility implementation study protocol to contribute to the real-world pilot test of a new digital PRO diabetes tool in routine diabetes care. The use of the tool involves two main steps. First, the people with diabetes will complete a digital PRO Diabetes Questionnaire in the days before a routine diabetes visit. Second, the health care professional (HCP) will use a digital PRO tool to review the PRO results together with the people with diabetes during the visit. The PRO diabetes tool is designed to encourage and support people to take an active role for the people with diabetes in their own care and to expedite the delivery of person-centered, collaborative, and coordinated care.

RESULTS

A multicenter pilot study protocol and psychometrically designed digital data collection tools for evaluation were developed and deployed as part of a national evaluation of a new digital PRO diabetes intervention. A total of 598 people with diabetes and 34 HCPs completed the study protocol by April 1, 2021.

CONCLUSIONS

A large-scale, mixed methods, multicenter study for evaluating the use of the nationally developed PRO Diabetes Questionnaire in routine care across all health care sectors in Denmark by using the RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model as a framework has been designed and is ongoing. This study is expected to provide new important and detailed information about the real-world acceptability, perceived relevance, and benefits of the PRO diabetes tool among a large heterogeneous population of people with diabetes in Denmark and HCPs in different care settings. The results will be used to further improve the PRO tool, design implementation facilitation support strategies, and design future controlled effectiveness studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/28391.

Einfluss akzeptanzfördernder Interventionen auf die Nutzung einer Online-Selbsthilfe

Hintergrund

Trotz wachsender empirischer Evidenz zur Wirksamkeit in der Behandlung psychischer Erkrankungen sind internetbasierte Interventionen (IBI) mit geringen Akzeptanz- und hohen Abbruchraten konfrontiert. Akzeptanzfördernde Interventionen (AFI) stellen eine vielversprechende Maßnahme dar, um die Akzeptanz zukünftiger Nutzer*innen zu verbessern. Die Wirksamkeit von AFI auf die Adhärenz, die maßgeblichen Einfluss auf die Wirksamkeit von IBI hat, wurde bisher in nur wenigen empirischen Untersuchungen überprüft.

Ziel der Arbeit (Fragestellung)

Ziel der vorliegenden Untersuchung ist die Überprüfung des Einflusses einer AFI auf die Akzeptanz, die initiale Nutzung und die Adhärenz des transdiagnostischen psychodynamischen Online-Selbsthilfeprogramms „Die Kraft der eigenen Emotionen nutzen (KEN-Online)“.

Material und Methoden

Es wurden Routinedaten von 231 Patient*innen ausgewertet, die während ihrer (teil‑)stationären Behandlung im Rahmen einer ins Routinesetting integrierten AFI das Angebot bekommen haben, KEN-Online behandlungsbegleitend zu nutzen. Im Kohortendesign werden Patient*innen, die an einer AFI teilgenommen haben, mit einer historischen Kontrollgruppe von Patient*innen verglichen, die dieses Angebot nicht erhielten. Zudem wird der Zusammenhang zwischen der Einstellung und der Akzeptanz des Programms in der Untersuchungsgruppe (mit AFI) überprüft.

Ergebnisse

Sowohl die Akzeptanz als auch die initiale Nutzung von KEN-Online waren um knapp 20 % höher (jeweils p < 0,01) unter den Teilnehmenden der AFI-Gruppe, verglichen mit der Kontrollgruppe. In Bezug auf die Adhärenz von KEN-Online zeigte sich ein kleiner Unterschied dahingehend, dass Teilnehmende der Kontrollgruppe signifikant (p < 0,05) mehr Einheiten abgeschlossen haben als Teilnehmende der Interventionsgruppe. Allerdings war der Anteil der „completer“ von KEN-Online mit 13,4 % insgesamt sehr gering. Ein Einfluss der Einstellung auf die Akzeptanz wurde nicht nachgewiesen.

Diskussion

Die vorliegende Untersuchung zeigt, dass AFI dazu beitragen können, die Akzeptanz und initiale Nutzung von IBI zu fördern, indem Patient*innen der (teil‑)stationären Routineversorgung standardisiert und strukturiert über die Intervention informiert werden. Hinsichtlich der Förderung der Adhärenz sind jedoch zusätzliche Maßnahmen erforderlich.

Determining Acceptance of e-Mental Health Interventions in Digital Psychodiabetology Using a Quantitative Web-Based Survey: Cross-sectional Study

Background

Diabetes is a very common chronic disease that exerts massive physiological and psychological burdens on patients. The digitalization of mental health care has generated effective e-mental health approaches, which offer an indubitable practical value for patient treatment. However, before implementing and optimizing e-mental health tools, their acceptance and underlying barriers and resources should be first determined for developing and establishing effective patient-oriented interventions.

Objective

This study aims to assess the acceptance of e-mental health interventions among patients with diabetes and explore its underlying barriers and resources.

Methods

A cross-sectional study was conducted in Germany from April 9, 2020, to June 15, 2020, through a web-based survey for which patients were recruited via web-based diabetes channels. The eligibility requirements were adult age (18 years or older), a good command of the German language, internet access, and a diagnosis of diabetes. Acceptance was measured using a modified questionnaire, which was based on the well-established Unified Theory of Acceptance and Use of Technology (UTAUT) and assessed health-related internet use, acceptance of e-mental health interventions, and its barriers and resources. Mental health was measured using validated and established instruments, namely the Generalized Anxiety Disorder Scale-7, Patient Health Questionnaire-2, and Distress Thermometer. In addition, sociodemographic and medical data regarding diabetes were collected.

Results

Of the 340 participants who started the survey, 261 (76.8%) completed it and the final sample comprised 258 participants with complete data sets. The acceptance of e-mental health interventions in patients with diabetes was overall moderate (mean 3.02, SD 1.14). Gender and having a mental disorder had a significant influence on acceptance (P<.001). In an extended UTAUT regression model (UTAUT predictors plus sociodemographics and mental health variables), distress (β=.11; P=.03) as well as the UTAUT predictors performance expectancy (β=.50; P<.001), effort expectancy (β=.15; P=.001), and social influence (β=.28; P<.001) significantly predicted acceptance. The comparison between an extended UTAUT regression model (13 predictors) and the UTAUT-only regression model (performance expectancy, effort expectancy, social influence) revealed no significant difference in explained variance (F_10,244=1.567; P=.12).

Conclusions

This study supports the viability of the UTAUT model and its predictors in assessing the acceptance of e-mental health interventions among patients with diabetes. Three UTAUT predictors reached a notable amount of explained variance of 75% in the acceptance, indicating that it is a very useful and efficient method for measuring e-mental health intervention acceptance in patients with diabetes. Owing to the close link between acceptance and use, acceptance-facilitating interventions focusing on these three UTAUT predictors should be fostered to bring forward the highly needed establishment of effective e-mental health interventions in psychodiabetology.

