Feasibility of an interactive voice response system for monitoring depressive symptoms in a lower-middle income Latin American country

Artificial intelligence and digital health in improving primary health care service delivery in LMICs: A systematic review

AIM

Technology including artificial intelligence (AI) may play a key role to strengthen primary health care services in resource-poor settings. This systematic review aims to explore the evidence on the use of AI and digital health in improving primary health care service delivery.

METHODS

Three electronic databases were searched using a comprehensive search strategy without providing any restriction in June 2023. Retrieved articles were screened independently using the "Rayyan" software. Data extraction and quality assessment were conducted independently by two review authors. A narrative synthesis of the included interventions was conducted.

RESULTS

A total of 4596 articles were screened, and finally, 48 articles were included from 21 different countries published between 2013 and 2021. The main focus of the included studies was noncommunicable diseases (n = 15), maternal and child health care (n = 11), primary care (n = 8), infectious diseases including tuberculosis, leprosy, and HIV (n = 7), and mental health (n = 6). Included studies considered interventions using AI, and digital health of which mobile-phone-based interventions were prominent. m-health interventions were well adopted and easy to use and improved the record-keeping, service deliver, and patient satisfaction.

CONCLUSION

AI and the application of digital technologies improve primary health care service delivery in resource-poor settings in various ways. However, in most of the cases, the application of AI and digital health is implemented through m-health. There is a great scope to conduct further research exploring the interventions on a large scale.

Measurement of depression in the Brazilian population: validation of the Patient Health Questionnaire (PHQ-8)

We aimed to evaluate the psychometric properties of the Brazilian version of the Patient Health Questionnaire (PHQ-8). A study with a sample of 4,170 individuals (≥ 15 years old) from the urban area. Conglomerate sampling was adopted in two stages (census sectors and streets), with weighting of estimates by sample weights. A structured questionnaire with sociodemographic data, the PHQ - the modules for depression, generalized anxiety disorder and panic disorder - and the Self-Reporting Questionnaire (SRQ-20) were used. In the evaluation of the PHQ-8, we verified the construct validity by analyzing the dimensional structure, convergent validity and internal consistency. We found a linear disorder without losses to maintain the four response categories. The factor analysis found unidimensionality of the depression construct, with strong factor loads, low residual variances, low residual correlation between items, good fit of the model, internal consistency and satisfactory convergent factorial validity (high loads and correlations with other tests/scales of similar constructs). The PHQ-8 has a one-dimensional structure with evidence of good validity and reliability, being suitable for use in the Brazilian population.

Care Management of Comorbid Medical and Psychiatric Illness: A Conceptual Framework for Improving Equity of Care

Psychiatric and medical comorbidities are common among adults in the United States. Due to the complex interplay between medical and psychiatric illness, comorbidities result in substantial disparities in morbidity, mortality, and health care costs. There is, thus, both an ethical and fiscal imperative to develop care management programs to address the needs of individuals with comorbid conditions. Although there is substantial evidence supporting the use of care management for improving health outcomes for patients with chronic diseases, the majority of interventions described in the literature are condition-specific. Given the prevalence of comorbidities, the authors of this article reviewed the literature and drew on their clinical expertise to guide the development of future multimorbidity care management programs. Their review yielded one study of multimorbidity care management and two studies of multimorbidity collaborative care. The authors supplemented their findings by describing three key pillars of effective care management, as well as specific interventions to offer patients based on their psychiatric diagnoses and illness severity. The authors proposed short-, medium-, and long-term indicators to measure and track the impact of care management programs on disparities in care. Future studies are needed to identify which elements of existing multimorbidity collaborative care models are active ingredients, as well as which of the suggested supplemental interventions offer the greatest value.

