The Effectiveness of Fully Automated Digital Interventions in Promoting Mental Well-Being in the General Population: Systematic Review and Meta-Analysis

BACKGROUND

Recent years have highlighted an increasing need to promote mental well-being in the general population. This has led to a rapidly growing market for fully automated digital mental well-being tools. Although many individuals have started using these tools in their daily lives, evidence on the overall effectiveness of digital mental well-being tools is currently lacking.

OBJECTIVE

This study aims to review the evidence on the effectiveness of fully automated digital interventions in promoting mental well-being in the general population.

METHODS

Following the preregistration of the systematic review protocol on PROSPERO, searches were carried out in MEDLINE, Web of Science, Cochrane, PsycINFO, PsycEXTRA, Scopus, and ACM Digital (initial searches in February 2022; updated in October 2022). Studies were included if they contained a general population sample and a fully automated digital intervention that exclusively used psychological mental well-being promotion activities. Two reviewers, blinded to each other's decisions, conducted data selection, extraction, and quality assessment of the included studies. Narrative synthesis and a random-effects model of per-protocol data were adopted.

RESULTS

We included 19 studies that involved 7243 participants. These studies included 24 fully automated digital mental well-being interventions, of which 15 (63%) were included in the meta-analysis. Compared with no intervention, there was a significant small effect of fully automated digital mental well-being interventions on mental well-being in the general population (standardized mean difference 0.19, 95% CI 0.04-0.33; P=.02). Specifically, mindfulness-, acceptance-, commitment-, and compassion-based interventions significantly promoted mental well-being in the general population (P=.006); insufficient evidence was available for positive psychology and cognitive behavioral therapy-based interventions; and contraindications were found for integrative approaches. Overall, there was substantial heterogeneity, which could be partially explained by the intervention duration, comparator, and study outcomes. The risk of bias was high, and confidence in the quality of the evidence was very low (Grading of Recommendations, Assessment, Development, and Evaluations), primarily because of the high rates of study dropout (average 37%; range 0%-85%) and suboptimal intervention adherence (average 40%).

CONCLUSIONS

This study provides a novel contribution to knowledge regarding the effectiveness, strengths, and weaknesses of fully automated digital mental well-being interventions in the general population. Future research and practice should consider these findings when developing fully automated digital mental well-being tools. In addition, research should aim to investigate positive psychology and cognitive behavioral therapy-based tools as well as develop further strategies to improve adherence and reduce dropout in fully automated digital mental well-being interventions. Finally, it should aim to understand when and for whom these interventions are particularly beneficial.

TRIAL REGISTRATION

PROSPERO CRD42022310702; https://tinyurl.com/yc7tcwy7.

How do we engage people in testing for COVID-19? A rapid qualitative evaluation of a testing programme in schools, GP surgeries and a university

BACKGROUND

The UK Scientific Advisory Group for Emergencies (SAGE) emphasises the need for high levels of engagement with communities and individuals to ensure the effectiveness of any COVID-19 testing programme. A novel pilot health surveillance programme to assess the feasibility of weekly community RT-LAMP (Reverse transcription loop-mediated isothermal amplification) testing for the SARS-CoV-2 virus using saliva samples collected at home was developed and piloted by the University of Southampton and Southampton City Council.

METHODS

Rapid qualitative evaluation was conducted to explore experiences of those who took part in the programme, of those who declined and of those in the educational and healthcare organisations involved in the pilot testing who were responsible for roll-out. This included 77 interviews and 20 focus groups with 223 staff, students, pupils and household members from four schools, one university, and one community healthcare NHS trust. The insights generated and informed the design and modification of the Southampton COVID-19 Saliva Testing Programme and the next phase of community-testing.

RESULTS

Discussions revealed that high levels of communication, trust and convenience were necessary to ensure people's engagement with the programme. Participants felt reassured by and pride in taking part in this novel programme. They suggested modifications to reduce the programme's environmental impact and overcome cultural barriers to participation.

CONCLUSIONS

Participants' and stakeholders' motivations, challenges and concerns need to be understood and these insights used to modify the programme in a continuous, real-time process to ensure and sustain engagement with testing over the extended period necessary. Community leaders and stakeholder organisations should be involved throughout programme development and implementation to optimise engagement.

Infection control in the home: a qualitative study exploring perceptions and experiences of adhering to protective behaviours in the home during the COVID-19 pandemic

OBJECTIVES

We sought to explore people's experiences and perceptions of implementing infection control behaviours in the home during the COVID-19 pandemic, guided by an online behavioural intervention.