A Brief Intervention to Increase Uptake and Adherence of an Internet-Based Program for Depression and Anxiety (Enhancing Engagement With Psychosocial Interventions): Randomized Controlled Trial

BACKGROUND

Psychosocial, self-guided, internet-based programs are effective in treating depression and anxiety. However, the community uptake of these programs is poor. Recent approaches to increasing engagement (defined as both uptake and adherence) in internet-based programs include brief engagement facilitation interventions (EFIs). However, these programs require evaluation to assess their efficacy.

OBJECTIVE

The aims of this hybrid implementation effectiveness trial are to examine the effects of a brief internet-based EFI presented before an internet-based cognitive behavioral therapy self-help program (myCompass 2) in improving engagement (uptake and adherence) with that program (primary aim), assess the relative efficacy of the myCompass 2 program, and determine whether greater engagement was associated with improved efficacy (greater reduction in depression or anxiety symptoms) relative to the control (secondary aim).

METHODS

A 3-arm randomized controlled trial (N=849; recruited via social media) assessed the independent efficacy of the EFI and myCompass 2. The myCompass 2 program was delivered with or without the EFI; both conditions were compared with an attention control condition. The EFI comprised brief (5 minutes), tailored audio-visual content on a series of click-through linear webpages.

RESULTS

Uptake was high in all groups; 82.8% (703/849) of participants clicked through the intervention following the pretest survey. However, the difference in uptake between the EFI + myCompass 2 condition (234/280, 83.6%) and the myCompass 2 alone condition (222/285, 77.9%) was not significant (n=565; χ²₁=29.2; P=.09). In addition, there was no significant difference in the proportion of participants who started any number of modules (1-14 modules) versus those who started none between the EFI + myCompass 2 (214/565, 37.9%) and the myCompass 2 alone (210/565, 37.2%) conditions (n=565; χ²₁<0.1; P=.87). Finally, there was no significant difference between the EFI + myCompass 2 and the myCompass 2 alone conditions in the number of modules started (U=39366.50; z=-0.32; P=.75) or completed (U=39494.0; z=-0.29; P=.77). The myCompass 2 program was not found to be efficacious over time for symptoms of depression (F_4,349.97=1.16; P=.33) or anxiety (F_4,445.99=0.12; P=.98). However, planned contrasts suggested that myCompass 2 may have been effective for participants with elevated generalized anxiety disorder symptoms (F_4,332.80=3.50; P=.01).

CONCLUSIONS

This brief internet-based EFI did not increase the uptake of or adherence to an existing internet-based program for depression and anxiety. Individuals' motivation to initiate and complete internet-based self-guided interventions is complex and remains a significant challenge for self-guided interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618001565235; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375839.

ACTonDiabetes-a guided psychological internet intervention based on Acceptance and Commitment Therapy (ACT) for adults living with type 1 or 2 diabetes: results of a randomised controlled feasibility trial

OBJECTIVES

This two-group randomised controlled trial evaluates the feasibility of an Acceptance and Commitment Therapy (ACT)-based internet intervention for diabetes distress in people with diabetes type 1 or type 2. Participants were assigned to a guided self-help intervention (EG) or waitlist control group (CG).

SETTING

Recruitment took place following an open recruitment strategy including different diabetes centres, self-help groups and social media platforms.

PARTICIPANTS

Eligibility criteria comprised being 18 years of age or older, self-reported diagnosis of type 1 or type 2 diabetes, internet access, sufficient German language skills and written informed consent.

INTERVENTION

ACTonDiabetes is an internet-based and mobile-based intervention and comprises an introduction and seven modules (one module per week, processing time about 45-60 min). Intervention contents are based on ACT.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were assessed before and 8 weeks after randomisation. Primary outcome was feasibility (trial recruitment, acceptability). Potential group differences in diabetes distress and other outcomes at follow-up were analysed using linear regression models with baseline values as predictors. All analyses were based on an intention-to-treat principle, potential negative effects were analysed on per-protocol basis.

RESULTS

From October 2017 to April 2018, N=42 people with diabetes consented and were randomised (EG n=21, CG n=21). Forty-three per cent of the EG completed all treatment modules within 8 weeks. Across modules, formative user feedback revealed that contents could be optimised regarding comprehensibility (34%), individualisation (20%) and text amount (21%). Overall, 57% of participants dropped out prior to full treatment completion. There were reductions of diabetes distress in the EG (d=0.65, p=0.042).

CONCLUSIONS

Modifications of the intervention content according to the user feedback will be performed to further improve acceptability. Mechanisms to foster intervention adherence should be considered for lowering the attrition rate. ACTonDiabetes is feasible for the implementation in a confirmatory trial.

TRIAL REGISTRATION NUMBER

WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (DRKS) (DRKS00013193).

Predicting Acceptance of e-Mental Health Interventions in Patients with Obesity by using an extended Unified Theory of Acceptance Model: Cross-sectional study (Preprint)

Background

The rapid increase in the number of people who are overweight and obese is a worldwide health problem. Obesity is often associated with physiological and mental health burdens. Owing to several barriers to face-to-face psychotherapy, a promising approach is to exploit recent developments and implement innovative e–mental health interventions that offer various benefits to patients with obesity and to the health care system.

Objective

This study aims to assess the acceptance of e–mental health interventions in patients with obesity and explore its influencing predictors. In addition, the well-established Unified Theory of Acceptance and Use of Technology (UTAUT) model is compared with an extended UTAUT model in terms of variance explanation of acceptance.

Methods

A cross-sectional web-based survey study was conducted from July 2020 to January 2021 in Germany. Eligibility requirements were adult age (≥18 years), internet access, good command of the German language, and BMI >30 kg/m² (obesity). A total of 448 patients with obesity (grades I, II, and III) were recruited via specialized social media platforms. The impact of various sociodemographic, medical, and mental health characteristics was assessed. eHealth-related data and acceptance of e–mental health interventions were examined using a modified questionnaire based on the UTAUT.

Results

Overall, the acceptance of e–mental health interventions in patients with obesity was moderate (mean 3.18, SD 1.11). Significant differences in the acceptance of e–mental health interventions among patients with obesity exist, depending on the grade of obesity, age, sex, occupational status, and mental health status. In an extended UTAUT regression model, acceptance was significantly predicted by the depression score (Patient Health Questionnaire-8; β=.07; P=.03), stress owing to constant availability via mobile phone or email (β=.06; P=.02), and confidence in using digital media (β=−0.058; P=.04) and by the UTAUT core predictors performance expectancy (β=.45; P<.001), effort expectancy (β=.22; P<.001), and social influence (β=.27; P<.001). The comparison between an extended UTAUT model (16 predictors) and the restrictive UTAUT model (performance expectancy, effort expectancy, and social influence) revealed a significant difference in explained variance (F_13,431=2.366; P=.005).