Technology-Facilitated Depression Self-Management Linked with Lay Supporters and Primary Care Clinics: Randomized Controlled Trial in a Low-Income Sample

Purpose: To test whether technology-facilitated self-management support improves depression in primary care settings. Methods: We randomized 204 low-income primary care patients who had at least moderate depressive symptoms to intervention or control. Intervention participants received 12 months of weekly automated interactive voice response telephone calls that assessed their symptom severity and provided self-management strategies. Their patient-nominated supporter (CarePartner) received corresponding guidance on self-management support, and their primary care team received urgent notifications. Those randomized to enhanced usual care received printed generic self-management instructions. Results: One-year attrition rate was 14%. By month 6, symptom severity on the Patient Health Questionnaire-9 (PHQ-9) decreased 2.5 points more in the intervention arm than in the control arm (95% CI -4.2 to -0.8, p = 0.003). This benefit was similar at month 12 (p = 0.004). Intervention was also over twice as likely to lead to ≥50% reduction in symptom severity by month 6 (OR = 2.2 (1.1, 4.7)) and a decrease of ≥5 PHQ-9 points by month 12 (OR = 2.3 (1.2, 4.4)). Conclusions: Technology-facilitated self-management guidance with lay support and clinician notifications improves depression for primary care patients. Subsequent research should examine implementation and generalization to other chronic conditions. clinicaltrials.gov, identifier NCT01834534.

Feasibility of mHealth interventions for depressive symptoms in Latin America: a systematic review

Depression is a prevalent disorder and leading cause of disability in Latin America, where the mental health treatment gap is still above 50%. We sought to synthesise and assess the quality of the evidence on the feasibility of mHealth-based interventions for depression in Latin America. We conducted a literature search of studies published in 2007 and after using four electronic databases. We included peer-reviewed articles, in English, Spanish or Portuguese, that evaluated interventions for depressive symptoms. Two authors independently extracted data using forms developed a priori. We assessed appropriateness of reporting utilising the CONSORT checklist for feasibility trials. Eight manuscripts were included for full data extraction. Appropriate reporting varied greatly. Most (n = 6, 75%) of studies were conducted in primary care settings and sought to deliver psychoeducation or behaviour change interventions for depressive symptoms. We found great heterogeneity in the assessment of feasibility. Two studies used comparator conditions. mHealth research for depression in Latin America is scarce. Included studies showed some feasibility despite methodological inconsistencies. Given the dire need for evidence-based mental health interventions in this region, governments and stakeholders must continue promoting and funding research tailored to cultural and population characteristics with subsequent pragmatic clinical trials.

Implementation of an Interactive Voice Response System for Cancer Awareness in Uganda: Mixed Methods Study

Background

Cancer awareness is crucial for cancer care and prevention. However, cancer awareness in Uganda is low, and access to cancer information is limited.

Objective

This study aims to (1) understand the cancer awareness situation in Uganda (perceptions, beliefs, information needs, and challenges to accessing cancer information) and opinions about interactive voice response (IVR) systems; (2) develop cancer awareness messages and implement them in an IVR system; and (3) evaluate user acceptance and use of the IVR system.

Methods

A participatory design approach was adopted. To understand cancer awareness needs and challenges, 3 interviews and 7 focus group discussions (FGDs) were conducted with cancer health care providers, patients with cancer, caregivers and survivors, administrators, and lay citizens (n=73). On the basis of the resulting qualitative data, audio messages addressing cancer information needs were developed and implemented in an IVR system. The system and messages were tested with users (n=12) during 2 co-design workshops before final rollout. Finally, the system was evaluated over 6 months after going live, using call records and user feedback from telephone interviews with callers (n=40).

Results

The cancer information needs included general topics such as what cancer is, what causes it, cancer screening and diagnosis, cancer treatment, and practical information on what to expect during cancer care. There were also myths and misconceptions that need to be addressed, such as that cancer is due to witchcraft and has no treatment. Information on COVID-19 was also sought after following the outbreak. We developed 20 audio cancer messages (approximately 2 minutes each) in English and Luganda, along with 14 IVR navigation instructions. These were implemented in an IVR system with 24/7 availability from all over Uganda via a toll-free multi-channel telephone number. The total number of calls made to the IVR system 6 months after going live was 3820. Of these, 2437 (63.8%) lasted at least 30 seconds and were made from 1230 unique telephone numbers. There were 191 voice messages and 760 calls to live agents, most of which (681/951, 71.6%) were in Luganda. Call volumes peaked following advertisement of the system and lockdowns due to COVID-19. Participants were generally familiar with IVR technology, and caller feedback was largely positive. Cited benefits included convenience, toll-free access, and detailed information. Recommendations for improvement of the system included adding live agents and marketing of the system to target users.

Conclusions

IVR technology provides an acceptable and accessible method for providing cancer information to patients and the general public in Uganda. However, a need remains for health system reforms to provide additional cancer information sources and improve cancer care services in general.

