The Concept and Components of Engagement in Different Domains Applied to eHealth: A Systematic Scoping Review

User journey method: a case study for improving digital intervention use measurement

BACKGROUND

Many digital mental health interventions meet low levels of use. However, current use measurement methods do not necessarily help identify which intervention elements are associated with dropout, despite this information potentially facilitating iterative intervention development. Here, we suggest improving the comprehensiveness of intervention use measurement with the user journey method, which evaluates every intervention element to identify intervention-specific use barriers.

METHODS

We applied user journey method in a clinical trial that investigated the efficacy of a novel game-based intervention, Meliora, for adult Major Depressive Disorder. We modelled the intervention for its four technological (Recruitment, Website, Questionnaires, Intervention Software) and two interpersonal elements (Assessment, Support). We then applied the user journey method to measure how many users proceeded from one element to the next combining social media analytics, website use data, signup data, clinical subject coordinator interview data, symptom questionnaire data, and behavioral intervention use data. These measurements were complemented with the qualitative analysis of the study discovery sources and email support contacts.

RESULTS

Recruitment: The intervention recruitment reached at least 145,000 Finns, with social media, word-of-mouth, and news and web sources being the most effective recruitment channels. Website: The study website received 16,243 visitors, which led to 1,007 sign-ups.

ASSESSMENT

895 participants were assessed and 735 were accepted. Intervention Software: 498 participants were assigned to the active intervention or comparator, of whom 457 used them at least once: on average, for 17.3 h (SD = 20.4 h) on 19.7 days (SD = 20.7 d) over a period of 38.9 days (SD = 31.2 d). The 28 intervention levels were associated with an average dropout rate of 2.6%, with two sections exhibiting an increase against this baseline. 150 participants met the minimum adherence goal of 24 h use. Questionnaires: 116 participants completed the post-intervention questionnaire.

SUPPORT

313 signed-up participants contacted the researchers via email.

CONCLUSION

The user journey method allowed for the comprehensive evaluation of the six intervention elements, and enabled identifying use barriers expediting iterative intervention development and implementation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05426265. Registered 28 June 2022, https://clinicaltrials.gov/ct2/show/NCT05426265 .

Methodological approaches and author-reported limitations in evaluation studies of digital health technologies (DHT): A scoping review of DHT interventions for cancer, diabetes mellitus, and cardiovascular diseases

Digital health technology (DHT) holds the potential to improve health services, and its adoption has proliferated in recent decades owing to technological advancement. Optimal evaluation methodologies appropriate for generating quality evidence on DHT have yet to be established; traditional comparative designs present several limitations. This study aimed to scope the literature to highlight common methodological approaches used and their limitations to inform considerations for designing robust DHT evaluation studies. A scoping review was conducted following the Joanna Briggs Institute (JBI) scoping review guidelines. A systematic search was conducted using the CINAHL (EBSCO), MEDLINE (EBSCOhost), PsycINFO (EBSCO), EMBASE (Elsevier) and Web of Science (Clarivate Analytics) databases using iteratively developed search terms. We selected studies published in English between January 2016 and March 2022 and focussed on primary research evaluating the effectiveness of DHT with technology-user interactive or asynchronous features for adults (≥18 years) with cancer, diabetes or cardiovascular conditions. The final number of articles, after the screening and selection process, comprised 140 records. Data were analysed descriptively (frequency and percentages) and summarised thematically. Results showed most studies (n = 104, 74.3%) employed the standard two-arm parallel RCT design, with usual/standard care as the preferred comparator in nearly half (n = 65, 47.1%) of all included studies. Of the 104 comparative studies reviewed, limitations in recruitment were most frequently reported (n = 70, 37%), followed by limitations in evaluation/measurement techniques (n = 57, 27%), presence of confounding factors (n = 50, 24%) and short duration of studies (n = 24, 11%). The review highlights the need to consider inclusive approaches to recruitment and adoption of the emerging methodological approaches that account for the fast-paced, multi-component and group contamination problem resulting from the unconcealable nature of DHT interventions.

Human-Centered Design to Enhance Implementation and Impact in Health

Human-centered design (HCD) is an approach that aligns innovation development with the needs of the people and the settings where those innovations will be used. HCD is increasingly being applied across a variety of health domains, most often with the goals of translating research into real-world settings and expanding innovation adoption. This review introduces key HCD concepts, reviews the growth of HCD in public health and its alignment with the complementary field of implementation science, and details four prominent proximal outcomes of design processes: (a) usability, (b) user burden, (c) contextual appropriateness, and (d) engagement. For each outcome, we provide a definition and background, measurement options, and critiques and future directions. We conclude with a series of opportunities and challenges, including an inclusive big tent spanning different design traditions, pathways for enhancing HCD's scientific legitimacy, and explicit promotion of equitable design processes to improve individual, community, and population health.

Increasing the Uptake of Breast and Cervical Cancer Screening Via the MAwar Application: Stakeholder-Driven Web Application Development Study

Background

Digital health interventions such as web health applications significantly enhance screening accessibility and uptake, particularly for individuals with low literacy and income levels. By involving stakeholders-including health care professionals, patients, and technical experts-an intervention can be tailored to effectively meet the users' needs, ensuring contextual relevance for better acceptance and impact.

Objective

The aim of this study is to prioritize the content and user interface appropriate for developing a web health application, known as the MAwar app, to promote breast and cervical cancer screening.

Methods

A cross-sectional study for stakeholder engagement was conducted to develop a web-based application known as the MAwar app as part of a larger study entitled "The Effectiveness of an Interactive Web Application to Motivate and Raise Awareness on Early Detection of Breast and Cervical Cancers (The MAwar study)". The stakeholder engagement process was conducted in a public health district that oversees 12 public primary care clinics with existing cervical and breast cancer screening programs. We purposively selected the stakeholders for their relevant roles in breast and cervical cancer screening (health care staff, patients, and public representatives), as well as expertise in software and user interface design (technology experts). The Quality Function Deployment method was used to reflect the priorities of diverse stakeholders (health care, technology experts, patients, and public representatives) in its design. The Quality Function Deployment method facilitated the translation of stakeholder perspectives into app features. Stakeholders rated features on a scale from 1 (least important) to 5 (most important), ensuring the app's design resonated with user needs. The correlations between the "WHATs" (user requirements) and the "HOWs" (technical requirements) were scored using a 3-point ordinal scale, with 1 indicating weak correlation, 5 indicating medium correlation, and 9 indicating the strongest correlation.

Results

A total of 13 stakeholders participated in the study, including women who had either underwent or never had health screening, a health administrator, a primary care physician, medical officers, nurses, and software designers. Stakeholder evaluations highlighted cost-free access (mean 4.64, SD 0.81), comprehensive cancer information (mean 4.55, SD 0.69), detailed screening benefits (mean 4.45, SD 0.68), detailed screening facilities (mean 4.45, SD 0.68) and personalized risk calculator for breast and cervical cancers (mean 4.45, SD 0.68) as essential priorities of the app. The highest-ranked features include detailed information on screening procedures (weighted score [WS]=367.84), information on treatment options (WS=345.80), benefits of screening (WS=333.75), information about breast and cervical cancers (WS=332.15), and frequently asked questions about the concerns around screening (WS=312.00).

Conclusions

The MAwar app, conceived through a collaborative, stakeholder-driven process, represents a significant step in leveraging digital health solutions to tackle cancer screening disparities. By prioritizing accessibility, information quality, and clarity on benefits, the app promises to encourage early cancer detection and management for targeted communities.

From Burden to Enjoyment: A User-Centered Approach to Engage Adolescents in Intensive Longitudinal Research

INTRODUCTION

Adolescent psychology is embracing intensive longitudinal methods, such as diaries and experience sampling techniques, to investigate real-life experiences. However, participants might perceive the repetitive self-reporting in these data collection techniques as burdensome and demotivating, resulting in decreased compliance rates. In this tutorial paper, we present a user-centered approach aimed at making participation in experience sampling and daily diary studies a meaningful and fun experience for adolescents.

METHODS

In three major research projects that took place between 2019 and 2023, more than 4,000 Dutch adolescents participated (12-25 years old). To improve the participants' user journey, adolescents were invited to codesign our studies and share their expertise in interviews (n = 459), focus groups (n = 101), design decisions (i.e., A/B tests, n = 107), pilots (n = 163), exit interviews (n = 167), and by answering user experience questionnaires (n = 2,109).

RESULTS

Across projects, we discovered five different main intrinsic and extrinsic motives to participate in intensive longitudinal studies: (1) rewards, (2) fun and interest, (3) helping science or the greater good, (4) helping the scientist or another person, and (5) gaining self-insight. We provide concrete examples of how we tailored our study designs to address these specific motives to optimize youth engagement.

CONCLUSIONS

The engagement of adolescents in intensive longitudinal studies can be enhanced by making it a meaningful and enjoyable experience, aligned with their own motives.

Engagement in computerized cognitive training instructions by older people. A within-subject design to evaluate comprehension and acceptability of serious games instructions

This article emphasizes the advantages of using a within-subject experimental design to assess the impact of salient visual cues on the comprehension and acceptability of computerized cognitive training (CCT) instructions among older adults. The study would involve participants aged 65 and above, who will engage in an online experiment presenting two sets of instructions for serious games: one with salient visual cues and one without. This within-subject design eliminates the need for random assignment, improves internal consistency, and enhances statistical power. Participants serve as their own controls, providing a more robust comparison of how visual cues affect instruction comprehension and software acceptance. The primary objective is to identify indicators of acceptability for CCT serious games and to evaluate how well participants comprehend the instructions, influencing their intention to use the software. The hypothesis suggests that salient visual cues will improve instruction comprehension and foster greater software acceptability. By focusing on this design method, the study aims to enhance the engagement of older adults in cognitive training programs, reducing dropout rates. This research offers valuable insights into methodological strengths that can be applied in future studies to improve the usability and acceptance of CCT tools for older adults without cognitive impairments.