Conclusions

The UTAUT model has proven to be a valuable instrument to predict the acceptance of e–mental health interventions in patients with obesity. The extended UTAUT model explained a significantly high percentage of variance in acceptance (in total 73.6%). On the basis of the strong association between acceptance and future use, new interventions should focus on these UTAUT predictors to promote the establishment of effective e–mental health interventions for patients with obesity who experience mental health burdens.

Clinical and Cost-Effectiveness of PSYCHOnlineTHERAPY: Study Protocol of a Multicenter Blended Outpatient Psychotherapy Cluster Randomized Controlled Trial for Patients With Depressive and Anxiety Disorders

Introduction: Internet- and mobile-based interventions (IMIs) and their integration into routine psychotherapy (i.e., blended therapy) can offer a means of complementing psychotherapy in a flexible and resource optimized way. Objective: The present study will evaluate the non-inferiority, cost-effectiveness, and safety of two versions of integrated blended psychotherapy for depression and anxiety compared to standard cognitive behavioral therapy (CBT). Methods: A three-armed multicenter cluster-randomized controlled non-inferiority trial will be conducted comparing two implementations of blended psychotherapy (PSYCHOnlineTHERAPYfix/flex) compared to CBT. Seventy-five outpatient psychotherapists with a CBT-license will be randomized in a 1:1:1 ratio. Each of them is asked to include 12 patients on average with depressive or anxiety disorders resulting in a total sample size of N = 900. All patients receive up to a maximum of 16 psychotherapy sessions, either as routine CBT or alternating with Online self-help sessions (fix: 8/8; flex: 0-16). Assessments will be conducted at patient study inclusion (pre-treatment) and 6, 12, 18, and 24 weeks and 12 months post-inclusion. The primary outcome is depression and anxiety severity at 18 weeks post-inclusion (post-treatment) using the Patient Health Questionnaire Anxiety and Depression Scale. Secondary outcomes are depression and anxiety remission, treatment response, health-related quality of life, patient satisfaction, working alliance, psychotherapy adherence, and patient safety. Additionally, several potential moderators and mediators including patient characteristics and attitudes toward the interventions will be examined, complemented by ecological day-to-day digital behavior variables via passive smartphone sensing as part of an integrated smart-sensing sub-study. Data-analysis will be performed on an intention-to-treat basis with additional per-protocol analyses. In addition, cost-effectiveness and cost-utility analyses will be conducted from a societal and a public health care perspective. Additionally, qualitative interviews on acceptance, feasibility, and optimization potential will be conducted and analyzed. Discussion: PSYCHOnlineTHERAPY will provide evidence on blended psychotherapy in one of the largest ever conducted psychotherapy trials. If shown to be non-inferior and cost-effective, PSYCHOnlineTHERAPY has the potential to innovate psychotherapy in the near future by extending the ways of conducting psychotherapy. The rigorous health care services approach will facilitate a timely implementation of blended psychotherapy into standard care. Trial Registration: The trial is registered in the German Clinical Trials Register (DRKS00023973; date of registration: December 28th 2020).

Predictors of acceptability and engagement in a self-guided online program for depression and anxiety

BACKGROUND

Low engagement with self-guided online programs limits the potential of these programs to provide effective and low-cost treatment of mild to moderate depression and anxiety at scale. Identifying factors that increase uptake and adherence in self-guided online programs may facilitate the development of targeted implementation strategies to increase engagement with these programs in the community. Using data from a randomized controlled trial of a self-guided online program for depression and anxiety, the aim of this study was to identify predictors of the acceptability of internet-based psychological programs, and engagement (uptake and adherence) with the online program tested in the trial.

METHODS

A total of 556 community members with elevated symptoms of depression or anxiety were recruited via social media into the two active conditions of a three-arm randomized controlled trial. This trial tested the effectiveness of a 7-week self-guided online program for depression and anxiety called myCompass 2, delivered with or without an Engagement-Facilitation Intervention. Predictors of uptake (accessing at least one therapeutic module of the program), adherence (modules completed), and acceptability of internet-based psychological programs (Unified Theory of Acceptance and Use of Technology, UTAUT scale) were examined, including demographics, mental health status, help-seeking attitudes, stigma, acceptability of internet programs, and personality factors.

RESULTS

Logistic regression demonstrated that higher levels of conscientiousness (OR = 1.06, p = .026, 95% CI =1.01-1.12), and acceptability of internet-based psychological programs (OR = 1.09, p = .005, 95% CI =1.03-1.16) predicted greater uptake, and that failing to complete a module was predicted by lower levels of acceptability (OR = 0.88, p = .027, 95% CI =0.78-0.99). Linear regression showed that higher levels of agreeableness (t = 4.66, p < .001), lower levels of stigma (t = -2.28, p = .023) and more positive help-seeking attitudes (t = 2.05, p = .041) predicted higher acceptability attitudes.

DISCUSSION

Acceptability of internet-based psychological programs was identified as a factor that increased both uptake and adherence to the myCompass 2 program. Efforts to increase the acceptability of these programs may improve engagement with these programs in the community. It may also be useful to consider personality traits and clinical profiles when considering the appropriate audience for self-guided internet interventions.

Are Internet- and mobile-based interventions effective in adults with diagnosed panic disorder and/or agoraphobia? A systematic review and meta-analysis

BACKGROUND

There is no meta-analysis that specifically evaluates the effectiveness of Internet- and mobile-based interventions (IMIs) in adults with diagnosed panic disorder and/or agoraphobia (PD/A) so far. The current meta-analysis aims to fill this gap (PROSPERO CRD 42016034016).

METHODS

Systematic literature searches in six databases for randomised and controlled clinical trials investigating IMIs in adults, who met diagnostic criteria for PD/A. Study selection and data extraction were conducted independently by two reviewers. Random-effects meta-analyses, pre-planned subgroup and sensitivity analyses were conducted when appropriate. Primary outcomes were PD and A symptom severity. In addition, adherence, response, remission, quality of life, anxiety and depression symptom severity were examined.

RESULTS

A total of 16 trials (1015 patients), with 21 comparisons (9 IMI vs. waitlist; 7 IMI vs. IMI; 5 IMI vs. active treatment condition), were included. IMIs revealed beneficial effects on panic (Hedges' g range -2.61 to -0.25) and agoraphobia symptom severity when compared to waitlist (pooled g = -1.15, [95%-CI = -1.56; -0.74]). Studies comparing IMIs to active controls (i.e., face-to-face CBT and applied relaxation) did not find significant differences for reductions in panic (g = -0.02, [95%-CI = -0.25; 0.21]) and agoraphobia symptom severity (g = -0.10, [95%-CI = -0.39; 0.19]). Furthermore, IMIs were superior to waitlist controls regarding anxiety and depression symptom severity and quality of life.

LIMITATIONS

Tests for publication bias were not feasible due to the limited number of trials per comparison, and the risk of bias assessment indicated some methodological shortcomings.