Implementation outcomes and strategies for depression interventions in low- and middle-income countries: a systematic review

BACKGROUND

We systematically reviewed implementation research targeting depression interventions in low- and middle-income countries (LMICs) to assess gaps in methodological coverage.

METHODS

PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of depression interventions in LMICs reporting at least one implementation outcome published through March 2019.

RESULTS

A total of 8714 studies were screened, 759 were assessed for eligibility, and 79 studies met inclusion criteria. Common implementation outcomes reported were acceptability (n = 50; 63.3%), feasibility (n = 28; 35.4%), and fidelity (n = 18; 22.8%). Only four studies (5.1%) reported adoption or penetration, and three (3.8%) reported sustainability. The Sub-Saharan Africa region (n = 29; 36.7%) had the most studies. The majority of studies (n = 59; 74.7%) reported outcomes for a depression intervention implemented in pilot researcher-controlled settings. Studies commonly focused on Hybrid Type-1 effectiveness-implementation designs (n = 53; 67.1), followed by Hybrid Type-3 (n = 16; 20.3%). Only 21 studies (26.6%) tested an implementation strategy, with the most common being revising professional roles (n = 10; 47.6%). The most common intervention modality was individual psychotherapy (n = 30; 38.0%). Common study designs were mixed methods (n = 27; 34.2%), quasi-experimental uncontrolled pre-post (n = 17; 21.5%), and individual randomized trials (n = 16; 20.3).

CONCLUSIONS

Existing research has focused on early-stage implementation outcomes. Most studies have utilized Hybrid Type-1 designs, with the primary aim to test intervention effectiveness delivered in researcher-controlled settings. Future research should focus on testing and optimizing implementation strategies to promote scale-up of evidence-based depression interventions in routine care. These studies should use high-quality pragmatic designs and focus on later-stage implementation outcomes such as cost, penetration, and sustainability.

Prevalence of psychological distress, depression and suicidal ideation in an indigenous population in Panamá

OBJECTIVE

The aim of this study was to investigate the prevalence of serious psychological distress (SPD), depression, and suicidal ideation in an adult Indigenous population in Panamá.

METHODS

Data were collected from 211 Kuna adults using a paper-based survey. Depression and suicidal ideation were measured using the Patient Health Questionnaire (PHQ-9), and SPD was measured using the Kessler-6. Univariate analyses were used to describe demographic variables, followed by chi² tests to compare differences in demographic variables for each of the mental health outcomes (depression, serious psychological distress, suicidal ideation). A regression model, adjusted for all demographic variables, was then run for each mental health outcome to understand independent correlates.

RESULTS

Within the sample surveyed, 6.2% (95% CI 3.4-10.4) reported serious psychological distress, 32.0% (95% CI 25.7-38.9) reported depression, and 22.9% (95% CI 17.4-29.1) reported suicidal ideation. Significant demographic differences existed with 14% of individuals between the age of 60-90 and 17% of individuals with no education reporting SPD. Women were nearly 5 times more likely to report depression than men (OR 4.90, 95% CI 1.27-19.00) and those with higher incomes were less likely to report depression (OR 0.32, 95% CI 0.13-0.78).

CONCLUSION

High levels of depression, SPD, and suicidal ideation were present in an Indigenous Kuna community in Panamá. Women and individuals with low income were more likely to report depression, and SPD was more common in older individuals and those with low levels of education. Suicidal ideation was high across all demographic factors, suggesting that a community-wide program to address suicide may be warranted.

Case Study: Cognitive Restructuring Hypnosis for Chronic Pain in a Quadriplegic Patient