DESIGN

Inductive qualitative study.

SETTING

UK public during the COVID-19 pandemic.

PARTICIPANTS

Thirteen people took part in telephone interviews, and 124 completed a qualitative open-text survey. All were recruited from the public. Most survey participants were aged over 60 years, while interview participants were more distributed in age. Most reported being at increased risk from COVID-19, and were white British.

INTERVENTION

Online behavioural intervention to support infection control behaviours in the home during the COVID-19 pandemic.

DATA COLLECTION

Telephone think-aloud interviews and qualitative survey data.

DATA ANALYSIS

The think-aloud interview data and qualitative survey data were analysed independently using inductive thematic analysis. The findings were subsequently triangulated.

RESULTS

Thematic analysis of the telephone interviews generated seven themes: perceived risk; belief in the effectiveness of protective behaviours; acceptability of distancing and isolation; having capacity to perform the behaviours; habit forming reduces effort; having the confidence to perform the behaviours; and social norms affect motivation to engage in the behaviours. The themes identified from the survey data mapped well onto the interview analysis. Isolating and social distancing at home were less acceptable than cleaning and handwashing, influenced by the need for intimacy with household members. This was especially true in the absence of symptoms and when perceived risk was low. People felt more empowered when they understood that even small changes, such as spending some time apart, were worthwhile to reduce exposure and lessen viral load.

CONCLUSIONS

The current study provided valuable insight into the acceptability and feasibility of protective behaviours, and how public health guidance could be incorporated into a behaviour change intervention for the public during a pandemic.

Effectiveness of digital interventions to improve household and community infection prevention and control behaviours and to reduce incidence of respiratory and/or gastro-intestinal infections: a rapid systematic review

Background

Digital interventions have potential to efficiently support improved hygiene practices to reduce transmission of COVID-19.

Objective

To evaluate the evidence for digital interventions to improve hygiene practices within the community.

Methods

We reviewed articles published between 01 January 2000 and 26 May 2019 that presented a controlled trial of a digital intervention to improve hygiene behaviours in the community. We searched MEDLINE, Embase, PsycINFO, Cochrane Controlled Register of Trials (CENTRAL), China National Knowledge Infrastructure and grey literature. Trials in hospitals were excluded, as were trials aiming at prevention of sexually transmitted infections; only target diseases with transmission mechanisms similar to COVID-19 (e.g. respiratory and gastrointestinal infections) were included. Trials had to evaluate a uniquely digital component of an intervention. Study designs were limited to randomised controlled trials, controlled before-and-after trials, and interrupted time series analyses. Outcomes could be either incidence of infections or change in hygiene behaviours. The Risk of Bias 2 tool was used to assess study quality.

Results

We found seven studies that met the inclusion criteria. Six studies reported successfully improving self-reported hygiene behaviour or health outcomes, but only one of these six trials, Germ Defence, confirmed improvements using objective measures (reduced consultations and antibiotic prescriptions). Settings included kindergartens, workplaces, and service station restrooms. Modes of delivery were diverse: WeChat, website, text messages, audio messages to mobiles, electronic billboards, and electronic personal care records. Four interventions targeted parents of young children with educational materials. Two targeted the general population; these also used behaviour change techniques or theory to inform the intervention. Only one trial had low risk of bias, Germ Defence; the most common concerns were lack of information about the randomisation, possible bias in reporting of behavioural outcomes, and lack of an analysis plan and possible selective reporting of results.

Conclusion

There was only one trial that was judged to be at low risk of bias, Germ Defence, which reduced incidence and severity of illness, as confirmed by objective measures. Further evaluation is required to determine the effectiveness of the other interventions reviewed.

Trial registration

PROSPERO CRD42020189919.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11150-8.

Adapting Behavioral Interventions for a Changing Public Health Context: A Worked Example of Implementing a Digital Intervention During a Global Pandemic Using Rapid Optimisation Methods