CONCLUSIONS

Findings from this meta-analytic review provide support for the effectiveness of IMIs in patients with verified PD/A. However, before IMIs can be included in treatment guidelines for PD/A, future high quality research is needed that substantiates and extends the evidence base, especially in regard to intervention safety.

Advantages and disadvantages of online and blended therapy: Replication and extension of findings on psychotherapists' appraisals

Therapists hold a key role for the uptake of digital mental health interventions (DMHI) within regular care services but have demonstrated cautious attitudes towards such interventions. It is relevant to explore in detail what factors may positively influence therapists' perception when considering DMHI implementation within routine care. We recently assessed therapist views towards Internet-based and blended treatment in Austria (low implementation level). The present study aims at testing the reliability of previous findings, and moreover, it compares therapists' appraisals to a country with advanced DMHI implementation (Sweden). An online survey was conducted February through June of 2019. Respondents were recruited via email and social media. The survey assessed first-hand experience with Internet-based treatment (IT) and blended treatment (BT). To start, the survey presented a short informational video to half of the respondents, then assessed therapists' views on 17 advantages and 13 disadvantages of IT and BT on 6-point Likert scales. In total N = 300 therapists responded to the invitation, of which N = 165 provided full survey data (Germany 114/220, 52%; Sweden 51/80, 64%). German therapists rated the advantages of IT and BT as neutral (IT, M = 3.6; BT, M = 3.8) and to some extent agreed with disadvantages of IT (IT, M = 4.5; BT, M = 3.5). In comparison, Swedish therapists rated significantly greater advantages (IT, M = 4.6; BT, M = 4.5) and less disadvantages (IT, M = 3.2; BT, M = 2.8). Effect sizes ranged from d = 0.89 to d = 1.83; all P's < .001. Those with first-hand experience with DMHI reported more positive appraisals in both countries. No significant effect was found for exposure to the short informational video. The German sample represented essential characteristics of current German therapists; in comparison Swedish respondents skewed towards younger less experienced therapists (P's < .001). Those confounders accounted for a small non-significant proportion of variance (0.1-4.7%). We found that therapists considered blended treatment to have less disadvantages than Internet treatment, and that first-hand experience with DMHI, but not exposure to an acceptance facilitating video clip, predicted greater acceptability on individual level. The responses among German therapists closely resembled findings from our preceding study in Austria, indicating that reliable results can be achieved in small survey studies if sample and population parameters correspond. Swedish therapists held significantly more favorable attitudes towards both interventions. The comparison between countries, however, is limited by a number of potential confounding variables.

Impact of an acceptance facilitating intervention on psychotherapists' acceptance of blended therapy

Blended therapy is a new approach combining advantages of face-to-face psychotherapy and Internet- and mobile-based interventions. Acceptance is a fundamental precondition for its implementation. The aim of this study was to assess 1) the acceptance of psychotherapists towards blended therapy, 2) the effectiveness of an acceptance facilitating intervention (AFI) on psychotherapists' acceptance towards blended therapy and 3) to identify potential effect moderators. Psychotherapists (N = 284) were randomly assigned to a control (CG) or an intervention group (IG). The IG received a short video showing an example of blended therapy, the CG an attention placebo video. Both groups received a reliable online questionnaire assessing acceptance, effort expectancy, performance expectancy, facilitating conditions, social influence and internet anxiety. Between group differences were examined using t-tests and Mann-Whitney tests. Exploratory analysis was conducted to identify moderators. Psychotherapists in CG showed mixed baseline acceptance towards blended therapy (low = 40%, moderate = 33%, high = 27%). IG showed significantly higher acceptance compared to CG (d = .27, pone-sided = .029; low = 24%, moderate = 47%, high = 30%). Bootstrapped confidence intervals were overlapping. Performance expectancy (d = .35), effort expectancy (d = .44) and facilitating conditions (d = .28) were significantly increased (p < .05). No effects on social influence and internet anxiety were found (p>.05). Exploratory analysis indicated psychodynamic oriented psychotherapists profiting particularly from the AFI. Blended therapy is a promising approach to improve healthcare. Psychotherapists show mixed acceptance, which might be improvable by AFIs, particularly in subpopulations of initially rather skeptical psychotherapists. Forthcoming studies should extend the present study by shifting focus from attitudes to the impact of different forms of AFIs on uptake.

[Online therapy for depressive disorders : An acceptance-based analysis from the perspective of therapists]

BACKGROUND

The supply of online therapy options for mild to moderate depressive disorders has substantially risen both nationally and internationally in the past years. While the efficacy and efficiency of specific online-based therapeutic services were indicated within the framework of scientific evaluations, little is known about the acceptance of these new therapy options.

METHODS

In a nationwide online survey of online-based therapy options for mild to moderate depressive disorders, the attitude and stance as well as the use intention and the subjectively perceived knowledge of 657 medical practitioners and therapists, active in psychotherapeutic and psychiatric treatment were collated. The impact of the potential predictors on the use intention of online-based therapies, based on the unified theory of acceptance and use of technology, was analyzed by means of a binary logistic regression model.

RESULTS

Besides the perceived performance and expense expectations, the supportive framework conditions, the influence of the cooperative environment, the individual technical affinity as well as the evaluation of the prospective significance of online-based therapy proved to be significantly influential predictors on the user intention. Special predictability for a positive user intention was shown related to the perceived potential of online therapy.

CONCLUSION

The results underline the relevance of further evidence-basing of online therapy for mild to moderate depressive disorders. A user-oriented, participatory technology development proves to be just as relevant as a comprehensive sensitization, elucidation and education of potential users for a successful implementation.

Digital interventions in adult mental healthcare settings: recent evidence and future directions

PURPOSE OF REVIEW

Internet and mobile-based interventions (IMI) can be used as online delivered forms of psychotherapeutic mental health treatments. These interventions can be an effective as well as time and cost-efficient treatment with the potential to scale up mental healthcare. In this review, we map implementation possibilities into routine mental healthcare settings and provide the most recent evidence.

RECENT FINDINGS

Fourteen articles on digital mental healthcare approaches published in the last 18 months were included. Despite the limited number, the studies provide evidence for the effectiveness of IMI in treating inpatients and outpatients with various disorders in different mental healthcare settings. IMI were investigated as stand-alone interventions, in combination with other treatment forms (blended-care), or as aftercare.

SUMMARY

Although there is encouraging evidence for the effectiveness of IMI in mental healthcare settings, several limitations have to be considered. The small number of studies conducted within the healthcare system, especially with inpatient samples, calls for more collaboration between researchers and clinical practitioners to unravel barriers and develop efficient protocols for the integration into routine care. Nonetheless, IMI are a promising tool for the endeavour of closing the treatment gap and should, therefore, be further explored in varying settings.