This case study reports on a 28-year-old male with spinal cord injury (SCI), quadriplegia, and chronic pain with neuropathic characteristics. The treatment had to be adapted to address the patient's needs, as he was on a respirator and paralyzed from the chin down. The intervention consisted of eight 90-minute sessions. The first four sessions were based on a standardized hypnotic cognitive therapy protocol developed for a randomized controlled trial (RCT). The sessions included training in cognitive restructuring skills and a hypnosis session with suggestions that was audiorecorded. Instructions to practice at home, both with the recording and by using self-hypnosis, were provided as well. Most of the outcome domains assessed (i.e., pain intensity, pain interference, sleep quality) showed clinically meaningful improvements that were maintained (or increased) at one-year follow-up. The patient reported that he was still using self-hypnosis at one-year follow-up. His subjective impression of change was positive and he did not report any negative side effects. Results show that the hypnotic cognitive therapy protocol used is a promising intervention that can benefit individuals with SCI presenting with complex symptomatology. Such therapy helps patients by teaching them effective coping strategies that they can use on their own to manage pain and its effects. In addition, it is important to note that this therapy provided benefits to someone who had not experienced any benefits from numerous medications he had tried before treatment. Therefore, the findings support continued efforts to make this treatment more accessible to patients who could benefit from this approach.

Strengths and limitations of computer assisted telephone interviews (CATI) for nutrition data collection in rural Kenya

Despite progress in fighting undernutrition, Africa has the highest rates of undernutrition globally, exacerbated by drought and conflict. Mobile phones are emerging as a tool for rapid, cost effective data collection at scale in Africa, as mobile phone subscriptions and phone ownership increase at the highest rates globally. To assess the feasibility and biases of collecting nutrition data via computer assisted telephone interviews (CATI) to mobile phones, we measured Minimum Dietary Diversity for Women (MDD-W) and Minimum Acceptable Diet for Infants and Young Children (MAD) using a one-week test-retest study on 1,821 households in Kenya. Accuracy and bias were assessed by comparing individual scores and population prevalence of undernutrition collected via CATI with data collected via traditional face-to-face (F2F) surveys. We were able to reach 75% (n = 1366) of study participants via CATI. Women’s reported nutrition scores did not change with mode for MDD-W, but children’s nutrition scores were significantly higher when measured via CATI for both the dietary diversity (mean increase of 0.45 food groups, 95% confidence interval 0.34–0.56) and meal frequency (mean increase of 0.75 meals per day, 95% confidence interval 0.53–0.96) components of MAD. This resulted in a 17% higher inferred prevalence of adequate diets for infants and young children via CATI. Women without mobile-phone access were younger and had fewer assets than women with access, but only marginally lower dietary diversity, resulting in a small non-coverage bias of 1–7% due to exclusion of participants without mobile phones. Thus, collecting nutrition data from rural women in Africa with mobile phones may result in 0% (no change) to as much as 25% higher nutrition estimates than collecting that information in face-to-face interviews.

USE OF NEUROFEEDBACK AND MINDFULNESS TO ENHANCE RESPONSE TO HYPNOSIS TREATMENT IN INDIVIDUALS WITH MULTIPLE SCLEROSIS: Results From a Pilot Randomized Clinical Trial

This pilot study evaluated the possibility that 2 interventions hypothesized to increase slower brain oscillations (e.g., theta) may enhance the efficacy of hypnosis treatment, given evidence that hypnotic responding is associated with slower brain oscillations. Thirty-two individuals with multiple sclerosis and chronic pain, fatigue, or both, were randomly assigned to 1 of 2 interventions thought to increase slow wave activity (mindfulness meditation or neurofeedback training) or no enhancing intervention, and then given 5 sessions of self-hypnosis training targeting their presenting symptoms. The findings supported the potential for both neurofeedback and mindfulness to enhance response to hypnosis treatment. Research using larger sample sizes to determine the generalizability of these findings is warranted.

Exploring chronic disease in Bolivia: A cross-sectional study in La Paz

Purpose

This study seeks to develop an understanding that can guide development of programs to improve health and care for individuals with Non-Communicable Diseases (NCDs) in La Paz, Bolivia, where NCDs are prevalent and primary care systems are weak. This exploratory investigation examines the characteristics of chronic disease patients in the region, key health related behaviors, and their perceptions of the care that they receive. The longer-term goal is to lay groundwork for interventional studies based on the principles of the Chronic Care Model (CCM).

Subjects and methods

The study is based on two surveys of adults (> 18 years old) administered in 2014 in La Paz, Bolivia. A total of 1165 adult patients participated in the first screening survey. A post-screening second survey, administered only on those who qualified based on Survey 1, collected more detailed information about the subjects’ general health and health related personal circumstances, several health behaviors, health literacy, and their perceptions of care received. A final data set of 651 merged records were used for analysis.