Self-Guided vs Clinician-Guided Online Cognitive Behavioral Therapy for Atopic Dermatitis: A Randomized Clinical Trial

Importance

Clinician-guided online self-help based on cognitive behavioral therapy (CBT) has been shown to be effective at decreasing symptom severity for people with atopic dermatitis (AD). A brief online self-guided CBT intervention could be more cost-effective and allow for easy implementation and broader outreach compared with more comprehensive clinician-guided interventions.

Objective

To investigate whether a brief online self-guided CBT intervention is noninferior to a comprehensive online clinician-guided CBT treatment.

Design, Setting, and Participants

This single-blind randomized clinical noninferiority trial was conducted at Karolinska Institutet, Stockholm, Sweden. Adult individuals with AD were enrolled from November 2022 to April 2023. The last postintervention data were collected in December 2023.

Interventions

Participants randomized to the self-guided group had access to a self-guided online CBT intervention for 12 weeks without clinician support. Participants randomized to the clinician-guided group received online CBT for 12 weeks.

Main Outcomes and Measures

The primary outcome was change in score from baseline to postintervention to 12-week follow-up on the self-reported Patient-Oriented Eczema Measure (POEM). The predefined noninferiority margin was 3 points on POEM.

Results

Of 168 randomized participants, 142 (84.5%) were female, and the mean (SD) age was 39 (10.5) years. A total of 86 participants were randomized to the self-guided group and 82 were randomized to the clinician-guided group. A total of 151 (90.0%) completed the main outcome postintervention assessment. Postintervention, the clinician-guided group had improved 4.20 points (95% CI, 1.94-6.05) on POEM and the self-guided group improved 4.60 points (95% CI, 2.57-6.64), corresponding to an estimated mean difference in change of 0.36 points (1-sided 97.5% CI, -∞ to 1.75), which was below the noninferiority margin of 3 points. No serious adverse events were reported. In the clinician-guided group, clinicians spent a mean (SD) of 36.0 (33.3) minutes (95% CI, 29.2-41.7) on treatment guidance and 14.0 (6.0) minutes (95% CI, 12.9-15.6) on assessments compared to 15.8 (6.4) minutes on assessments in the self-guided group.

Conclusions and Relevance

In this randomized clinical noninferiority trial, a brief self-guided CBT intervention was noninferior to clinician-guided CBT. Given the limited clinical resources required to deliver self-guided CBT, this treatment might be a promising means to disseminate evidence-based psychological treatment for patients with AD.

Trial Registration

ClinicalTrials.gov Identifier: NCT05517850.

The recent history and near future of digital health in the field of behavioral medicine: an update on progress from 2019 to 2024

The field of behavioral medicine has a long and successful history of leveraging digital health tools to promote health behavior change. Our 2019 summary of the history and future of digital health in behavioral medicine (Arigo in J Behav Med 8: 67-83, 2019) was one of the most highly cited articles in the Journal of Behavioral Medicine from 2010 to 2020; here, we provide an update on the opportunities and challenges we identified in 2019. We address the impact of the COVID-19 pandemic on behavioral medicine research and practice and highlight some of the digital health advances it prompted. We also describe emerging challenges and opportunities in the evolving ecosystem of digital health in the field of behavioral medicine, including the emergence of new evidence, research methods, and tools to promote health and health behaviors. Specifically, we offer updates on advanced research methods, the science of digital engagement, dissemination and implementation science, and artificial intelligence technologies, including examples of uses in healthcare and behavioral medicine. We also provide recommendations for next steps in these areas with attention to ethics, training, and accessibility considerations. The field of behavioral medicine has made meaningful advances since 2019 and continues to evolve with impressive pace and innovation.

Engagement With an Internet-Administered, Guided, Low-Intensity Cognitive Behavioral Therapy Intervention for Parents of Children Treated for Cancer: Analysis of Log-Data From the ENGAGE Feasibility Trial

BACKGROUND

Parents of children treated for cancer may experience psychological difficulties including depression, anxiety, and posttraumatic stress. Digital interventions, such as internet-administered cognitive behavioral therapy, offer an accessible and flexible means to support parents. However, engagement with and adherence to digital interventions remain a significant challenge, potentially limiting efficacy. Understanding factors influencing user engagement and adherence is crucial for enhancing the acceptability, feasibility, and efficacy of these interventions. We developed an internet-administered, guided, low-intensity cognitive behavioral therapy (LICBT)-based self-help intervention for parents of children treated for cancer, (EJDeR [internetbaserad självhjälp för föräldrar till barn som avslutat en behandling mot cancer or internet-based self-help for parents of children who have completed cancer treatment]). EJDeR included 2 LICBT techniques-behavioral activation and worry management. Subsequently, we conducted the ENGAGE feasibility trial and EJDeR was found to be acceptable and feasible. However, intervention adherence rates were marginally under progression criteria.

OBJECTIVE

This study aimed to (1) describe user engagement with the EJDeR intervention and examine whether (2) sociodemographic characteristics differed between adherers and nonadherers, (3) depression and anxiety scores differed between adherers and nonadherers at baseline, (4) user engagement differed between adherers and nonadherers, and (5) user engagement differed between fathers and mothers.

METHODS

We performed a secondary analysis of ENGAGE data, including 71 participants. User engagement data were collected through log-data tracking, for example, communication with e-therapists, homework submissions, log-ins, minutes working with EJDeR, and modules completed. Chi-square tests examined differences between adherers and nonadherers and fathers and mothers concerning categorical data. Independent-samples t tests examined differences regarding continuous variables.

RESULTS

Module completion rates were higher among those who worked with behavioral activation as their first LICBT module versus worry management. Of the 20 nonadherers who opened the first LICBT module allocated, 30% (n=6) opened behavioral activation and 70% (n=14) opened worry management. No significant differences in sociodemographic characteristics were found. Nonadherers who opened behavioral activation as the first LICBT module allocated had a significantly higher level of depression symptoms at baseline than adherers. No other differences in depression and anxiety scores between adherers and nonadherers were found. Minutes working with EJDeR, number of log-ins, days using EJDeR, number of written messages sent to e-therapists, number of written messages sent to participants, and total number of homework exercises submitted were significantly higher among adherers than among nonadherers. There were no significant differences between fathers and mothers regarding user engagement variables.

CONCLUSIONS

Straightforward techniques, such as behavioral activation, may be well-suited for digital delivery, and more complex techniques, such as worry management, may require modifications to improve user engagement. User engagement was measured behaviorally, for example, through log-data tracking, and future research should measure emotional and cognitive components of engagement.

TRIAL REGISTRATION

ISRCTN Registry 57233429; https://doi.org/10.1186/ISRCTN57233429.

Development and effectiveness evaluation of an interactive e-learning environment to enhance digital health literacy in cancer patients: study protocol for a randomized controlled trial

Background

The Internet allows cancer patients to access information about their disease at any time. However, the quality of online information varies widely and is often inaccurate or does not provide all the details patients need to make informed decisions. Additionally, patients' often limited ability to find and evaluate cancer-related online information can lead to misinformation.

Objective

An interactive e-learning environment to promote digital health literacy will be developed and evaluated for effectiveness.

Primary hypothesis

Cancer patients who use the e-learning environment (IG1.1-IG1.3) or the content of the environment as a non-interactive PDF file (IG2) will show greater improvement in their digital health literacy from baseline to 8 weeks after baseline compared to patients who receive no such intervention, but are referred to a standard information brochure.

Methods

The hypothesis will be tested in a stratified randomized controlled superiority trial with five parallel groups and the primary endpoint of digital health literacy. In an e-learning environment, patients will learn strategies to use when searching for reliable cancer-related online information. During development, a prototype will be refined through focus groups and tested for usability by experts and patients. 660 cancer patients will be recruited using convenience sampling and randomly assigned in a 3:1:1 ratio to IG1.1-IG1.3 (three variants of the environment), IG2, or the control group. Two thirds of the 660 participants will be recruited through the German Cancer Information Service (CIS) and one third through non-CIS routes. Allocation will follow stratified randomization, accounting for recruitment route (CIS vs. non-CIS) and cancer type (breast cancer vs. other cancers), with variable block length. The primary outcome, digital health literacy, will be measured at baseline, 2 weeks, and 8 weeks after baseline.

Conclusion

If the results support the primary hypothesis, then the e-learning environment could empower patients to retrieve more reliable information about their disease. Concerns about the generalizability of the results, since a disproportionate number of inquiries to the CIS come from breast cancer patients, are addressed by a proportionally stratified randomization strategy and diversified recruitment routes.

Developing a Machine Learning-Based Automated Patient Engagement Estimator for Telehealth: Algorithm Development and Validation Study

BACKGROUND

Patient engagement is a critical but challenging public health priority in behavioral health care. During telehealth sessions, health care providers need to rely predominantly on verbal strategies rather than typical nonverbal cues to effectively engage patients. Hence, the typical patient engagement behaviors are now different, and health care provider training on telehealth patient engagement is unavailable or quite limited. Therefore, we explore the application of machine learning for estimating patient engagement. This can assist psychotherapists in the development of a therapeutic relationship with the patient and enhance patient engagement in the treatment of mental health conditions during tele-mental health sessions.

OBJECTIVE

This study aimed to examine the ability of machine learning models to estimate patient engagement levels during a tele-mental health session and understand whether the machine learning approach could support therapeutic engagement between the client and psychotherapist.