Designing for the Co-Use of Consumer Health Technology in Self-Management of Adolescent Overweight and Obesity: Mixed Methods Qualitative Study

Background

Overweight and obesity in adolescents has reached epidemic proportions in the United States. Consumer health technology (CHT) can serve as a behavioral and social support tool for the management of overweight in adolescence. Recognizing CHT as a social support tool during design enables input from multiple stakeholders who engage in shared co-use to reinforce and empower adolescents in their self-management efforts.

Objective

This study aimed to explore design requirements and enabling factors for the use of CHT as a social support tool for patients (as primary users) and parents and health care providers (as co-users). Our model incorporates key components of the unified theory of acceptance and use of technology (UTAUT) within the framework of the obesity care model (OCM) by recognizing patient self-management as the central process with the influence of their care support network on CHT use and outcomes.

Methods

This study was part of a larger two-staged usability study combining focus group, semistructured interviews, and usability walkthroughs of CHT mockups from adolescents (BMI in the 85th-99th percentile range), parents, and physicians. In phase 1, 48 adolescents between the ages of 12 and 17 years, 10 of their parents, and 6 health care providers participated in identifying design requirements and enabling factors for the use of a potential CHT. In phase 2, 70 adolescents and 10 health care providers evaluated the CHT mockups and indicated enabling factors and willingness to use the proposed CHT.

Results

Our qualitative analysis identified adolescents’ intention for the use of CHT in alignment with UTAUT elements of performance expectancy, effort expectancy, and facilitating conditions. Our reconceptualization of social influence identified the expectations and envisioned roles of parents and health care providers as co-users and influencing factors on the co-use of CHT in managing overweight in adolescence. Parents were expected to monitor, to provide guidance and motivation, and to suggest modifications in daily habits, for example, recipes and meals, whereas health care providers were expected to encourage and monitor progress in a clinical setting. These expected roles and co-use patterns were congruent among all 3 stakeholders; the co-use of CHT was desired to be minimally invasive for parents and health care providers and controlled by the adolescents.

Conclusions

Our study integrates and extends the perspectives of 2 seminal models to explore design features and social influence roles for the successful user-centered design of CHT for weight self-management in adolescents. Although the co-users (ie, adolescents, parents, health care providers) suggested differing features consistent with their roles, role definitions were congruent. All users recognized the adolescent as the primary user with differential, supportive use from parents and health care providers. This multistakeholder approach can guide successful CHT design that reinforces the collective perspective of self-management.

Prevention of eating disorders at universities: A systematic review and meta-analysis

BACKGROUND

Eating problems are highly prevalent among young adults. Universities could be an optimal setting to prevent the onset of eating disorders through psychological intervention. As part of the World Mental Health-International College Student initiative, this systematic review and meta-analysis synthesizes data on the efficacy of eating disorder prevention programs targeting university students.

METHOD

A systematic literature search of bibliographical databases (CENTRAL, MEDLINE, PsycINFO) for randomized trials comparing psychological preventive interventions for eating disorders targeting university students with psychoeducation or inactive controls was performed on October 22, 2019.

RESULTS

Twenty-seven studies were included. Thirteen (48.1%) were rated to have a low risk of bias. The relative risk of developing a subthreshold or full-blown eating disorder was incidence rate ratio = 0.62 (95% CI [0.44, 0.87], n _c = 8, numbers-needed-to-treat [NNT] = 26.08; standardized clinical interviews only), indicating a 38% decrease in incidence in the intervention groups compared to controls. Small to moderate between-group effects at posttest were found on eating disorder symptoms (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n _c = 26), dieting (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n _c = 21), body dissatisfaction (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n _c = 25), drive for thinness (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n _c = 12), weight concerns (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n _c = 13), and affective symptoms (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n _c = 18). The effects on bulimia nervosa symptoms were not significant. Heterogeneity was moderate across comparisons.

DISCUSSION

Eating disorder prevention on campus can have significant, small-to-moderate effects on eating disorder symptoms and risk factors. Results also suggest that the prevention of subthreshold and full-syndrome eating disorders is feasible using such interventions. More research is needed to identify ways to motivate students to use preventive eating disorder interventions.

ANTECEDENTES

Los trastornos de la conducta alimentaria son altamente prevalentes entre los adultos jóvenes. Las universidades podrían ser un entorno óptimo para prevenir la aparición de trastornos alimentarios a través de la intervención psicológica. Como parte de la iniciativa World Mental Health-International College Student, esta revisión sistemática y meta-análisis sintetiza datos sobre la eficacia de los programas de prevención de trastornos alimentarios dirigidos a estudiantes universitarios. MÉTODO: Una búsqueda bibliográfica sistemática de datos bibliográficas (CENTRAL, MEDLINE, PsycINFO) para ensayos aleatorios que comparaban intervenciones preventivas psicológicas para trastornos alimentarios dirigidos a estudiantes universitarios con psicoeducación o controles inactivos fue realizada hasta el 22 de octubre de 2019.

RESULTADOS

Se incluyeron 27 estudios. Trece (48,1%) fueron calificados como de bajo riesgo de sesgo. El riesgo relativo de desarrollar un trastorno de la conducta alimentaria subclínico (parcial) o completo fue IRR = 0.62 (95% CI [0.44, 0.87], n_c = 8, NNT = 26.08; sólo entrevistas clínicas estandarizadas), lo que indica una disminución del 38% en la incidencia en los grupos de intervención en comparación con los controles. Se encontraron efectos pequeños a moderados entre los grupos en la post-prueba en los síntomas del trastorno alimentario (g = 0.35, 95% CI [0.24, 0.46], NNT = 5.10, n_c = 26), dieta (g = 0.43, 95% CI [0.29, 0.57], NNT = 4.17, n_c = 21), insatisfacción corporal (g = 0.40, 95% CI [0.27, 0.53], NNT = 4.48, n_c = 25), impulso por delgadez (g = 0.43, 95% CI [0.27, 0.59], NNT = 4.23, n_c = 12), problemas de peso (g = 0.33, 95% CI [0.10, 0.57], NNT = 5.35, n_c = 13) y síntomas afectivos (g = 0.27, 95% CI [0.15, 0.38], NNT = 6.70, n_c = 18). Los efectos sobre los síntomas de la bulimia nervosa no fueron significativos. La heterogeneidad fue moderada en las comparaciones. DISCUSIÓN: La prevención de los trastornos de la conducta alimentaria en el campus universitario puede tener efectos significativos, de pequeños a moderados, sobre los síntomas del trastorno alimentario y los factores de riesgo. Los resultados también sugieren que la prevención de los trastornos alimentarios subclínicos o parciales y síndromes completos es factible utilizando tales intervenciones. Se necesita más investigación para identificar formas de motivar a los estudiantes a usar intervenciones preventivas para los trastornos de la conducta alimentaria.