Results

Characteristic of a low-income country, the majority of participants had low levels of education, income, health literacy and high rates of under/unemployment. Nearly 50% of participants reported 2 or more NCDs. Seventy-four percent (74%) of respondents reported low levels of medication adherence and 26% of the population was found to have an undiagnosed depressive disorder. Overall, the perception of care quality was low (60%), particularly in those under the age of 45. Significant relationships emerged between several sociodemographic characteristics, health behaviors, and perceptions that have major implications for improving NCD care in this population.

Conclusions

These findings illustrate some of the challenges facing low-income countries where reversing the tide of NCDs is of great importance. The prevalence of NCDs coupled with challenging social determinants of health, poor medication adherence, low health literacy, and perceptions of low quality of healthcare highlight several areas of opportunity for intervention.

A Transmedia Storytelling Intervention With Interactive Elements to Benefit Latinas' Mental Health: Feasibility, Acceptability, and Efficacy

BACKGROUND

Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs.

OBJECTIVE

The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both.

METHODS

A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression.

RESULTS

All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (F2,54=9.0, P<.001) and anxiety (F2,54=18.7, P<.001) significantly reduced across time. Higher levels of confidence were significantly associated with actions taken at 1 (P=.005) and 6 weeks (P=.04), and higher levels of importance were significantly associated with actions taken at 1 (P=.009) and 6 weeks (P=.003). Higher levels of confidence were associated with lower levels of depression (P=.04) and anxiety (P=.01) at 6 weeks.

CONCLUSIONS

Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression.

Mobile phone-based interactive voice response as a tool for improving access to healthcare in remote areas in Ghana - an evaluation of user experiences

OBJECTIVES

To investigate and determine the factors that enhanced or constituted barriers to the acceptance of an mHealth system which was piloted in Asante-Akim North District of Ghana to support healthcare of children.

METHODS

Four semi-structured focus group discussions were conducted with a total of 37 mothers. Participants were selected from a study population of mothers who subscribed to a pilot mHealth system which used an interactive voice response (IVR) for its operations. Data were evaluated using qualitative content analysis methods. In addition, a short quantitative questionnaire assessed system's usability (SUS).

RESULTS

Results revealed 10 categories of factors that facilitated user acceptance of the IVR system including quality-of-care experience, health education and empowerment of women. The eight categories of factors identified as barriers to user acceptance included the lack of human interaction, lack of update and training on the electronic advices provided and lack of social integration of the system into the community. The usability (SUS median: 79.3; range: 65-97.5) of the system was rated acceptable.

CONCLUSIONS

The principles of the tested mHealth system could be of interest during infectious disease outbreaks, such as Ebola or Lassa fever, when there might be a special need for disease-specific health information within populations.

An investigation of users' attitudes, requirements and willingness to use mobile phone-based interactive voice response systems for seeking healthcare in Ghana: a qualitative study

OBJECTIVES

In implementing mobile health interventions, user requirements and willingness to use are among the most crucial concerns for success of the investigation and have only rarely been examined in sub-Saharan Africa. This study aimed to specify the requirements of caregivers of children in order to use a symptom-based interactive voice response (IVR) system for seeking healthcare. This included (i) the investigation of attitudes towards mobile phone use and user experiences and (ii) the assessment of facilitators and challenges to use the IVR system.

STUDY DESIGN

This is a population-based cross-sectional study.

METHODS

Four qualitative focus group discussions were conducted in peri-urban and rural towns in Shai Osudoku and Ga West district, as well as in Tema- and Accra Metropolitan Assembly. Participants included male and female caregivers of at least one child between 0 and 10 years of age. A qualitative content analysis was conducted for data analysis.

RESULTS

Participants showed a positive attitude towards the use of mobile phones for seeking healthcare. While no previous experience in using IVR for health information was reported, the majority of participants stated that it offers a huge advantage for improvement in health performance. Barriers to IVR use included concerns about costs, lack of familiarly with the technology, social barriers such as lack of human interaction and infrastructural challenges. The establishment of a toll-free number as well as training prior to IVR system was discussed for recommendation.

CONCLUSIONS

This study suggests that caregivers in the socio-economic environment of Ghana are interested and willing to use mobile phone-based IVR to receive health information for child healthcare. Important identified users' needs should be considered by health programme implementers and policy makers to help facilitate the development and implementation of IVR systems in the field of seeking healthcare.