Background: A rigorous approach is needed to inform rapid adaptation and optimisation of behavioral interventions in evolving public health contexts, such as the Covid-19 pandemic. This helps ensure that interventions are relevant, persuasive, and feasible while remaining evidence-based. This paper provides a set of iterative methods to rapidly adapt and optimize an intervention during implementation. These methods are demonstrated through the example of optimizing an effective online handwashing intervention called Germ Defense. Methods: Three revised versions of the intervention were rapidly optimized and launched within short timeframes of 1-2 months. Optimisations were informed by: regular stakeholder engagement; emerging scientific evidence, and changing government guidance; rapid qualitative research (telephone think-aloud interviews and open-text surveys), and analyses of usage data. All feedback was rapidly collated, using the Table of Changes method from the Person-Based Approach to prioritize potential optimisations in terms of their likely impact on behavior change. Written feedback from stakeholders on each new iteration of the intervention also informed specific optimisations of the content. Results: Working closely with clinical stakeholders ensured that the intervention was clinically accurate, for example, confirming that information about transmission and exposure was consistent with evidence. Patient and Public Involvement (PPI) contributors identified important clarifications to intervention content, such as whether Covid-19 can be transmitted via air as well as surfaces, and ensured that information about difficult behaviors (such as self-isolation) was supportive and feasible. Iterative updates were made in line with emerging evidence, including changes to the information about face-coverings and opening windows. Qualitative research provided insights into barriers to engaging with the intervention and target behaviors, with open-text surveys providing a useful supplement to detailed think-aloud interviews. Usage data helped identify common points of disengagement, which guided decisions about optimisations. The Table of Changes was modified to facilitate rapid collation and prioritization of multiple sources of feedback to inform optimisations. Engagement with PPI informed the optimisation process. Conclusions: Rapid optimisation methods of this kind may in future be used to help improve the speed and efficiency of adaptation, optimization, and implementation of interventions, in line with calls for more rapid, pragmatic health research methods.

Housing and youth mental health during a COVID-19 lockdown

Introduction

Declines in mental health among youth in the COVID-19 pandemic have been observed, yet longitudinal studies on how housing may impact these declines are lacking.

Objectives

Our aim was to determine whether changes in mental health among Danish youth were dependent on their housing conditions.

Methods

Young participants from the Danish National Birth Cohort, who had responded to an online questionnaire at 18 years of age, and later during the initial national Danish lockdown, were included. Associations between housing conditions (direct access to outdoor spaces, urbanicity, household density, and household composition) and changes in mental health (mental well-being, quality of life (QoL) and loneliness) were examined in multivariate linear and logistic regression analyses.

Results

We included 7455 participants. Greater decreases in mental well-being were observed for youth with no access to direct outdoor spaces and those living in denser households (mean difference -0.83 [95 % CI -1.19, -0.48], -0.30 [-0.43, -0.18], respectively). Onset of low mental well-being was associated with no access and living alone (odds ratios (OR) 1.68 [1.15, 2.47] and OR 1.47 [1.05, 2.07], respectively). Household density was negatively associated with QoL (mean difference -0.21 [-0.30, -0.12]). Youth living alone experienced more loneliness (OR 2.12 [95 % CI 1.59, 2.82]).

Conclusions

How youth’s mental health changed from before to during lockdown was associated with housing conditions. Among the Danish youth in our study, greater decreases in mental health during lockdown were observed among youth without access to outdoor spaces, living alone, or living in denser households.

Disclosure

No significant relationships.

Infection Control Behavior at Home During the COVID-19 Pandemic: Observational Study of a Web-Based Behavioral Intervention (Germ Defence)

BACKGROUND

To control the COVID-19 pandemic, people should adopt protective behaviors at home (self-isolation, social distancing, putting shopping and packages aside, wearing face coverings, cleaning and disinfecting, and handwashing). There is currently limited support to help individuals conduct these behaviors.

OBJECTIVE

This study aims to report current household infection control behaviors in the United Kingdom and examine how they might be improved.

METHODS

This was a pragmatic cross-sectional observational study of anonymous participant data from Germ Defence between May 6-24, 2020. Germ Defence is an open-access fully automated website providing behavioral advice for infection control within households. A total of 28,285 users sought advice from four website pathways based on household status (advice to protect themselves generally, to protect others if the user was showing symptoms, to protect themselves if household members were showing symptoms, and to protect a household member who is at high risk). Users reported current infection control behaviors within the home and intentions to change these behaviors.

RESULTS

Current behaviors varied across all infection control measures but were between sometimes (face covering: mean 1.61, SD 1.19; social distancing: mean 2.40, SD 1.22; isolating: mean 2.78, SD 1.29; putting packages and shopping aside: mean 2.75, SD 1.55) and quite often (cleaning and disinfecting: mean 3.17, SD 1.18), except for handwashing (very often: mean 4.00, SD 1.03). Behaviors were similar regardless of the website pathway used. After using Germ Defence, users recorded intentions to improve infection control behavior across all website pathways and for all behaviors (overall average infection control score mean difference 0.30, 95% CI 0.29-0.31).