METHODS

We proposed a multimodal learning-based approach. We uniquely leveraged latent vectors corresponding to affective and cognitive features frequently used in psychology literature to understand a person's level of engagement. Given the labeled data constraints that exist in health care, we explored a semisupervised learning solution. To support the development of similar technologies for telehealth, we also plan to release a dataset called Multimodal Engagement Detection in Clinical Analysis (MEDICA). This dataset includes 1229 video clips, each lasting 3 seconds. In addition, we present experiments conducted on this dataset, along with real-world tests that demonstrate the effectiveness of our method.

RESULTS

Our algorithm reports a 40% improvement in root mean square error over state-of-the-art methods for engagement estimation. In our real-world tests on 438 video clips from psychotherapy sessions with 20 patients, in comparison to prior methods, positive correlations were observed between psychotherapists' Working Alliance Inventory scores and our mean and median engagement level estimates. This indicates the potential of the proposed model to present patient engagement estimations that align well with the engagement measures used by psychotherapists.

CONCLUSIONS

Patient engagement has been identified as being important to improve therapeutic alliance. However, limited research has been conducted to measure this in a telehealth setting, where the therapist lacks conventional cues to make a confident assessment. The algorithm developed is an attempt to model person-oriented engagement modeling theories within machine learning frameworks to estimate the level of engagement of the patient accurately and reliably in telehealth. The results are encouraging and emphasize the value of combining psychology and machine learning to understand patient engagement. Further testing in the real-world setting is necessary to fully assess its usefulness in helping therapists gauge patient engagement during online sessions. However, the proposed approach and the creation of the new dataset, MEDICA, open avenues for future research and the development of impactful tools for telehealth.

Unveiling the impact of perceived stigma on psychological well-being in adult patients with inflammatory bowel disease: The mediating role of patient engagement

This study elucidated the impact of perceived stigma on the well-being of inflammatory bowel disease (IBD) patients and explored the mediating role of patient engagement. A descriptive cross-sectional study was conducted using an online survey, recruiting participants through the Italian IBD patient organization. The survey assessed perceived stigma, psychological well-being, and patient engagement using validated instruments. Data were analyzed using multiple regressions and bias-corrected bootstrapping analysis. Perceived stigma significantly predicted psychological well-being, and patient engagement significantly predicted well-being. Patient engagement partially mediated the relationship between perceived stigma and well-being, suggesting that lower levels of patient engagement were associated with higher perceived stigma, negatively affecting well-being. Perceived stigma significantly impairs the psychological well-being of IBD patients. However, patient engagement is important for mitigating adverse effects of stigma and enhancing overall well-being. Interventions to reduce stigma and promote patient engagement are essential for improving health outcomes in IBD management.

The CeHRes Roadmap 2.0: Update of a Holistic Framework for Development, Implementation, and Evaluation of eHealth Technologies

To ensure that an eHealth technology fits with its intended users, other stakeholders, and the context within which it will be used, thorough development, implementation, and evaluation processes are necessary. The CeHRes (Centre for eHealth and Wellbeing Research) Roadmap is a framework that can help shape these processes. While it has been successfully used in research and practice, new developments and insights have arisen since the Roadmap's first publication in 2011, not only within the domain of eHealth but also within the different disciplines in which the Roadmap is grounded. Because of these new developments and insights, a revision of the Roadmap was imperative. This paper aims to present the updated pillars and phases of the CeHRes Roadmap 2.0. The Roadmap was updated based on four types of sources: (1) experiences with its application in research; (2) literature reviews on eHealth development, implementation, and evaluation; (3) discussions with eHealth researchers; and (4) new insights and updates from relevant frameworks and theories. The updated pillars state that eHealth development, implementation, and evaluation (1) are ongoing and intertwined processes; (2) have a holistic approach in which context, people, and technology are intertwined; (3) consist of continuous evaluation cycles; (4) require active stakeholder involvement from the start; and (5) are based on interdisciplinary collaboration. The CeHRes Roadmap 2.0 consists of 5 interrelated phases, of which the first is the contextual inquiry, in which an overview of the involved stakeholders, the current situation, and points of improvement is created. The findings from the contextual inquiry are specified in the value specification, in which the foundation for the to-be-developed eHealth technology is created by formulating values and requirements, preliminarily selecting behavior change techniques and persuasive features, and initiating a business model. In the Design phase, the requirements are translated into several lo-fi and hi-fi prototypes that are iteratively tested with end users and other stakeholders. A version of the technology is rolled out in the Operationalization phase, using the business model and an implementation plan. In the Summative Evaluation phase, the impact, uptake, and working mechanisms are evaluated using a multimethod approach. All phases are interrelated by continuous formative evaluation cycles that ensure coherence between outcomes of phases and alignment with stakeholder needs. While the CeHRes Roadmap 2.0 consists of the same phases as the first version, the objectives and pillars have been updated and adapted, reflecting the increased emphasis on behavior change, implementation, and evaluation as a process. There is a need for more empirical studies that apply and reflect on the CeHRes Roadmap 2.0 to provide points of improvement because just as with any eHealth technology, the Roadmap has to be constantly improved based on the input of its users.

Assessing the Effectiveness of an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Single-Case and Pre-Post Experimental Design Study

BACKGROUND

This study focuses on the Budd app, a mobile health intervention designed for gay, bisexual, and other men who have sex with men who participate in chemsex. Chemsex, the use of psychoactive drugs in a sexual context, presents substantial health risks including increased HIV transmission and mental health issues. Addressing these risks requires innovative interventions tailored to the unique needs of this population.

OBJECTIVE

This study aims to evaluate the effectiveness of the Budd app in promoting drug harm reduction practices among its users, focusing on knowledge, behavioral intention, risk behavior awareness, and self-efficacy.

METHODS

The study used a mixed methods approach, combining a single-case experimental design and a pre-post study. A total of 10 participants from an outpatient clinic were recruited, and each attended the clinic 3 times. During the first visit, participants installed a restricted version of the Budd app, which allowed them to report daily mood and risk behavior after chemsex sessions. Phase A (baseline) lasted at least 2 weeks depending on chemsex participation. In the second visit, participants gained full access to the Budd app, initiating phase B (intervention). Phase B lasted at least 6 weeks, depending on chemsex participation, with identical data input as phase A. Participants completed pre- and postintervention surveys assessing behavioral determinants during the first and third visit.

RESULTS

The study observed an increased knowledge about chemsex substances postintervention, with a mean percentage improvement in knowledge scores of 20.59% (SD 13.3%) among participants. Behavioral intention and self-efficacy showed mixed results, with some participants improving while others experienced a decrease. There was also a variable impact on awareness of risk behavior, with half of the participants reporting a decrease postintervention. Despite these mixed results, the app was generally well-received, with participants engaging with the app's features an average of 50 times during the study.

CONCLUSIONS

The Budd app showed effectiveness in enhancing knowledge about chemsex substances among gay, bisexual, and other men who have sex with men. However, its impact on safe dosing behavior, behavioral intention, self-efficacy, and risk behavior awareness was inconsistent. These findings suggest that while educational interventions can increase knowledge, translating this into behavioral change is more complex and may require more participants, a longer follow-up period, and additional strategies and support mechanisms.

Just-in-Time Adaptive Interventions for Behavior Change in Physiological Health Outcomes and the Use Case for Knee Osteoarthritis: Systematic Review

BACKGROUND

The prevalence of knee osteoarthritis (KOA) in the adult population is high and patients profit from individualized therapy approaches. Just-in-time adaptive interventions (JITAIs) are upcoming digital interventions for behavior change.

OBJECTIVE

This systematic review summarizes the features and effectiveness of existing JITAIs regarding important physiological health outcomes and derives the most promising features for the use case of KOA.

METHODS

The electronic databases PubMed, Web of Science, Scopus, and EBSCO were searched using keywords related to JITAIs, physical activity (PA), sedentary behavior (SB), physical function, quality of life, pain, and stiffness. JITAIs for adults that focused on the effectiveness of at least 1 of the selected outcomes were included and synthesized qualitatively. Study quality was assessed with the Quality Assessment Tool Effective Public Health Practice Project.

RESULTS

A total of 45 studies with mainly weak overall quality were included in this review. The studies were mostly focused on PA and SB and no study examined stiffness. The design of JITAIs varied, with a frequency of decision points from a minute to a day, device-based measured and self-reported tailoring variables, intervention options including audible or vibration prompts and tailored feedback, and decision rules from simple if-then conditions based on 1 variable to more complex algorithms including contextual variables.

CONCLUSIONS

The use of frequent decision points, device-based measured tailoring variables accompanied by user input, intervention options tailored to user preferences, and simple decision rules showed the most promising results in previous studies. This can be transferred to a JITAI for the use case of KOA by using target variables that include breaks in SB and an optimum of PA considering individual knee load for the health benefits of patients.

Revisiting the hospital-issued gown in hospitalizations from a locus of control and patient-centered care perspectives: a call for design thinking

Introduction

Patient-centered care (PCC) is the preferred health policy approach that emphasizes responding to individual patient preferences, wishes, and needs. PCC requires active patient engagement. While there has been extensive research on physicians' robes, there is limited research on hospital-issued patient gowns during hospitalizations. How does the gown affect the cognitive-emotional experience of hospitalized patients? How is the gown associated with PCC?

Methods

The sample of this cross-sectional study consisted of 965 patients who were hospitalized at least once during the past year in a tertiary hospital. Measures were previously published.

Results

The gown was strongly associated with lack of control and increased distress, and was negatively associated with patient proactiveness, engagement, and taking responsibility for self-management of chronic illness. Compared to male patients, female patients wearing the gown had stronger negative emotions and cognitively strong associations with the external locus of control, which inhibited engagement.

