Enhanced control of periodontitis by an artificial intelligence-enabled multimodal-sensing toothbrush and targeted mHealth micromessages: A randomized trial

AIM

Treatment of periodontitis, a chronic inflammatory disease driven by biofilm dysbiosis, remains challenging due to patients' poor performance and adherence to the necessary oral hygiene procedures. Novel, artificial intelligence-enabled multimodal-sensing toothbrushes (AI-MST) can guide patients' oral hygiene practices in real-time and transmit valuable data to clinicians, thus enabling effective remote monitoring and guidance. The aim of this trial was to assess the effect of such a system as an adjunct to clinical practice guideline-conform treatment.

MATERIALS AND METHODS

This was a single-centre, double-blind, standard-of-care controlled, randomized, parallel-group, superiority trial. Male and female adults with generalized Stage II/III periodontitis were recruited at the Shanghai Ninth People's Hospital, China. Subjects received a standard-of-care oral hygiene regimen or a technology-enabled, theory-based digital intervention consisting of an AI-MST and targeted doctor's guidance by remote micromessaging. Additionally, both groups received guideline-conform periodontal treatment. The primary outcome was the resolution of inflamed periodontal pockets (≥4 mm with bleeding on probing) at 6 months. The intention-to-treat (ITT) analysis included all subjects who received the allocated treatment and at least one follow-up.

RESULTS

One hundred patients were randomized and treated (50 tests/controls) between 1 February and 30 November 2022. Forty-eight tests (19 females) and 47 controls (16 females) were analysed in the ITT population. At 6 months, the proportion of inflamed periodontal pockets decreased from 80.7% (95% confidence interval [CI] 76.5-84.8) to 52.3% (47.7-57.0) in the control group, and from 81.4% (77.1-85.6) to 44.4% (39.9-48.9) in the test group. The inter-group difference was 7.9% (1.6-14.6, p < .05). Test subjects achieved better levels of oral hygiene (p < .001). No significant adverse events were observed.

CONCLUSIONS

The tested digital health intervention significantly improved the outcome of periodontal therapy by enhancing the adherence and performance of self-performed oral hygiene. The model breaks the traditional model of oral health care and has the potential to improve efficiency and reduce costs (NCT05137392).

Implementing a Sodium-Glucose Cotransporter 2 Inhibitor Module With a Software Tool (Future Health Today): Qualitative Study

BACKGROUND

Primary care plays a key role in the management of type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce hospitalization and cardiac and renal complications. Tools that optimize management, including appropriate prescribing, are a priority for treating chronic diseases. Future Health Today (FHT) is software that facilitates clinical decision support and quality improvement. FHT applies algorithms to data stored in electronic medical records in general practice to identify patients who are at risk of a chronic disease or who have a chronic disease that may benefit from intensification of management. The platform continues to evolve because of rigorous evaluation, continuous improvement, and expansion of the conditions hosted on the platform. FHT currently displays recommendations for the identification and management of chronic kidney disease, cardiovascular disease, type 2 diabetes, and cancer risk. A new module will be introduced to FHT focusing on SGLT2 inhibitors in patients with type 2 diabetes who have chronic kidney diseases, cardiovascular diseases, or risk factors for cardiovascular disease.

OBJECTIVE

The study aims to explore the barriers and enablers to the implementation of an SGLT2 inhibitor module within the Future Health Today software.

METHODS

Clinic staff were recruited to participate in interviews on their experience in their use of a tool to improve prescribing behavior for SGLT2 inhibitors. Thematic analysis was guided by Clinical Performance Feedback Intervention Theory.

RESULTS

In total, 16 interviews were completed. Identified enablers of use included workflow alignment, clinical appropriateness, and active delivery of the module. Key barriers to use were competing priorities, staff engagement, and knowledge of the clinical topic.

CONCLUSIONS

There is a recognized benefit to the use of a clinical decision support tool to support type 2 diabetes management, but barriers were identified that impeded the usability and actionability of the module. Successful and effective implementation of this tool could support the optimization of patient management of type 2 diabetes in primary care.