Exploring User-Related Drivers of the Early Acceptance of Certified Digital Stress Prevention Programs in Germany

Electronic mental health services represent innovative instruments to increase the dissemination of stress programs in primary prevention. However, little is known about facilitators of their uptake. This study aimed to explore determinants of the acceptance of centrally certified digital stress coping programs and preferences for service delivery modes among adult members of German statutory health insurances. Participants completed a multi-construct 45-item questionnaire covering acceptance of digital stress prevention (behavioral use intention) and potential predictors we assessed using hierarchical regression analysis-(1) socio-demographic variables and time spent online, (2) openness to experience, (3) perceived stress, and (4) attitudes toward e-mental health. Preferences in terms of the willingness to use online, face-to-face and blended programs were analyzed using paired t-tests. Participants (N = 171, 66% female, 18-69 years) reported a moderate acceptance of digital stress management (M = 2.76, SD = 1.16, range: 1-5). We identified younger age (ß = -0.16, P = .009), openness to experience (ß = 0.17, P = .003), and positive attitudes (ß = 0.61, P < .001) as predictors of acceptance (R ² = .50, P < .001). Face-to-face was preferred over online (d = 0.40) and blended (d = 0.33), and blended over stand-alone online delivery mode (d = 0.19; all P < .001). Our findings indicate that promoting favorable attitudes toward digital stress prevention through tailored information may be a starting point to facilitate their adoption.

Scared to Trust? - Predicting Trust in Highly Automated Driving by Depressiveness, Negative Self-Evaluations and State Anxiety

The advantages of automated driving can only come fully into play if these systems are used in an appropriate way, which means that they are neither used in situations they are not designed for (misuse) nor used in a too restricted manner (disuse). Trust in automation has been found to be an essential psychological basis for appropriate interaction with automated systems. Well-balanced system use requires a calibrated level of trust in correspondence with the actual ability of an automated system. As for these far-reaching implications of trust for safe and efficient system use, the psychological processes, in which trust is dynamically calibrated prior and during the use of automated technology, need to be understood. At this point, only a restricted body of research investigated the role of personality and emotional states for the formation of trust in automated systems. In this research, the role of the personality variables depressiveness, self-efficacy, self-esteem, and locus of control for the experience of anxiety before the first experience with a highly automated driving system were investigated. Additionally, the relationship of the investigated personality variables and anxiety to subsequent formation of trust in automation was investigated. In a driving simulator study, personality variables and anxiety were measured before the interaction with an automated system. Trust in the system was measured after participants drove with the system for a while. Trust in the system was significantly predicted by state anxiety and the personality characteristics self-esteem and self-efficacy. The relationships of self-esteem and self-efficacy were mediated by state anxiety as supported by significant specific indirect effects. While for depression the direct relationship with trust in automation was not found to be significant, an indirect effect through the experience of anxiety was supported. Locus of control did not show a significant association to trust in automation. The reported findings support the importance of considering individual differences in negative self-evaluations and anxiety when being introduced to a new automated system for individual differences in trust in automation. Implications for future research as well as implications for the design of automated technology in general and automated driving systems are discussed.

Determinant Factors of Public Acceptance of Stress Management Apps: Survey Study

BACKGROUND

Chronic stress is a major public health concern. Mobile health (mHealth) apps can help promote coping skills in daily life and prevent stress-related issues. However, little is known about the determinant factors of public acceptance of stress management in relation to preferences for psychological services.

OBJECTIVE

The aim of this survey study was to (1) assess determinant factors of public acceptance (behavioral use intention) of stress management apps based on an adapted and extended version of the Unified Theory of Acceptance and Use of Technology (UTAUT) model and (2) explore preferences for mHealth apps compared with other mental health services.

METHODS

Using convenience sampling, participants completed a multiscale 54-item Web-based survey. Based on significant correlations with acceptance, hierarchical stepwise regression analysis was performed within three blocks: (1) background and stress-related control variables, (2) beliefs and attitudes toward using mHealth, and (3) the core UTAUT determinants. The preference for mHealth apps in comparison with nine other mental health services (operationalized as readiness to use) was analyzed using paired t tests.

RESULTS

Of 141 participants, nearly half (69/141, 48.9%) indicated prior mHealth use. Acceptance of stress coping apps was moderate (mean 3.10, SD 1.03, range 1-5). Hierarchical stepwise regression including four of 11 variables (R²=.62; P=.01, f²=1.63) identified positive attitudes toward using mHealth for stress coping (beta=0.69, P<.001, 46% R² increase above block 1, f²=0.85), skepticism/perceived risks (beta=-0.14, P=.01, f²=0.16), and stress symptoms (beta=0.12, P=.03, f²=0.14) as significant predictors of acceptance. UTAUT determinants added no predictive contribution beyond attitudes (all P>.05, R² increase of 1%), whereas post hoc analysis showed significant R² increases of attitudes and skepticism/perceived risks beyond UTAUT determinants (all P<.001, R² increase of 13%). The readiness to use apps was equivalent to or significantly higher than most service types, but lower than information websites.

CONCLUSIONS

Attitudes may be at least as predictive for the acceptance of stress management apps as for more elaborated outcome beliefs. Efforts aimed at improving the public adoption of mHealth could put more emphasis on the pleasant aspects of app use, address misconceptions, offer stress screening tools on health websites, and increase options to try high-quality apps.

Clinical and cost-effectiveness of guided internet-based interventions in the indicated prevention of depression in green professions (PROD-A): study protocol of a 36-month follow-up pragmatic randomized controlled trial

BACKGROUND

People in green professions are exposed to a variety of risk factors, which could possibly enhance the development of depression. Amongst possible prevention approaches, internet- and mobile-based interventions (IMIs) have been shown to be effective and scalable. However, little is known about the effectiveness in green professions. The aim of the present study is to examine the (cost-)effectiveness of a tailored IMI program for reducing depressive symptoms and preventing the onset of clinical depression compared to enhanced treatment as usual (TAU+).

METHODS

A pragmatic randomized controlled trial (RCT) will be conducted to evaluate a tailored and therapeutically guided preventive IMI program in comparison to TAU+ with follow-ups at post-treatment (9 weeks), 6-, 12-, 24-, and 36-months. Entrepreneurs in green professions, collaborating spouses, family members and pensioners (N = 360) with sufficient insurance status and at least subthreshold depression (PHQ-9 ≥ 5) are eligible for inclusion. Primary outcome is depressive symptom severity (QIDS-SR16). Secondary outcomes include incidence of depression (QIDS-SR16), quality of life (AQoL-8D) and negative treatment effects (INEP). A health-economic evaluation will be conducted from a societal perspective. The IMI program is provided by psychologists of an external service company and consists of six guided IMIs (6-8 modules, duration: 6-8 weeks) targeting different symptoms (depressive mood, depressive mood with comorbid diabetes, perceived stress, insomnia, panic and agoraphobic symptoms or harmful alcohol use). Intervention choice depends on a screening of participants' symptoms and individual preferences. The intervention phase is followed by a 12-months consolidating phase with monthly contact to the e-coach.