CONCLUSIONS

Self-reported infection control behaviors other than handwashing are lower than is optimal for infection prevention, although handwashing is much higher. Advice using behavior change techniques in Germ Defence led to intentions to improve these behaviors. Promoting Germ Defence within national and local public health and primary care guidance could reduce COVID-19 transmission.

Clinical characteristics including cardiovascular and metabolic risk factors in adolescents with psoriasis

BACKGROUND

Clinical studies on psoriasis in adolescents have mainly been performed in patients with severe psoriasis. Population-based studies of clinical characteristics and risk factors for later cardiovascular and metabolic disease in children and adolescents are lacking.

OBJECTIVES

To examine the clinical characteristics of adolescents with psoriasis nested in a general population cohort. Furthermore, to investigate cardiovascular and metabolic risk factors in the adolescents with psoriasis compared to parentally predisposed and non-predisposed adolescents without psoriasis from the same birth cohort.

METHODS

We identified adolescents with and without psoriasis using a nationwide general population birth cohort in Denmark. A clinical examination included skin inspection and scoring of psoriasis severity, completion of a questionnaire on psoriasis and comorbidities, physical measurements, and blood sampling. Participants also completed self-administered questionnaires on quality of life and mental health.

RESULTS

We included 81 adolescents with psoriasis and 234 controls (110 with genetic predisposition for psoriasis and 124 without predisposition). Median age was 15.6 (13.5-18.5) years, and in those with active psoriasis, median Psoriasis Area and Severity Index score was 1.2 (0.1-11.4). The scalp was the most common site of psoriasis, both at debut and at time of examination. Diaper rash in infancy was more frequent in the psoriasis group. No significant differences regarding quality of life, anxiety and depression were found. More adolescents with psoriasis were obese (8.6% vs. 1.7%, P = 0.008), and physical measures of abdominal obesity were also significantly higher. HbA1c was significantly higher (31.55 vs. 30.81 mmol/mol, P = 0.048), while no differences were found for blood pressure, lipids or high-sensitivity C-reactive protein. In a subgroup analysis, this was evident in the non-predisposed psoriasis-free controls only.

CONCLUSIONS

Overall, adolescents with psoriasis from this general population had mild disease. Still, early markers of cardiovascular and metabolic disease were elevated.

Associations between maternal socioeconomic position and psoriasis: a cohort study among the offspring of the Danish National Birth Cohort

BACKGROUND

The socioeconomic determinants of paediatric-onset psoriasis have not been previously investigated.

OBJECTIVE

To identify whether a social gradient exists for paediatric-onset psoriasis, using measures of maternal socioeconomic position.

METHODS

Data on paediatric-onset psoriasis from 36 003 Danish National Birth Cohort offspring were cross-linked with nationwide registry data on maternal age and three measures of maternal socioeconomic position: maternal educational attainment, maternal labour market attachment and equivalized household income. Univariable and multivariable logistic regression analyses were conducted to estimate the odds ratios (ORs) of psoriasis in the offspring, in cohort analyses for data from the year of enrolment and cross-sectional analyses from the year of the 11-year follow-up.

RESULTS

Maternal age at birth, maternal educational attainment and equivalized household income were inversely associated with psoriasis in the offspring. Low maternal educational attainment was associated with offspring psoriasis [adjusted OR 1·62, 95% confidence interval (CI) 1·20-2·18] after adjusting for maternal psoriasis and age in the cohort analysis. The crude OR of psoriasis in offspring of mothers in the highest quartile compared with mothers in the lowest quartile of equivalized household income was 0·57 (95% CI 0·43-0·76), and the adjusted OR was 0·59 (95% CI 0·44-0·80) after adjusting for maternal psoriasis and age. Similar results were observed for data on maternal socioeconomic position at enrolment and at follow-up.

CONCLUSIONS

A steep social gradient in paediatric-onset psoriasis was observed. Maternal socioeconomic position may play a role in early-life exposure to modifiable risk factors for psoriasis. Future studies may help to elucidate which biological factors mediate the social gradient observed in our study.