Discussion

The hospital gown is an unacknowledged barrier to achieving PCC, inhibits patient engagement, and reflects the paradoxes of inadvertently excluding patients' needs from hospital practice. The hospital gown must be modified to protect the patient's voice and enhance engagement. Policymakers are called to apply design thinking to facilitate patient participation in decision-making to accord hospital clothing to PCC and improve healthcare delivery.

Effects on patient activation of eHealth support in addition to standard care in patients after radical prostatectomy: Analysis of secondary outcome from a randomized controlled trial

INTRODUCTION

Prostate cancer is often treated with radical prostatectomy, but surgery can leave patients with side effects. Patients who actively take part in their rehabilitation have been shown to achieve better clinical outcomes. eHealth support has the potential to increase patient activation, but has rarely been evaluated in long-term randomized controlled trials. Therefore, we evaluated the effects on patient activation of eHealth support (electronic Patient Activation in Treatment at Home, ePATH) based on motivational theory. The aim was to investigate the effects of eHealth support on patient activation at 6 and 12 months after radical prostatectomy, compared with standard care alone, and associations with baseline patient activation and depression.

METHODS

A multicentre randomized controlled trial with two study arms was conducted. Men planned for radical prostatectomy at three county hospitals in southern Sweden were included and randomized to the intervention or control group. The effects of ePATH on the secondary outcome, patient activation, were evaluated for one year after surgery using the patient activation measure and analysed using a linear mixed model.

RESULTS

The study included 170 men during 2018-2019. In the intervention group, 64% (53/83) used ePATH. The linear mixed model showed no significant differences between groups in patient activation [β -2.32, P .39; CI -7.64-3.00]. Baseline patient activation [β 0.65, P < .001; CI 0.40-0.91] and depression [β -0.86, P .03; CI -1.64- -0.07] statistically impacted patient activation scores over one year.

CONCLUSIONS

ePATH had no impact on patient activation during long-term prostate cancer rehabilitation. However, patient activation at baseline and depression scores significantly influenced patient activation, underlining the need to assess these aspects in prostate cancer surgery rehabilitation.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN18055968, (07/06/2018); https://www.isrctn.com/ISRCTN18055968; International Registered Report Identifier: RR2-10.2196/11625.

Application of Positive Psychology in Digital Interventions for Children, Adolescents, and Young Adults: Systematic Review and Meta-Analysis of Controlled Trials

BACKGROUND

The rising prevalence of mental health issues in children, adolescents, and young adults has become an escalating public health issue, impacting approximately 10%-20% of young people on a global scale. Positive psychology interventions (PPIs) can act as powerful mental health promotion tools to reach wide-ranging audiences that might otherwise be challenging to access. This increased access would enable prevention of mental disorders and promotion of widespread well-being by enhancing self-efficacy, thereby supporting the achievement of tangible objectives.

OBJECTIVE

We aimed to conduct a comprehensive synthesis of all randomized controlled trials and controlled trials involving children, adolescents, and young adults, encompassing both clinical and nonclinical populations, to comprehensively evaluate the effectiveness of digital PPIs in this age group.

METHODS

After a literature search in 9 electronic databases until January 12, 2023, and gray literature until April 2023, we carried out a systematic review of 35 articles, of which 18 (51%) provided data for the meta-analysis. We included randomized controlled trials and controlled trials mainly based on web-based, digital, or smartphone-based interventions using a positive psychology framework as the main component. Studies included participants with a mean age of <35 years. Outcomes of PPIs were classified into indicators of well-being (compassion, life satisfaction, optimism, happiness, resilience, emotion regulation and emotion awareness, hope, mindfulness, purpose, quality of life, gratitude, empathy, forgiveness, motivation, and kindness) and ill-being (depression, anxiety, stress, loneliness, and burnout). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used for the selection of studies and data extraction. Quality assessment was performed following the CONSORT (Consolidated Standards of Reporting Trials) guidelines.

RESULTS

For well-being outcomes, meta-analytic results showed that PPIs augmented the feeling of purpose, gratitude, and hope (Hedges g=0.555), compassion (Hedges g=0.447), positive coping behaviors (Hedges g=0.421), body image-related outcomes (Hedges g=0.238), and positive mindset predisposition (Hedges g=0.304). For ill-being outcomes, PPIs reduced cognitive biases (Hedges g=-0.637), negative emotions and mood (Hedges g=-0.369), and stress levels (Hedges g=-0.342). Of note, larger effect sizes were found when a waiting list control group was considered versus a digital control group. A funnel plot showed no publication bias. Meta-regression analyses showed that PPIs tended to show a larger effect size on well-being outcomes in studies including young adults, whereas no specific effect was found for ill-being outcomes.

CONCLUSIONS

Revised evidence suggests that PPIs benefit young people's well-being and mitigate ill-being symptoms. Digital platforms offer a unique way to address their mental health challenges, although not without limitations. Future research should explore how they work for the needs of the young population and further examine what specific PPIs or combination of interventions is most beneficial with respect to other digital control groups.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42023420092; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=420092.

Measuring Engagement in Provider-Guided Digital Health Interventions With a Conceptual and Analytical Framework Using Nurse WRITE as an Exemplar: Exploratory Study With an Iterative Approach

BACKGROUND

Limited guidance exists for analyzing participant engagement in provider-guided digital health interventions (DHIs). System usage is commonly assessed, with acknowledged limitations in measuring socio-affective and cognitive aspects of engagement. Nurse WRITE, an 8-week web-based nurse-guided DHI for managing symptoms among women with recurrent ovarian cancer, offers an opportunity to develop a framework for assessing multidimensional engagement.

OBJECTIVE

This study aims to develop a conceptual and analytic framework to measure socio-affective, cognitive, and behavioral engagement with provider-guided DHIs. We then illustrate the framework's ability to describe and categorize engagement using Nurse WRITE as an example.

METHODS

A sample of 68 participants from Nurse WRITE who posted on the message boards were included. We adapted a prior framework for conceptualizing and operationalizing engagement across 3 dimensions and finalized a set of 6 distinct measures. Using patients' posts, we created 2 socio-affective engagement measures-total count of socio-affective engagement classes (eg, sharing personal experience) and total word count-and 2 cognitive engagement measures-total count of cognitive engagement classes (eg, asking information-seeking questions) and average question completion percentage. Additionally, we devised behavioral engagement measures using website data-the total count of symptom care plans and plan reviews. k-Means clustering categorized the participants into distinct groups based on levels of engagement across 3 dimensions. Descriptive statistics and narratives were used to describe engagement in 3 dimensions.

RESULTS

On average, participants displayed socio-affective engagement 34.7 times, writing 14,851 words. They showed cognitive engagement 19.4 times, with an average of 78.3% completion of nurses' inquiries. Participants also submitted an average of 1.6 symptom care plans and 0.7 plan reviews. Participants were clustered into high (n=13), moderate (n=17), and low engagers (n=38) based on the 6 measures. High engagers wrote a median of 36,956 (IQR 26,199-46,265) words. They demonstrated socio-affective engagement approximately 81 times and cognitive engagement around 46 times, approximately 6 times that of the low engagers and twice that of the moderate engagers. High engagers had a median of 91.7% (IQR 82.2%-93.7%) completion of the nurses' queries, whereas moderate engagers had 86.4% (IQR 80%-96.4%), and low engagers had 68.3% (IQR 60.1%-79.6%). High engagers completed a median of 3 symptom care plans and 2 reviews, while moderate engagers completed 2 plans and 1 review. Low engagers completed a median of 1 plan with no reviews.

CONCLUSIONS

This study developed and reported an engagement framework to guide behavioral intervention scientists in understanding and analyzing participants' engagement with provider-guided DHIs. Significant variations in engagement levels across 3 dimensions highlight the importance of measuring engagement with provider-guided DHIs in socio-affective, cognitive, and behavioral dimensions. Future studies should validate the framework with other DHIs, explore the influence of patient and provider factors on engagement, and investigate how engagement influences intervention efficacy.

The conceptualisation and measurement of engagement in digital health

Digital tools are an increasingly important component of healthcare, but their potential impact is commonly limited by a lack of user engagement. Digital health evaluations of engagement are often restricted to system usage metrics, which cannot capture a full understanding of how and why users engage with an intervention. This study aimed to examine how theory-based, multifaceted measures of engagement with digital health interventions capture different components of engagement (affective, cognitive, behavioural, micro, and macro) and to consider areas that are unclear or missing in their measurement. We identified and compared two recently developed measures that met these criteria (the Digital Behaviour Change Intervention Engagement Scale and the TWente Engagement with Ehealth Technologies Scale). Despite having similar theoretical bases and being relatively strongly correlated, there are key differences in how these scales aim to capture engagement. We discuss the implications of our analysis for how affective, cognitive, and behavioural components of engagement can be conceptualised and whether there is value in distinguishing between them. We conclude with recommendations for the circumstances in which each scale may be most useful and for how future measure development could supplement existing scales.

An mHealth Intervention Promoting Physical Activity and Healthy Eating in a Family Setting (SMARTFAMILY): Randomized Controlled Trial

BACKGROUND

Numerous smartphone apps are targeting physical activity (PA) and healthy eating (HE), but empirical evidence on their effectiveness for the initialization and maintenance of behavior change, especially in children and adolescents, is still limited. Social settings influence individual behavior; therefore, core settings such as the family need to be considered when designing mobile health (mHealth) apps.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a theory- and evidence-based mHealth intervention (called SMARTFAMILY [SF]) targeting PA and HE in a collective family-based setting.