DISCUSSION

This is the first pragmatic RCT investigating long-term effectiveness of a tailored guided IMI program for depression prevention in green professions. The present trial builds on a large-scale strategy for depression prevention in green professions. The intended implementation of the IMI program with a nationwide rollout has the potential to reduce overall depression burden and associated health care costs in case of given effectiveness.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000 . Registered on 09 April 2018.

Development and initial psychometric evaluation of the computer-based prostate Cancer screening decision aid acceptance scale for African-American men

BACKGROUND

To reliably evaluate the acceptance and use of computer-based prostate cancer decision aids (CBDAs) for African-American men, culturally relevant measures are needed. This study describes the development and initial psychometric evaluation of the 24-item Computer-Based Prostate Cancer Screening Decision Aid Acceptance Scale among 357 African-American men.

METHODS

Exploratory factor analysis (EFA) with maximum likelihood estimation and polychoric correlations followed by Promax and Varimax rotations.

RESULTS

EFA yielded three factors: Technology Use Expectancy and Intention (16 items), Technology Use Anxiety (5 items), and Technology Use Self-Efficacy (3 items) with good to excellent internal consistency reliability at .95, .90, and .85, respectively. The standardized root mean square residual (0.035) indicated the factor structure explained most of the correlations.

CONCLUSIONS

Findings suggest the three-factor, 24-item Computer-Based Prostate Cancer Screening Decision Aid Acceptance Scale has utility in determining the acceptance and use of CBDAs among African-American men at risk for prostate cancer. Future research is needed to confirm this factor structure among socio-demographically diverse African-Americans.

Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the World Health Organization's World Mental Health International College Student Initiative

BACKGROUND

The majority of university students with mental health problems are untreated. Only a small empirical literature exists on strategies to increase mental health service use.

AIMS

To investigate the effects and moderators of a brief acceptance-facilitating intervention on intention to use mental health services among university students.

METHOD

Within the German site of the World Health Organization's World Mental Health International College Student (WMH-ICS) initiative, 1,374 university students were randomized to an intervention condition (IC; n = 664) or a control condition (CC; n = 710) that was implemented in the survey itself. Both conditions received the questions assessing mental disorders and suicidality that were included in other WMH-ICS surveys. The IC group then additionally received: Internet-based personalized feedback based on subject symptom severity in the domains of depression, anxiety, substance use, suicidal thoughts and behaviors, and nonsuicidal self-injury; psychoeducation tailored to the personal symptom profile; and information about available university and community mental health services. The primary outcome was reported intention to use psychological interventions in the next semester, which was the last question in the survey. A broad range of potential moderating factors was explored.

RESULTS

There was a significant main effect of the intervention with students randomized to IC, reporting significantly higher intentions to seek help in the next semester than students in the CC condition (d = 0.12, 95% CI: 0.02 to 0.23). Moderator analyses indicated that the intervention was more effective among students that fulfilled the criteria for lifetime (d = 0.34; 95% CI: -0.08 to 0.7) and 12-month panic-disorder (d = 0.32; 95% CI: -0.10 to 0.74) compared with those without lifetime (d = 0.11; 95% CI: 0.00 to 0.22) or 12-month panic disorder (d = 0.11; 95% CI: 0.00 to 0.22), students with lower (d = 0.37; 95% CI: -0.77 to 1.51) than higher (d = -0.01; 95% CI: -0.36 to 0.34) self-reported physical health, and students with nonheterosexual (d = 0.38; 95% CI: 0.08 to 0.67) compared with heterosexual (d = 0.06; 95% CI: -0.06 to 0.17) sexual orientation. The intervention had no effects among students who reported that they recognized that they had an emotional problem and "are already working actively to change it" (Stage 4 "stages of change").

CONCLUSIONS

A simple acceptance-facilitating intervention can increase intention to use mental health services, although effects, are on average, small. Future studies should investigate more personalized approaches with interventions tailored to barriers and clinical characteristics of students. In order to optimize intervention effects, the development and evaluation should be realized in designs that are powered to allow incremental value of different intervention components and tailoring strategies to be evaluated, such as in multiphase optimization designs.

Barriers of mental health treatment utilization among first-year college students: First cross-national results from the WHO World Mental Health International College Student Initiative

BACKGROUND

Although mental disorders and suicidal thoughts-behaviors (suicidal thoughts and behaviors) are common among university students, the majority of students with these problems remain untreated. It is unclear what the barriers are to these students seeking treatment.

AIMS

The aim of this study is to examine the barriers to future help-seeking and the associations of clinical characteristics with these barriers in a cross-national sample of first-year college students.

METHOD

As part of the World Mental Health International College Student (WMH-ICS) initiative, web-based self-report surveys were obtained from 13,984 first-year students in eight countries across the world. Clinical characteristics examined included screens for common mental disorders and reports about suicidal thoughts and behaviors. Multivariate regression models adjusted for socio-demographic, college-, and treatment-related variables were used to examine correlates of help-seeking intention and barriers to seeking treatment.

RESULTS

Only 24.6% of students reported that they would definitely seek treatment if they had a future emotional problem. The most commonly reported reasons not to seek treatment among students who failed to report that they would definitely seek help were the preference to handle the problem alone (56.4%) and wanting to talk with friends or relatives instead (48.0%). Preference to handle the problem alone and feeling too embarrassed were also associated with significantly reduced odds of having at least some intention to seek help among students who failed to report that they would definitely seek help. Having 12-month major depression, alcohol use disorder, and suicidal thoughts and behaviors were also associated with significantly reduced reported odds of the latter outcome.

CONCLUSIONS

The majority of first-year college students in the WMH-ICS surveys report that they would be hesitant to seek help in case of future emotional problems. Attitudinal barriers and not structural barriers were found to be the most important reported reasons for this hesitation. Experimental research is needed to determine whether intention to seek help and, more importantly, actual help-seeking behavior could be increased with the extent to which intervention strategies need to be tailored to particular student characteristics. Given that the preference to handle problems alone and stigma and appear to be critical, there could be value in determining if internet-based psychological treatments, which can be accessed privately and are often build as self-help approaches, would be more acceptable than other types of treatments to student who report hesitation about seeking treatment.

A brief intervention to increase uptake and adherence of an online program for depression and anxiety: Protocol for the Enhancing Engagement with Psychosocial Interventions (EEPI) Randomized Controlled Trial

BACKGROUND

There is substantial evidence that psychosocial programs delivered online can be effective in treating and preventing mental health problems. However, use of evidence-based programs in the community is currently suboptimal, and there is a lack of evidence around how to increase engagement with existing evidence-based programs. Novel approaches to increasing the acceptability of online programs such as the use of brief engagement-facilitation interventions (EFI) require evaluation.

AIMS

The aims of this study are to 1) examine the effectiveness of a brief online engagement-facilitation intervention (EFI) presented prior to an online self-help mental health program (myCompass) in improving uptake of and adherence to that program, and 2) assess if greater uptake and/or adherence are associated with improved efficacy (greater reduction in symptoms of depression and anxiety) relative to a control condition).