Patients' Experiences of Digital Health Interventions for the Self-Management of Chronic Pain: Protocol for a Systematic Review and Thematic Synthesis

BACKGROUND

Chronic pain is a highly prevalent condition that requires multidisciplinary treatment. However, in the United Kingdom, access to specialist pain clinics where patients can receive medical multidisciplinary treatment is limited, and provision varies between health boards. As such, self-management of chronic pain using digital tools has been gaining traction recently, but evidence of its effectiveness from clinical-based trials focuses mainly on quantitative outcomes.

OBJECTIVE

This systematic review aims to identify, appraise, and synthesize qualitative evidence on patients' experiences with digital health interventions (DHIs) for the management of chronic pain.

METHODS

This systematic review will consider qualitative and mixed methods studies that explore the experience of patients (aged 18 years and older) with chronic pain engaging in DHIs to manage their pain. MEDLINE Ovid, PubMed, Embase, CINAHL, PsycINFO, and Scopus databases will be searched for published studies. The systematic review will be conducted in accordance with the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines. Following the 3-step thematic synthesis methodology of Thomas and Harden, titles and abstracts will be screened by 2 independent reviewers (AM and HM), and a third reviewer (MI or FM) will resolve any conflict that arises before the full-text screening. The Critical Appraisal Skills Programme checklist tool will be used to critically appraise the included studies. The extracted data will be imported to NVivo (QSR International), where thematic synthesis will be used to derive analytical themes from the included studies.

RESULTS

Themes that encapsulate the patient experience will be identified from qualitative evidence, and these themes will shed light on the perceived benefits and disadvantages, usability, acceptability, and the overall impact digital tools can have on the lives of those with chronic pain.

CONCLUSIONS

This systematic review will identify, appraise, and synthesize the overall experience of patients engaging in DHI to manage a diverse range of chronic pain conditions. By elaborating the patient experience through qualitative analysis, the findings from this review will enhance our current understanding of the experiences of patients with chronic pain using digital tools for the self-management of their pain and highlight what person-centered elements are essential for future DHI development.

TRIAL REGISTRATION

PROSPERO CRD42023445100; http://tinyurl.com/4z77khfs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52469.

Evaluation of Patient-Facing Mobile Apps to Support Physiotherapy Care: Systematic Review

BACKGROUND

Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation.

OBJECTIVE

The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential.

METHODS

A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app's potential to change behavior.

RESULTS

In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15).

CONCLUSIONS

Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29047.

Periodic mobile application (eMOM) with self-tracking of glucose and lifestyle improves treatment of diet-controlled gestational diabetes without human guidance: a randomized controlled trial

BACKGROUND

Digitalization with minimal human resources could support self-management among women with gestational diabetes and improve maternal and neonatal outcomes.

OBJECTIVE

This study aimed to investigate if a periodic mobile application (eMOM) with wearable sensors improves maternal and neonatal outcomes among women with diet-controlled gestational diabetes without additional guidance from healthcare personnel.

STUDY DESIGN

Women with gestational diabetes were randomly assigned in a 1:1 ratio at 24 to 28 weeks' gestation to the intervention or the control arm. The intervention arm received standard care in combination with use of the periodic eMOM, whereas the control arm received only standard care. The intervention arm used eMOM with a continuous glucose monitor, an activity tracker, and a food diary 1 week/month until delivery. The primary outcome was the change in fasting plasma glucose from baseline to 35 to 37 weeks' gestation. Secondary outcomes included capillary glucose, weight gain, nutrition, physical activity, pregnancy complications, and neonatal outcomes, such as macrosomia.