[Pelvic inflammatory disease and an abscessed endometriosis cyst: a diagnostic problem and a therapeutic dilemma]

A 52-year-old woman with known endometriosis was treated with a levonorgestrel-containing IUD for irregular vaginal blood loss. Two weeks later she was admitted with signs ofpelvic inflammatory disease (PID) and was treated with antibiotics. As no clinical improvement ensued, laparoscopy was performed which demonstrated an infected endometriosis cyst in her right ovary. Ovariectomy was performed. In a 29-year-old woman with a symptomatic endometriosis cyst in the right ovary, PID was also suspected. After an initially good response to antibiotic therapy her condition deteriorated. Laparotomy revealed an infected endometriosis cyst. It was drained with subsequent cystectomy. A third, 43-year-old, woman with known endometriosis was admitted with signs of PID. Although she had a good clinical response to antibiotic therapy, her C-reactive protein (CRP) level remained elevated. Diagnostic laparoscopy demonstrated a large abscess in the right ovary. Ovariectomy was performed. Histology showed signs of an infected endometriosis cyst. All these women presented with PID and, in addition, a cystic adnexal mass on ultrasonography. The incidence oftubo-ovarian and ovarian abscesses is higher in the presence of an endometriosis cyst. Irrespective of the presence of an endometriosis cyst, antibiotics should be the first line of treatment. Reduction in the size of the abscess is not a useful parameter for monitoring conservative treatment when an infected endometriosis cyst is present. If it is decided to perform surgery on the infected endometriosis cyst, drainage of the abscess is usually not sufficient: excision of the endometriosis cyst is the only adequate therapy.

Stress-induced decrease of the intestinal barrier function. The role of muscarinic receptor activation

Recently the breakdown of the barrier function of the intestinal epithelium after application of an experimental psychological and physical stress protocol in rats has been observed. Not only did smaller molecules pass from the luminal to the serosal side, but so also did larger proteins with the dimensions of luminal antigens and toxins. The increased permeability for macromolecules is primarily due to a decrease of the tightness of the zonula occludens, but an increased endocytotic uptake indicates that transcytosis is increased also. From studies of model systems it can be concluded that activation of the intracellular protein kinase C route by muscarinic receptor activation or histamine receptor activation can be one of the underlying cellular pathways. The physical pathway relaying the stress from the brain to the intestinal tract appears to be the parasympathetic branch of the autonomic nervous system. The difference in reaction of different strains suggests that coping style is an important determinant of the response of the intestinal barrier to stress.

Molecular physiology and pathophysiology of tight junctions III. Tight junction regulation by intracellular messengers: differences in response within and between epithelia

Tight junction permeability differs with the type of permeants, their size, and their charge. Selective changes in permeability do occur, and they illustrate the diversity in functional reactions of tight junctions. This suggests that special structures in the tight junctions are involved. More and more structural components of the tight junctions are becoming known. The divergence in behavior of native tissue and filter-grown epithelial monolayers with respect to the effects of intracellular messengers offers the possibility to relate structure and function. In addition to the tools for conventional permeability studies, probes have become available to detect changes in activation of intracellular effector proteins such as the protein kinase C isotypes, and with in situ imaging techniques the way is open for a functional approach in the study of tight junctions.

Neurotensin, substance P, gastrin/cholecystokinin, and bombesin in the intestine of the tilapia (Oreochromis mossambicus) and the goldfish (Carassius auratus): immunochemical detection and effects on electrophysiological characteristics

The distribution of neurotensin-, substance P-, gastrin/cholecystokinin/carerulein- and bombesin-like immunoreactivities has been studied in the gut of the tilapia (Oreochromis mossambicus) and the goldfish (Carassius auratus) using immunohistochemistry and radioimmunoassay; the electrophysiological effects of these peptides on the intestinal epithelium were also examined with the Ussing-type chamber technique. Neurotensin- and gastrin/cholecystokinin/caerulein-like immunoreactivities were present in endocrine cells in both species. Substance P- and bombesin-like immunoreactive endocrine cells were present in the intestine of the tilapia. Neurotensin-like immunoreactivity was observed in varicose fibers and nerve cell bodies in the muscle layers and myenteric plexus of both species, whereas nerve fibers showing substance P-like immunoreactivity were found in the goldfish only. Using radioimmunoassays, neurotensin- and gastrin/cholecystokinin/caerulein-like immunoreactive materials were detected in intestinal extracts of both species. The amounts of substance P- and bombesin-like material were below detection level. The ion selectivity of the intestinal epithelium of both species was modulated by exogenously applied neurotensin. This effect was blocked by tetrodotoxin in the tilapia but not in the goldfish. In the tilapia, neurotensin may act via stimulation of a cAMP-dependent increase of the Cl- conductance of the tight junctions, whereas in the goldfish, neurotensin induced, via an unknown messenger, a transient decrease of the cation selectivity without a decrease in the resistance. Substance P, cholecystokinin, and bombesin were without effect on the electrophysiological characteristics of the epithelium.