METHODS

A smartphone app based on behavior change theories and techniques was developed, implemented, and evaluated with a cluster randomized controlled trial in a collective family setting. Baseline (t0) and postintervention (t1) measurements included PA (self-reported and accelerometry) and HE measurements (self-reported fruit and vegetable intake) as primary outcomes. Secondary outcomes (self-reported) were intrinsic motivation, behavior-specific self-efficacy, and the family health climate. Between t0 and t1, families of the intervention group (IG) used the SF app individually and collaboratively for 3 consecutive weeks, whereas families in the control group (CG) received no treatment. Four weeks following t1, a follow-up assessment (t2) was completed by participants, consisting of all questionnaire items to assess the stability of the intervention effects. Multilevel analyses were implemented in R (R Foundation for Statistical Computing) to acknowledge the hierarchical structure of persons (level 1) clustered in families (level 2).

RESULTS

Overall, 48 families (CG: n=22, 46%, with 68 participants and IG: n=26, 54%, with 88 participants) were recruited for the study. Two families (CG: n=1, 2%, with 4 participants and IG: n=1, 2%, with 4 participants) chose to drop out of the study owing to personal reasons before t0. Overall, no evidence for meaningful and statistically significant increases in PA and HE levels of the intervention were observed in our physically active study participants (all P>.30).

CONCLUSIONS

Despite incorporating behavior change techniques rooted in family life and psychological theories, the SF intervention did not yield significant increases in PA and HE levels among the participants. The results of the study were mainly limited by the physically active participants and the large age range of children and adolescents. Enhancing intervention effectiveness may involve incorporating health literacy, just-in-time adaptive interventions, and more advanced features in future app development. Further research is needed to better understand intervention engagement and tailor mHealth interventions to individuals for enhanced effectiveness in primary prevention efforts.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00010415; https://drks.de/search/en/trial/DRKS00010415.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/20534.

Designing mHealth Apps to Incorporate Evidence-Based Techniques for Prolonging User Engagement

Maintaining user engagement with mobile health (mHealth) apps can be a challenge. Previously, we developed a conceptual model to optimize patient engagement in mHealth apps by incorporating multiple evidence-based methods, including increasing health literacy, enhancing technical competence, and improving feelings about participation in clinical trials. This viewpoint aims to report on a series of exploratory mini-experiments demonstrating the feasibility of testing our previously published engagement conceptual model. We collected data from 6 participants using an app that showed a series of educational videos and obtained additional data via questionnaires to illustrate and pilot the approach. The videos addressed 3 elements shown to relate to engagement in health care app use: increasing health literacy, enhancing technical competence, and improving positive feelings about participation in clinical trials. We measured changes in participants' knowledge and feelings, collected feedback on the videos and content, made revisions based on this feedback, and conducted participant reassessments. The findings support the feasibility of an iterative approach to creating and refining engagement enhancements in mHealth apps. Systematically identifying the key evidence-based elements intended to be included in an app's design and then systematically testing the implantation of each element separately until a satisfactory level of positive impact is achieved is feasible and should be incorporated into standard app design. While mHealth apps have shown promise, participants are more likely to drop out than to be retained. This viewpoint highlights the potential for mHealth researchers to test and refine mHealth apps using approaches to better engage users.

Mobile app activity engagement by cancer patients and their caregivers informs remote monitoring

Mobile phone applications ("apps") are potentially an effective, low-burden method to collect patient-reported outcomes outside the clinical setting. Using such apps consistently and in a timely way is critical for complete and accurate data capture, but no studies of concurrent reporting by cancer patient-caregiver dyads have been published in the peer-reviewed literature. This study assessed app engagement, defined as adherence, timing, and attrition with two smartphone applications, one for adult cancer patients and one for their informal caregivers. This was a single-arm, pilot study in which adult cancer patients undergoing IV chemotherapy or immunotherapy used the DigiBioMarC app, and their caregivers used the TOGETHERCare app, for approximately one month to report weekly on the patients' symptoms and wellbeing. Using app timestamp metadata, we assessed user adherence, overall and by participant characteristics. Fifty patient-caregiver dyads completed the study. Within the one-month study period, both adult cancer patients and their informal caregivers were highly adherent, with app activity completion at 86% for cancer patients and 84% for caregivers. Caregivers completed 86% of symptom reports, while cancer patients completed 89% of symptom reports. Cancer patients and their caregivers completed most activities within 48 h of availability on the app. These results suggest that the DigiBioMarC and TOGETHERCare apps can be used to collect patient- and caregiver-reported outcomes data during intensive treatment. From our research, we conclude that metadata from mobile apps can be used to inform clinical teams about study participants' engagement and wellbeing outside the clinical setting.

Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas

BACKGROUND

Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.

METHODS

SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up.

DISCUSSION

Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.

What does it mean to be engaged with digital health interventions? A qualitative study into the experiences of engaged users and the views of professionals

Objective

Digital health interventions (DHIs) hold promise for influencing health behaviors positively, but their widespread implementation and effectiveness remain limited. Engagement is crucial for DHI effectiveness, yet its conceptualization is debated. This qualitative study explores engagement from user and professional perspectives.

Methods

Twenty self-proclaimed engaged health app users participated in semistructured interviews, and 13 professionals working with DHIs completed an online survey.

Results

Interviews with health app users revealed three key components of their sense of engagement: behavioral, cognitive, and affective. Behavioral engagement includes routine, effortless, and dynamic usage; emphasizing the importance of the quality of fit between user and technology over frequency of use. Cognitive engagement encompasses the technology's utility as a tool for supporting behavior change, providing new insights, and enhancing motivation. Affective engagement involves enjoying progress, deriving pleasure from using the technology, and identifying with the technology. Notably, participants exhibited varying emphasis on these components. Professionals, in a parallel inquiry, agreed on the relevance of behavior, cognition, and affect in defining engagement. In their understanding, behavioral engagement is often associated with adherence and frequency of use, while cognitive engagement emphasizes understanding, motivation, and achieving cognitive outcomes. Affective engagement, although diverse, is recognized as a critical dimension. In addition, it was noticeable that users and professionals perceived microengagement (with the DHI) and macroengagement (with the target behavior) as interconnected.

Conclusion

To conclude, this study contributes a nuanced understanding of the multifaceted nature of engagement, informing future measurement of the concept, DHI design, and implementation strategies for improved user experiences and outcomes.

The added value of an internet-based intervention for treatment of aggression in forensic psychiatric outpatients-study protocol for a multicentre, mixed-methods randomized controlled trial

Background

Even though internet-based interventions have been used in treatment of forensic psychiatric outpatients for over 10 years, no robust effectiveness studies have been conducted in this complex branch of mental healthcare.

Objectives

To present the protocol of a study that investigates whether the addition of the internet-based intervention "Dealing with Aggression" to treatment as usual (TAU) leads to better treatment outcomes than TAU that is delivered solely in-person.

Methods

This study uses a multicentre mixed-methods randomized controlled trial (RCT) design, with four Dutch forensic outpatient organizations. Patients are included if they receive outpatient treatment for aggression. They will be randomized into an experimental condition, in which the intervention is added to TAU (n = 64), or a control condition, with only TAU (n = 64). Participants are assessed four times: at baseline (T0), halfway during the 10-week intervention (T1), after completing the intervention (T2), and after 3 months (T3). Primary outcome measure is self-reported aggression, other outcome measures are regulatory emotional self-efficacy and treatment readiness, the number of treatment sessions, and dynamic risk factors. Adherence to and engagement with the internet-based intervention will be investigated as predictors for effectiveness. Perceived effect and points of improvement are identified via semistructured interviews with patients and therapists.

Discussion

This will be the first study to investigate the effectiveness of an internet-based intervention in a forensic psychiatric outpatient sample. By means of the mixed-methods design and use of adherence and engagement as predictors, this study will answers questions about if, but also why and for whom this intervention works.

Macro-engagement in mHealth: Exploring user engagement beyond the screen

While digital technology holds great promise for health and well-being, some users feel sceptical about the time they spend online and how they use their mobile devices. This attitude could hamper uptake of digital health technologies and engagement with them. This study uses the concept of macro-engagement as a starting point to investigate how users of digital behaviour change interventions (DBCIs) engage with their behaviour change goals beyond the screens of their tools. Thirty semi-structured interviews were conducted with individuals who take part in behaviour change processes in different ways (i.e. mental health professionals, digital health experts and users of DBCIs). A qualitative analysis of their data through a grounded theory approach highlighted a wide array of offscreen behaviors and strategies that complement a behavior change process offscreen. Furthermore, implications for designing technology that encourages progressive non-reliance on DBCI usage are drawn out.

Cultural Responsivity in Technology-Enabled Services: Integrating Culture Into Technology and Service Components

Technology-enabled services (TESs) are clinical interventions that combine technological and human components to provide health services. TESs for mental health are efficacious in the treatment of anxiety and depression and are currently being offered as frontline treatments around the world. It is hoped that these interventions will be able to reach diverse populations across a range of identities and ultimately decrease disparities in mental health treatment. However, this hope is largely unrealized. TESs include both technology and human service components, and we argue that cultural responsivity must be considered in each of these components to help address existing treatment disparities. To date, there is limited guidance on how to consider cultural responsivity within these interventions, including specific targets for the development, tailoring, or design of the technologies and services within TESs. In response, we propose a framework that provides specific recommendations for targets based on existing models, both at the technological component level (informed by the Behavioral Intervention Technology Model) and the human support level (informed by the Efficiency Model of Support). We hope that integrating culturally responsive considerations into these existing models will facilitate increased attention to cultural responsivity within TESs to ensure they are ethical and responsive for everyone.