RESULTS

In total, 148 women (76 in the intervention arm, 72 in the control arm; average age, 34.1±4.0 years; body mass index, 27.1±5.0 kg/m2) were randomized. The intervention arm showed a lower mean change in fasting plasma glucose than the control arm (difference, -0.15 mmol/L vs -2.7 mg/mL; P=.022) and lower capillary fasting glucose levels (difference, -0.04 mmol/L vs -0.7 mg/mL; P=.002). The intervention arm also increased their intake of vegetables (difference, 11.8 g/MJ; P=.043), decreased their sedentary behavior (difference, -27.3 min/d; P=.043), and increased light physical activity (difference, 22.8 min/d; P=.009) when compared with the control arm. In addition, gestational weight gain was lower (difference, -1.3 kg; P=.015), and there were less newborns with macrosomia in the intervention arm (difference, -13.1 %; P=.036). Adherence to eMOM was high (daily use >90%), and the usage correlated with lower maternal fasting (P=.0006) and postprandial glucose levels (P=.017), weight gain (P=.028), intake of energy (P=.021) and carbohydrates (P=.003), and longer duration of the daily physical activity (P=.0006). There were no significant between-arm differences in terms of pregnancy complications.

CONCLUSION

Self-tracking of lifestyle factors and glucose levels without additional guidance improves self-management and the treatment of gestational diabetes, which also benefits newborns. The results of this study support the use of digital self-management and education tools in maternity care.

Perception and appropriation of a web-based recovery narratives intervention: qualitative interview study

Introduction

Mental health recovery narratives are widely available to the public, and can benefit people affected by mental health problems. The NEON Intervention is a novel web-based digital health intervention providing access to the NEON Collection of recovery narratives. The NEON Intervention was found to be effective and cost-effective in the NEON-O Trial for people with nonpsychosis mental health problems (ISRCTN63197153), and has also been evaluated in the NEON Trial for people with psychosis experience (ISRCTN11152837). We aimed to document NEON Intervention experiences, through an integrated process evaluation.

Methods

Analysis of interviews with a purposive sample of intervention arm participants who had completed trial participation.

Results

We interviewed 34 NEON Trial and 20 NEON-O Trial participants (mean age 40.4 years). Some users accessed narratives through the NEON Intervention almost daily, whilst others used it infrequently or not at all. Motivations for trial participation included: exploring the NEON Intervention as an alternative or addition to existing mental health provision; searching for answers about mental health experiences; developing their practice as a mental health professional (for a subset who were mental health professionals); claiming payment vouchers. High users (10 + narrative accesses) described three forms of appropriation: distracting from difficult mental health experiences; providing an emotional boost; sustaining a sense of having a social support network. Most participants valued the scale of the NEON Collection (n = 659 narratives), but some found it overwhelming. Many felt they could describe the characteristics of a desired narrative that would benefit their mental health. Finding a narrative meeting their desires enhanced engagement, but not finding one reduced engagement. Narratives in the NEON Collection were perceived as authentic if they acknowledged the difficult reality of mental health experiences, appeared to describe real world experiences, and described mental health experiences similar to those of the participant.

Discussion

We present recommendations for digital health interventions incorporating collections of digital narratives: (1) make the scale and diversity of the collection visible; (2) provide delivery mechanisms that afford appropriation; (3) enable contributors to produce authentic narratives; (4) enable learning by healthcare professionals; (5) consider use to address loneliness.

Factors associated with the use of digital health among healthcare workers in the Buea and Tiko health districts of Cameroon: a cross-sectional study

Introduction

digital health has been demonstrated to improve the efficiency and scale of health service delivery in resource-limited settings. Understanding factors influencing its use could accelerate the process of its implementation in routine practice.

Methods

we conducted a cross-sectional analytic study in Buea and Tiko health districts from January to May 2021. We included healthcare workers selected using multistage stratified sampling. Use of digital health was defined as using at least two digital tools and one digital health intervention (DHI) or at least two DHIs by a healthcare worker. Epi Info was used for statistical analysis. Binary logistic regression was used to evaluate factors associated with the use of digital health.