METHODS

A three-arm randomized controlled trial will be conducted (target sample: N = 693 participants recruited via social media). An active online cognitive behavioral therapy (iCBT) intervention will be delivered either with (arm 1) or without (arm 2) the EFI. An attention control group (arm 3) will enable testing of the relative efficacy of the iCBT intervention. Primary outcomes are uptake of the intervention (initiation) and adherence (module completion).

RESULTS

Findings will inform the more efficient dissemination of a range of psychosocial programs into the community, with potential for significant efficiency gains in treating common mental health problems.

CONCLUSIONS

Greater engagement with online psychosocial programs may lead to significant reductions in the burden of common mental health problems in the community.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001565235.

Digital Interventions for Mental Disorders: Key Features, Efficacy, and Potential for Artificial Intelligence Applications

Mental disorders are highly prevalent and often remain untreated. Many limitations of conventional face-to-face psychological interventions could potentially be overcome through Internet-based and mobile-based interventions (IMIs). This chapter introduces core features of IMIs, describes areas of application, presents evidence on the efficacy of IMIs as well as potential effect mechanisms, and delineates how Artificial Intelligence combined with IMIs may improve current practices in the prevention and treatment of mental disorders in adults. Meta-analyses of randomized controlled trials clearly show that therapist-guided IMIs can be highly effective for a broad range of mental health problems. Whether the effects of unguided IMIs are also clinically relevant, particularly under routine care conditions, is less clear. First studies on IMIs for the prevention of mental disorders have shown promising results. Despite limitations and challenges, IMIs are increasingly implemented into routine care worldwide. IMIs are also well suited for applications of Artificial Intelligence and Machine Learning, which provides ample opportunities to improve the identification and treatment of mental disorders. Together with methodological innovations, these approaches may also deepen our understanding of how psychological interventions work, and why. Ethical and professional restraints as well as potential contraindications of IMIs, however, should also be considered. In sum, IMIs have a high potential for improving the prevention and treatment of mental health disorders across various indications, settings, and populations. Therefore, implementing IMIs into routine care as both adjunct and alternative to face-to-face treatment is highly desirable. Technological advancements may further enhance the variability and flexibility of IMIs, and thus even further increase their impact in people's lives in the future.

The Advantages and Disadvantages of Online and Blended Therapy: Survey Study Amongst Licensed Psychotherapists in Austria

Background

Web-based and blended (face-to-face plus Web-based) interventions for mental health disorders are gaining significance. However, many licensed psychotherapists still have guarded attitudes toward computer-assisted therapy, hindering dissemination efforts.

Objective

The objective of this study was to provide a therapist-oriented evaluation of Web-based and blended therapies and identify commonalities and differences in attitudes toward both formats. Furthermore, it aimed to test the impact of an information clip on expressed attitudes.

Methods

In total, 95 Austrian psychotherapists were contacted and surveyed via their listed occupational email address. An 8-minute information video was shown to half of the therapists before 19 advantages and 13 disadvantages had to be rated on a 6-point Likert scale.

Results

The sample resembled all assessed properties of Austrian psychotherapists (age, theoretical orientation, and region). Therapists did not hold a uniform overall preference. Instead, perceived advantages of both interventions were rated as neutral (t₉₄=1.89, P=.06; d=0.11), whereas Web-based interventions were associated with more disadvantages and risks (t₉₄=9.86, P<.001; d=0.81). The information clip did not excerpt any detectable effect on therapists’ attitudes (r₉₅=−.109, P=.30). The application of modern technologies in the own therapeutic practice and cognitive behavioral orientation were positively related to the given ratings.

Conclusions

This study is the first to directly compare therapists’ attitudes toward Web-based and blended therapies. Positive attitudes play a pivotal role in the dissemination of new technologies, but unexperienced therapists seem to lack knowledge on how to benefit from technology-aided treatments. To speed up implementation, these aspects need to be addressed in the development of new interventions. Furthermore, the preference of blended treatments over Web-based interventions seems to relate to avoidance of risks. Although this study is likely to represent therapists’ attitudes in countries with less advanced electronic health services, therapists’ attitudes in more advanced countries might present differently.

Acceptance of Mobile Health Apps for Disease Management Among People With Multiple Sclerosis: Web-Based Survey Study

Background

Mobile health (mHealth) apps might have the potential to promote self-management of people with multiple sclerosis (MS) in everyday life. However, the uptake of MS apps remains poor, and little is known about the facilitators and barriers for their efficient utilization, such as technology acceptance.

Objective

The aim of this study was to examine the acceptance of mHealth apps for disease management in the sense of behavioral intentions to use and explore determinants of utilization among people with MS based on the Unified Theory of Acceptance and Use of Technology (UTAUT).

Methods

Participants for this Web-based cross-sectional study were recruited throughout Germany with the support of regional MS associations and self-help groups. To identify determinants of intention to use MS apps, a measure based on the UTAUT was adapted with 4 key determinants (performance expectancy, effort expectancy, social influence, and facilitating conditions) and extended by Intolerance of Uncertainty (IU) and electronic health literacy. Potential influencing effects of both MS and computer self-efficacy (C-SE) as mediators and fatigue as a moderator were analyzed using Hayes’s PROCESS macro (SPSS version 3.0) for IBM SPSS version 24.0.

Results

A total of 98 participants (mean age 47.03 years, SD 10.17; 66/98, 67% female) with moderate fatigue levels completed the survey. Although most participants (91/98, 92%) were daily smartphone users, almost two-thirds (62/98, 63%) reported no experience with MS apps. Overall, the acceptance was moderate on average (mean 3.11, SD 1.31, minimum=1 and maximum=5), with lower scores among persons with no experience (P=.04) and higher scores among current users (P<.001). In multiple regression analysis (R²=63% variance explained), performance expectancy (beta=.41) and social influence (beta=.33) were identified as significant predictors of acceptance (all P<.001). C-SE was confirmed as a partial mediator in the relationship between IU and acceptance (indirect effect: B=−.095, 95% CI −0.227 to −0.01). Furthermore, a moderated mediation by C-SE was shown in the relationship between IU and behavioral intentions to use MS apps for low (95% CI −0.42 to −0.01) and moderate levels (95% CI −0.27 to −0.01) of fatigue.

Conclusions

Overall, this exploratory pilot study indicates for the first time that positive expectations about the helpfulness for self-management purposes and social support might be important factors to be considered for improving the acceptance of MS apps among smartphone users with MS. However, given some inconsistent findings, especially regarding the role of effort expectancy and IU and self-efficacy, the conceptual model needs replication with a larger sample of people with MS, varying more in fatigue levels, and a longitudinal assessment of the actual usage of MS apps predicted by acceptance in the sense of behavioral intentions to use.