The Effect of a Digital Mental Health Program on Anxiety and Depression Symptoms: Retrospective Analysis of Clinical Severity

BACKGROUND

Evidence-based digital health programs have shown efficacy in being primary tools to improve emotional and mental health, as well as offering supplementary support to individuals undergoing psychotherapy for anxiety, depression, and other mental health disorders. However, information is lacking about the dose response to digital mental health interventions.

OBJECTIVE

The objective of the study was to examine the effect of time in program and program usage on symptom change among individuals enrolled in a real-world comprehensive digital mental health program (myStrength) who are experiencing severe anxiety or depression.

METHODS

Eligible participants (N=18,626) were adults aged 18 years and older who were enrolled in myStrength for at least four weeks as part of their employee wellness benefit program, who completed baseline, the 2-week, 2-month, and 6-month surveys querying symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD-7]) and depression (Patient Health Questionnaire-9 [PHQ-9]). Linear growth curve models were used to analyze the effect of average weekly program usage on subsequent GAD-7 and PHQ-9 scores for participants with scores indicating severe anxiety (GAD-7≥15) or depression (PHQ-9≥15). All models were adjusted for baseline score and demographics.

RESULTS

Participants in the study (N=1519) were 77.4% female (1176/1519), had a mean age of 45 years (SD 14 years), and had an average enrollment time of 3 months. At baseline, participants reported an average of 9.39 (SD 6.04) on the GAD-7 and 11.0 (SD 6.6) on the PHQ-9. Those who reported 6-month results had an average of 8.18 (SD 6.15) on the GAD-7 and 9.18 (SD 6.79) on the PHQ-9. Participants with severe scores (n=506) experienced a significant improvement of 2.97 (SE 0.35) and 3.97 (SE 0.46) at each time point for anxiety and depression, respectively (t=-8.53 and t=-8.69, respectively; Ps<.001). Those with severe baseline scores also saw a reduction of 0.27 (SE 0.08) and 0.25 (SE 0.09) points in anxiety and depression, respectively, for each additional program activity per week (t=-3.47 and t=-2.66, respectively; Ps<.05).

CONCLUSIONS

For participants with severe baseline scores, the study found a clinically significant reduction of approximately 9 points for anxiety and 12 points for depression after 6 months of enrollment, suggesting that interventions targeting mental health must maintain active, ongoing engagement when symptoms are present and be available as a continuous resource to maximize clinical impact, specifically in those experiencing severe anxiety or depression. Moreover, a dosing effect was shown, indicating improvement in outcomes among participants who engaged with the program every other day for both anxiety and depression. This suggests that digital mental health programs that provide both interesting and evidence-based activities could be more successful in further improving mental health outcomes.

A blended preconception lifestyle programme for couples undergoing IVF: lessons learned from a multicentre randomized controlled trial

STUDY QUESTION

What is the effect of a blended preconception lifestyle programme on reproductive and lifestyle outcomes of couples going through their first 12 months of IVF as compared to an attention control condition?

SUMMARY ANSWER

This randomized controlled trial (RCT) was stopped prematurely because of the coronavirus disease 2019 (Covid-19) pandemic but the available data did not suggest that a blended preconception lifestyle programme could meaningfully affect time to ongoing pregnancy or other reproductive and lifestyle outcomes.

WHAT IS KNOWN ALREADY

Increasing evidence shows associations between a healthy lifestyle and IVF success rates. Lifestyle programmes provided through a mobile phone application have yet to be evaluated by RCTs in couples undergoing IVF.

STUDY DESIGN SIZE DURATION

A multicentre RCT (1:1) was carried out. The RCT started in January 2019 and was prematurely stopped because of the Covid-19 pandemic, leading to a reduced sample size (211 couples initiating IVF) and change in primary outcome (cumulative ongoing pregnancy to time to ongoing pregnancy).

PARTICIPANTS/MATERIALS SETTING METHODS

Heterosexual couples initiating IVF in five fertility clinics were randomized between an attention control arm and an intervention arm for 12 months. The attention control arm received treatment information by mobile phone in addition to standard care. The intervention arm received the blended preconception lifestyle (PreLiFe)-programme in addition to standard care. The PreLiFe-programme included a mobile application, offering tailored advice and skills training on diet, physical activity and mindfulness, in combination with motivational interviewing over the telephone. The primary outcome was 'time to ongoing pregnancy'. Secondary reproductive outcomes included the Core Outcome Measures for Infertility Trials and IVF discontinuation. Changes in the following secondary lifestyle outcomes over 3 and 6 months were studied in both partners: diet quality, fruit intake, vegetable intake, total moderate to vigorous physical activity, sedentary behaviour, emotional distress, quality of life, BMI, and waist circumference. Finally, in the intervention arm, acceptability of the programme was evaluated and actual use of the mobile application part of the programme was tracked. Analysis was according to intention to treat.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 211 couples were randomized (105 control arm, 106 intervention arm). The hazard ratio of the intervention for time to ongoing pregnancy was 0.94 (95% CI 0.63 to 1.4). Little to no effect on other reproductive or lifestyle outcomes was identified. Although acceptability of the programme was good (6/10), considerable proportions of men (38%) and 9% of women did not actively use all the modules of the mobile application (diet, physical activity, or mindfulness).

LIMITATIONS REASONS FOR CAUTION

The findings of this RCT should be considered exploratory, as the Covid-19 pandemic limited its power and the actual use of the mobile application was low.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first multicentre RCT evaluating the effect of a blended preconception lifestyle programme for women and their partners undergoing IVF on both reproductive and lifestyle outcomes. This exploratory RCT highlights the need for further studies into optimal intervention characteristics and actual use of preconception lifestyle programmes, as well as RCTs evaluating effectiveness.

STUDY FUNDING/COMPETING INTERESTS

Supported by the Research foundation Flanders (Belgium) (FWO-TBM; reference: T005417N). No competing interests to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03790449.

TRIAL REGISTRATION DATE

31 December 2018.

DATE OF FIRST PATIENT’S ENROLMENT

2 January 2019.

Potential associations between behavior change techniques and engagement with mobile health apps: a systematic review

Introduction

Lack of engagement is a common challenge for digital health interventions. To achieve their potential, it is necessary to understand how best to support users' engagement with interventions and target health behaviors. The aim of this systematic review was to identify the behavioral theories and behavior change techniques being incorporated into mobile health apps and how they are associated with the different components of engagement.

Methods

The review was structured using the PRISMA and PICOS frameworks and searched six databases in July 2022: PubMed, Embase, CINAHL, APA PsycArticles, ScienceDirect, and Web of Science. Risk of bias was evaluated using the Cochrane Collaboration Risk of Bias 2 and the Mixed Methods Appraisal Tools.

Analysis

A descriptive analysis provided an overview of study and app characteristics and evidence for potential associations between Behavior Change Techniques (BCTs) and engagement was examined.

Results

The final analysis included 28 studies. Six BCTs were repeatedly associated with user engagement: goal setting, self-monitoring of behavior, feedback on behavior, prompts/cues, rewards, and social support. There was insufficient data reported to examine associations with specific components of engagement, but the analysis indicated that the different components were being captured by various measures.

Conclusion

This review provides further evidence supporting the use of common BCTs in mobile health apps. To enable developers to leverage BCTs and other app features to optimize engagement in specific contexts and individual characteristics, we need a better understanding of how BCTs are associated with different components of engagement.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022312596.

Compassion apps for better mental health: qualitative review

BACKGROUND

There is increasing empirical evidence for the positive mental health effects of compassion-based interventions. Although numerous smartphone apps offering compassion-based interventions ('compassion apps') are now available for the general public, the quality of these apps has not yet been reviewed. A qualitative review of existing compassion apps serves as a crucial first step toward testing the efficacy of these apps, by identifying good-quality compassion apps that might be worth the investment of a scientific trial.

AIMS

The current study focuses on reviewing the quality of existing compassion apps.

METHOD

Existing compassion apps were identified through searches in the Google Play Store and App Store. The 24 included apps were reviewed on their quality by using the Mobile App Rating Scale, and on their consistency with current evidence by comparing them to existing and studied compassion-based interventions.

RESULTS

Of the 24 included apps, eight were identified that met the criteria of being consistent with existing and studied compassion-based interventions, and acceptable to good overall quality. The other 16 apps failed to meet one or both of these criteria.

CONCLUSIONS

Good-quality compassion apps are available, but many of the available apps fail to meet certain quality criteria. In particular, many apps failed to offer sufficient relevant and correct information, or failed to offer this information in an entertaining and interesting way. It is recommended that future compassion apps are based on a clear definition of compassion, offer evidence- and theory-based exercises and implement tools for increasing engagement.

Patient engagement practice within perinatal eHealth: A scoping review

BACKGROUND

There is a gap in knowledge about how perinatal eHealth programs function to support autonomy for new and expectant parents from pursuing wellness goals.

OBJECTIVES

To examine patient engagement (access, personalization, commitment and therapeutic alliance) within the practice of perinatal eHealth.

DESIGN

Scoping review.

METHODS

Five databases were searched in January 2020 and updated in April 2022. Reports were vetted by three researchers and included if they documented maternity/neonatal programs and utilized World Health Organization (WHO) person-centred digital health intervention (DHI) categories. Data were charted using a deductive matrix containing WHO DHI categories and patient engagement attributes. A narrative synthesis was conducted utilizing qualitative content analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 'extension for scoping reviews' guidelines were followed for reporting.

RESULTS

Twelve eHealth modalities were found across 80 included articles. The analysis yielded two conceptual insights: (1) The nature of perinatal eHealth programs: (1) emergence of a complex structure of practice and (2) practising patient engagement within perinatal eHealth.