Results

in total, 221 participants were included in the study. The mean age was 33±9.1 years and 76.5% were female. Only 39.4% (n=87) of participants used digital health. The most frequently used digital tools for health-related purposes included: Microsoft (MS) Excel (29.9%), MS PowerPoint (26.8%) and MS Word (39.1%). The main DHIs used were research (30.2%) and diagnosing (24.1%) software. The main use of digital health was for research (75.6%). Owning a laptop (adjusted odds ratio (aOR)=1.98, 95% CI, 1.01 - 3.86), availability of internet connection in the health facility (1.99, 1.05 - 3.7) and receiving professional training in ICT/Computer Sciences (2.04, 1.06 - 3.93), were associated with higher odds of using digital health.

Conclusion

this study shows a low level of use of digital health by healthcare workers. Providing newer devices, internet connection in health facilities and training in ICT for healthcare workers could improve its uptake.

Benefits, Recruitment, Dropout, and Acceptability of the Strength Back Digital Health Intervention for Patients Undergoing Spinal Surgery: Nonrandomized, Qualitative, and Quantitative Pilot Feasibility Study

BACKGROUND

Patients undergoing spinal surgery report high levels of insecurity, pain, stress, and anxiety before and after surgery. Unfortunately, there is no guarantee that surgery will resolve all issues; postsurgical recovery often entails moderate to severe postoperative pain, and some patients undergoing spinal surgery do not experience (long-term) pain relief after surgery. Therefore, focusing on sustainable coping skills and resilience is crucial for these patients. A digital health intervention based on acceptance and commitment therapy (ACT) and positive psychology (PP) was developed to enhance psychological flexibility and well-being and reduce postsurgical pain.

OBJECTIVE

The objective of this study was 3-fold: to explore the potential benefits for patients undergoing spinal surgery of the digital ACT and PP intervention Strength Back (research question [RQ] 1), explore the feasibility of a future randomized controlled trial in terms of recruitment and dropout (RQ 2), and assess the acceptability of Strength Back by patients undergoing spinal surgery (RQ 3).

METHODS

We used a nonrandomized experimental design with an intervention group (n=17) and a control group (n=20). To explore the potential benefits of the intervention, participants in both groups filled out questionnaires before and after surgery. These questionnaires included measurements of pain intensity (Numeric Pain Rating Scale), pain interference (Multidimensional Pain Inventory), anxiety and depression (Hospital Anxiety and Depression Scale), valued living (Engaged Living Scale), psychological flexibility (Psychological Inflexibility in Pain Scale), and mental well-being (Mental Health Continuum-Short Form). Semistructured interviews combined with log data and scores on the Twente Engagement With eHealth Technologies Scale were used to assess the acceptability of the intervention.

RESULTS

A significant improvement over time in emotional (V=99; P=.03) and overall (V=55; P=.004) well-being (Mental Health Continuum-Short Form) was observed only in the intervention group. In addition, the intervention group showed a significantly larger decline in pain intensity (Numeric Pain Rating Scale) than did the control group (U=75; P=.003). Of the available weekly modules on average 80% (12/15) was completed by patients undergoing spinal fusion and 67% (6/9) was completed by patients undergoing decompression surgery. A total of 68% (17/25) of the participants used the intervention until the final interview. Most participants (15/17, 88%) in the intervention group would recommend the intervention to future patients.

CONCLUSIONS

This pilot feasibility study showed that combining ACT and PP in a digital health intervention is promising for patients undergoing spinal surgery as the content was accepted by most of the participants and (larger) improvements in pain intensity and well-being were observed in the intervention group. A digital intervention for patients undergoing (spinal) surgery can use teachable moments, when patients are open to learning more about the surgery and rehabilitation afterward. A larger randomized controlled trial is now warranted.