CONCLUSION

Results will be used to operationalize a model of patient engagement within perinatal eHealth.

The Role of Compassionate Technology in Blended and Digital Mental Health Interventions: Systematic Scoping Review

BACKGROUND

An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context.

OBJECTIVE

This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care.

METHODS

Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion.

RESULTS

We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion.

CONCLUSIONS

We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Measuring Engagement with Mental Health and Behavior Change Interventions: an Integrative Review of Methods and Instruments

BACKGROUND

Engagement is a complex construct consisting of behavioral, cognitive, and affective dimensions, making engagement a difficult construct to measure. This integrative review aims to (1) present a multidisciplinary overview of measurement methods that are currently used to measure engagement with adult mental health and behavior change interventions, delivered in-person, blended, or digitally, and (2) provide a set of recommendations and considerations for researchers wishing to study engagement.

METHODS

We used an integrative approach and identified original studies and reviews on engagement with mental health or behavior change interventions that were delivered in-person, digitally, or blended.

RESULTS

Forty articles were analyzed in this review. Common methods to assess engagement were through objective usage data, questionnaire-based data, and qualitative data, with objective usage data being used most frequently. Based on the synthesis of engagement measures, we advise researchers to (1) predefine the operationalization of engagement for their specific research context, (2) measure behavioral, cognitive, and affective dimensions of engagement in all cases, and (3) measure engagement over time.

CONCLUSIONS

Current literature shows a bias towards behavioral measures of engagement in research, as most studies measured engagement exclusively through objective usage data, without including cognitive and affective measures of engagement. We hope that our recommendations will help to reduce this bias and to steer engagement research towards an integrated approach.

Design Features Associated With Engagement in Mobile Health Physical Activity Interventions Among Youth: Systematic Review of Qualitative and Quantitative Studies

BACKGROUND

Globally, 81% of youth do not meet the physical activity (PA) guidelines. Youth of families with a low socioeconomic position are less likely to meet the recommended PA guidelines. Mobile health (mHealth) interventions are preferred by youth over traditional in-person approaches and are in line with their media preferences. Despite the promise of mHealth interventions in promoting PA, a common challenge is to engage users in the long term or effectively. Earlier reviews highlighted the association of different design features (eg, notifications and rewards) with engagement among adults. However, little is known about which design features are important for increasing engagement among youth.

OBJECTIVE

To inform the design process of future mHealth tools, it is important to investigate the design features that can yield effective user engagement. This systematic review aimed to identify which design features are associated with engagement in mHealth PA interventions among youth who were aged between 4 and 18 years.

METHODS

A systematic search was conducted in EBSCOhost (MEDLINE, APA PsycINFO, and Psychology & Behavioral Sciences Collection) and Scopus. Qualitative and quantitative studies were included if they documented design features associated with engagement. Design features and related behavior change techniques and engagement measures were extracted. Study quality was assessed according to the Mixed Method Assessment Tool, and one-third of all screening and data extraction were double coded by a second reviewer.

RESULTS

Studies (n=21) showed that various features were associated with engagement, such as a clear interface, rewards, multiplayer game mode, social interaction, variety of challenges with personalized difficulty level, self-monitoring, and variety of customization options among others, including self-set goals, personalized feedback, progress, and a narrative. In contrast, various features need to be carefully considered while designing mHealth PA interventions, such as sounds, competition, instructions, notifications, virtual maps, or self-monitoring, facilitated by manual input. In addition, technical functionality can be considered as a prerequisite for engagement. Research addressing youth from low socioeconomic position families is very limited with regard to engagement in mHealth apps.

CONCLUSIONS

Mismatches between different design features in terms of target group, study design, and content translation from behavior change techniques to design features are highlighted and set up in a design guideline and future research agenda.

TRIAL REGISTRATION

PROSPERO CRD42021254989; https://tinyurl.com/5n6ppz24.

Examining young adults daily perspectives on usage of anxiety apps: A user study

The growing number of mental health smartphone applications has led to increased interest in how these tools might support users in different models of care. However, research on the use of these interventions in real-world settings has been scarce. It is important to understand how apps are used in a deployment setting, especially among populations where such tools might add value to current models of care. The objective of this study is to explore the daily use of commercially-available mobile apps for anxiety that integrate CBT, with a focus on understanding reasons for and barriers for app use and engagement. This study recruited 17 young adults (age M = 24.17 years) while on a waiting list to receive therapy in a Student Counselling Service. Participants were asked to select up to two of a list of three selected apps (Wysa, Woebot, and Sanvello) and instructed to use the apps for two weeks. Apps were selected because they used techniques from cognitive behavioral therapy, and offer diverse functionality for anxiety management. Qualitative and quantitative data were gathered through daily questionnaires to capture participants' experiences with the mobile apps. In addition, eleven semi-structured interviews were conducted at the end of the study. We used descriptive statistics to analyze participants' interaction with different app features and used a general inductive approach to analyze the collected qualitative data. The results highlight that users form opinions about the apps during the first days of app use. A number of barriers to sustained use are identified including cost-related issues, inadequate content to support long-term use, and a lack of customization options for different app functions. The app features used differ among participants with self-monitoring and treatment elements being the most used features.

Can digital health apps provide patients with support to promote structured diabetes education and ongoing self-management? A real-world evaluation of myDiabetes usage

Objective

Structured diabetes education has evidenced benefits yet reported uptake rates for those referred to traditional in-person programmes within 12 months of diagnosis were suboptimal. Digital health interventions provide a potential solution to improve diabetes education delivery at population scale, overcoming barriers identified with traditional approaches. myDiabetes is a cloud-based interactive digital health self-management app. This evaluation analysed usage data for people with type 2 diabetes focusing on digital structured diabetes education.

Methods

Descriptive quantitative analyses were conducted on existing anonymised user data over 12 months (November 2019-2020) to evaluate whether digital health can provide additional support to deliver diabetes education. Data was divided into two equal 6-month periods. As this overlapped the onset of COVID-19, analyses of its effect on usage were included as a secondary outcome. All data was reported via myDiabetes. Users were prescribed myDiabetes by National Health Service healthcare primary care teams. Those who registered for app use within the study period (n = 2783) were assessed for eligibility (n = 2512) and included if activated.

Results

Within the study period, n = 1245/2512 (49.6%) registered users activated myDiabetes. No statistically significant differences were observed between gender (p = 0.721), or age (p = 0.072) for those who activated (59.2 years, SD 12.93) and those who did not activate myDiabetes (57.6 years, SD 13.77). Activated users (n = 1119/1245 (89.8%)) viewed 11,572 education videos. No statistically significant differences were observed in education video views across age groups (p = 0.384), gender (p = 0.400), diabetes treatment type (p = 0.839) or smoking status (p = 0.655). Comparison of usage pre-COVID-19 and post-COVID-19 showed statistically significant increases in app activity (p ≤0.001).

Conclusion

Digital health is rapidly evolving in its role of supporting patients to self-manage. Since COVID-19 the benefits of digital technology have become increasingly recognised. There is potential for increasing diabetes education rates by offering patients a digital option in combination with traditional service delivery which should be substantiated through future research.

Time-out for well-being: A mixed methods evaluation of attitudes and likelihood to engage in different types of online emotional well-being programmes in the perinatal period

BACKGROUND

Positive maternal mental health during the perinatal period contributes to general well-being and positive emotional bonds with the child, encouraging an optimal developmental trajectory. Online interventions to enhance maternal well-being and develop coping skills, such as meditation-based interventions, can be a low-cost way to improve mother and child outcomes. However, this depends on end-user engagement. To date, there is limited evidence about women's willingness to engage and preferences for online programmes.

OBJECTIVES

This study explored pregnant women's attitudes towards and likelihood to undertake minimal online well-being training programmes (mindfulness, self-compassion, or general relaxation), engagement barriers and enablers, and programme structure preferences.

DESIGN

A mixed methods triangulation design was undertaken using a validating quantitative model. Quantile regressions were applied to the quantitative data. Content analysis was undertaken for the qualitative data.

METHODS

Consenting pregnant women (n = 151) were randomized equally to read about three online programme types. Participants were sent an information leaflet, tested by a consumer panel prior to distribution.

RESULTS

Participants generally held positive attitudes about all three types of interventions, with no statistically significant differences in preferences between programme types. Participants appreciated the importance of mental health and were receptive to fostering skills to support their emotional well-being and stress management. The most frequent perceived barriers were lack of time, tiredness, and forgetfulness. Programme structure preferences indicated one to two modules per week, less than 15 min in duration, and over 4 weeks. Programme functionality, such as regular reminders and easy accessibility, is important to end users.

CONCLUSION

Our findings reinforce the importance of determining participant preferences in designing and communicating engaging interventions for perinatal women. This research contributes to the understanding of population-based interventions that can be provided as simple, scalable, cost-effective, and home-based activities in pregnancy for the benefit of individuals, their families, and society more broadly.

Factors Impacting User Engagement in Reablement: A Qualitative Study of User, Family Member and Practitioners' Views

Background

The challenges of population aging have fostered the adoption of reablement as a core pillar of older people's care in many developed economies. Aligning with wider literature on the association between "patient" engagement and outcomes, emerging evidence points to the impact user engagement may have on reablement outcomes. To date, existing research on the factors implicated in engagement with reablement is rather limited.

Objective

To identify and describe factors which impact user engagement in reablement from the perspectives of reablement staff, staff in interfacing services, service users and family members.

Sample and Methods

A total of 78 staff were recruited from five sites across England and Wales. Twelve service users and five family members were recruited from three of these sites. Data were collected via focus groups with staff and interviews with service users and families, and subject to thematic analysis.

Results

The data revealed a complex picture of factors potentially impacting user engagement, ranging from user-, family-, and staff-centered factors, the nature of the relationship between staff and users, and aspects of service organization and delivery across referral and intervention pathways. Many are amenable to intervention. As well as offering a more fine-grained understanding of factors reported by previous research, new factors impacting engagement were identified. These included staff morale, equipment provision systems, assessment and reviewing processes, and attention to social reablement needs. Aspects of the wider service context (eg, degree of integration of health and social care) played a role in determining which factors were pertinent.

Conclusion

Findings highlight the complexity of factors influencing engagement with reablement, and the need to ensure features of the wider service context (eg delivery models, referral pathways) do not work against securing and sustaining older people's engagement with reablement.

Exploring engagement with a web-based dietary intervention for adults with type 2 diabetes: A mixed methods evaluation of the T2Diet study

BACKGROUND

Improved understanding of participant engagement in web-based dietary interventions is needed. Engagement is a complex construct that may be best explored through mixed methods to gain comprehensive insight. To our knowledge, no web-based dietary intervention in people with type 2 diabetes (T2D) has previously used a mixed methods approach. The aim of this study was to explore factors that may contribute to effective engagement in a web-based dietary program for people with T2D.

METHODS

This study employed a mixed methods intervention design, with a convergent design embedded for post-intervention evaluation. The convergent design collected and analyzed quantitative and qualitative data independent of each other, with the two datasets merged/compared during results/interpretation. Quantitative data collected from intervention group participants (n = 40) were self-administered questionnaires and usage data with average values summarized. Qualitative data were participant semi-structured interviews (n = 15) incorporating a deductive-inductive thematic analysis approach.

RESULTS

The results from the quantitative and qualitative data indicated positive overall engagement with the web-based dietary program. Factors that contributed to effective engagement were sustained frequency and intensity of engagement; structured weekly program delivery; participants affective engagement prior to and during the intervention, with positive affective states enhancing cognitive and behavioral engagement; and participants experience of value and reward. In addition, the user-centered development process employed prior to intervention delivery played an important role in facilitating positive engagement outcomes.

CONCLUSION

This study yielded novel findings by integrating qualitative and quantitative data to explore engagement with a web-based dietary program involving people with T2D. Effective engagement occurred in this intervention through a combination of factors related to usage and participants' affective, cognitive and behavioral states. The engagement outcomes that emerged will be useful to current and future researchers using digital technologies to deliver lifestyle interventions for T2D or other chronic health conditions.

Addressing people's current and future states in a reinforcement learning algorithm for persuading to quit smoking and to be physically active

Behavior change applications often assign their users activities such as tracking the number of smoked cigarettes or planning a running route. To help a user complete these activities, an application can persuade them in many ways. For example, it may help the user create a plan or mention the experience of peers. Intuitively, the application should thereby pick the message that is most likely to be motivating. In the simplest case, this could be the message that has been most effective in the past. However, one could consider several other elements in an algorithm to choose a message. Possible elements include the user's current state (e.g., self-efficacy), the user's future state after reading a message, and the user's similarity to the users on which data has been gathered. To test the added value of subsequently incorporating these elements into an algorithm that selects persuasive messages, we conducted an experiment in which more than 500 people in four conditions interacted with a text-based virtual coach. The experiment consisted of five sessions, in each of which participants were suggested a preparatory activity for quitting smoking or increasing physical activity together with a persuasive message. Our findings suggest that adding more elements to the algorithm is effective, especially in later sessions and for people who thought the activities were useful. Moreover, while we found some support for transferring knowledge between the two activity types, there was rather low agreement between the optimal policies computed separately for the two activity types. This suggests limited policy generalizability between activities for quitting smoking and those for increasing physical activity. We see our results as supporting the idea of constructing more complex persuasion algorithms. Our dataset on 2,366 persuasive messages sent to 671 people is published together with this article for researchers to build on our algorithm.

Engaging patients and citizens in digital health technology development through the virtual space

Digital technologies are increasingly empowering individuals to take charge of their health and improve their well-being. However, there are disparities in access related to demographic, economic, and sociocultural factors that result in exclusion from the use of digital technologies for different groups of the population. The development of digital technology in health is a powerful lever for improving care and services, but also brings risks for certain users in vulnerable situations. Increased digital health inequalities are associated with limited digital literacy, lack of interest, and low levels of self-efficacy in using technology. In the context of the COVID-19 pandemic and post-pandemic healthcare systems, the leap to digital is essential. To foster responsible innovation and optimal use of digital health by all, including vulnerable groups, we propose that patient and citizen engagement must be an essential component of the research strategy. Patient partners will define expectations and establish research priorities using their experiential knowledge, while benefiting from rich exposure to the research process to increase their self-efficacy and digital literacy. We will support this proposition with an operationalised example aiming to implement a Virtual Community of Patients and Citizens Partners (COMVIP), a digital tool co-created with patients and public experts, as active team members in research. Founded on the principles of equity, diversity and inclusion, this base of citizen expertise will assemble individuals from different backgrounds and literacy levels living in vulnerable situations to acquire knowledge, and share their experiences, while contributing actively in the co-development of innovative strategies and health technology assessment.

Exploring the Relationship Between Usage and Outcomes of an eHealth Cardiac Rehabilitation Intervention: Subanalysis of a Randomized Controlled Trial

This study aimed to explore the relationship between patients' characteristics and eHealth cardiac rehabilitation adherence and between eHealth usage metrics and behavior change. A subanalysis of 73 patients in the intervention group who received eHealth cardiac rehabilitation was conducted. Usage metrics on the number of Web site logins, health data uploads, and times of peer interaction and professional consultation were captured. Linear regression analysis was used. Participants (n = 73) were predominantly male with an average age of 55.53 (SD, 7.3) years. Younger age, having been treated with percutaneous coronary intervention, and hypertension predict higher Web site logins, whereas higher education, comorbidity with hypertension and diabetes, larger family size, and having been treated with percutaneous coronary intervention predict higher chatroom engagement. The Web site logins, Web site data uploads, chatroom nurse consultation, age, number of family members, drinking, and coresidency status were identified as significant correlates and explained 41.8% of the improvement in behavior change. This study demonstrated empirical evidence that Web site visits, health data uploads, and nurse consultations are crucial for behavior modification. Further studies may monitor usage metrics and investigate self-reported usage to explore the role of peer interaction in modifying behavior. Trial registration: Chinese Clinical Trial Registry: ChiCTR1800020411.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

System design of a text messaging program to support the mental health needs of non-treatment seeking young adults

Young adults (ages 18-25) experience the highest levels of mental health problems of any adult age group, but have the lowest mental health treatment rates. Text messages are the most used feature on the mobile phone and provide an opportunity to reach non-treatment engaged users throughout the day in a conversational manner. We present the design of an automated text message-based intervention for symptom self-management. The intervention comprises: (1) psychological strategies (i.e., types of evidence-based techniques leveraged to achieve symptom reduction) and (2) interaction types or the form that intervention content takes as it is delivered to and elicited from users.

Piloting of the virtual telecare technology 'Addison Care' to promote self-management in persons with chronic diseases in a community setting: protocol for a mixed-methods user experience, user engagement and usability pilot study

INTRODUCTION

Chronic diseases in older adults are one of the major epidemiological challenges of current times and leading cause of disability, poor quality of life, high healthcare costs and death. Self-management of chronic diseases is essential to improve health behaviours and health outcomes. Technology-assisted interventions have shown to improve self-management of chronic diseases. Virtual avatars can be a key factor for the acceptance of these technologies. Addison Care is a home-based telecare solution equipped with a virtual avatar named Addison, connecting older persons with their caregivers via an easy-to-use technology. A central advantage is that Addison Care provides access to self-management support for an up-to-now highly under-represented population-older persons with chronic disease(s), which enables them to profit from e-health in everyday life.

METHODS AND ANALYSIS

A pragmatic, non-randomised, one-arm pilot study applying an embedded mixed-methods approach will be conducted to examine user experience, usability and user engagement of the virtual avatar Addison. Participants will be at least 65 years and will be recruited between September 2022 and November 2022 from hospitals during the discharge process to home care. Standardised instruments, such as the User Experience Questionnaire, System Usability Scale, Instrumental Activities of Daily Living scale, Short-Form-8-Questionnaire, UCLA Loneliness Scale, Geriatric Depression Scale, Stendal Adherence with Medication Score and Self-Efficacy for Managing Chronic Diseases Scale, as well as survey-based assessments, semistructured interviews and think-aloud protocols, will be used. The study seeks to enrol 20 patients that meet the criteria.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethic committee of the German Society for Nursing Science (21-037). The results are intended to be published in peer-reviewed journals and disseminated through conference papers.

TRIAL REGISTRATION NUMBER

DRKS00025992.

Understanding users’ perspectives on mobile apps for anxiety management

Anxiety disorders are the most common type of mental health problem. The potential of apps to improve mental health has led to an increase in the number of anxiety apps available. Even though anxiety apps hold the potential to enhance mental health care for individuals, there is relatively little knowledge concerning users’ perspectives. This mixed-methods study aims to understand the nature of user burden and engagement with mental health apps (MHapps) targeting anxiety management, in order to identify ways to improve the design of these apps. Users’ perspectives on these apps were gathered by analyzing 600 reviews from 5 apps on the app stores (Study 1), and conducting 15 interviews with app users (Study 2). The results shed light on several barriers to adoption and sustained use. Users appreciate apps that offer content variation, customizability, and good interface design, and often requested an enhanced, personalized experience to improve engagement. We propose addressing the specific app quality issues identified through human-centered design, more personalized content delivery, and by improving features for social and therapeutic support.