Effectiveness and cost-effectiveness of online recorded recovery narratives in improving quality of life for people with non-psychotic mental health problems: a pragmatic randomized controlled trial

Narratives describing first-hand experiences of recovery from mental health problems are widely available. Emerging evidence suggests that engaging with mental health recovery narratives can benefit people experiencing mental health problems, but no randomized controlled trial has been conducted as yet. We developed the Narrative Experiences Online (NEON) Intervention, a web application providing self-guided and recommender systems access to a collection of recorded mental health recovery narratives (n=659). We investigated whether NEON Intervention access benefited adults experiencing non-psychotic mental health problems by conducting a pragmatic parallel-group randomized trial, with usual care as control condition. The primary endpoint was quality of life at week 52 assessed by the Manchester Short Assessment (MANSA). Secondary outcomes were psychological distress, hope, self-efficacy, and meaning in life at week 52. Between March 9, 2020 and March 26, 2021, we recruited 1,023 participants from across England (the target based on power analysis was 994), of whom 827 (80.8%) identified as White British, 811 (79.3%) were female, 586 (57.3%) were employed, and 272 (26.6%) were unemployed. Their mean age was 38.4±13.6 years. Mood and/or anxiety disorders (N=626, 61.2%) and stress-related disorders (N=152, 14.9%) were the most common mental health problems. At week 52, our intention-to-treat analysis found a significant baseline-adjusted difference of 0.13 (95% CI: 0.01-0.26, p=0.041) in the MANSA score between the intervention and control groups, corresponding to a mean change of 1.56 scale points per participant, which indicates that the intervention increased quality of life. We also detected a significant baseline-adjusted difference of 0.22 (95% CI: 0.05-0.40, p=0.014) between the groups in the score on the "presence of meaning" subscale of the Meaning in Life Questionnaire, corresponding to a mean change of 1.1 scale points per participant. We found an incremental gain of 0.0142 quality-adjusted life years (QALYs) (95% credible interval: 0.0059 to 0.0226) and a £178 incremental increase in cost (95% credible interval: -£154 to £455) per participant, generating an incremental cost-effectiveness ratio of £12,526 per QALY compared with usual care. This was lower than the £20,000 per QALY threshold used by the National Health Service in England, indicating that the intervention would be a cost-effective use of health service resources. In the subgroup analysis including participants who had used specialist mental health services at baseline, the intervention both reduced cost (-£98, 95% credible interval: -£606 to £309) and improved QALYs (0.0165, 95% credible interval: 0.0057 to 0.0273) per participant as compared to usual care. We conclude that the NEON Intervention is an effective and cost-effective new intervention for people experiencing non-psychotic mental health problems.

Improving self-management behaviour through a digital lifestyle intervention: An internal pilot study

BACKGROUND

Self-management is a key component of successful chronic kidney disease (CKD) management. Here, we present the findings from the internal pilot of a multicentre randomised controlled trial (RCT) aimed to test the effect of a digital self-management programme ('My Kidneys & Me' (MK&M)).

METHODS

Participants (aged ≥18 years and CKD stages 3-4) were recruited from hospital kidney services across England. Study processes were completed virtually. Participants were randomised 2:1 to either intervention (MK&M) or control group. The first 60 participants recruited were included in a 10-week internal pilot which assessed study feasibility and acceptability against pre-specified progression criteria: 1) eligibility and recruitment, acceptability of 2) randomisation and 3) outcomes, 4) MK&M activation, and 5) retention and attrition rates. Semi-structured interviews further explored views on trial participation.

RESULTS

Of the 60 participants recruited, 41 were randomised to MK&M and 19 to control. All participants completed baseline measures and 62% (n=37) completed post-intervention outcome measures. All progression criteria met the minimum thresholds to proceed. Nine participants were interviewed. The themes identified were satisfaction with study recruitment processes (openness to participate, reading and agreeing to "terms and conditions"), acceptability of study design (remote study participation, acceptability of randomisation, completion of online assessment(s)), and methods to improve recruitment and retention (personalised approach, follow-up communication).

CONCLUSION

This internal pilot demonstrated the feasibility and acceptability of a virtually run RCT. Progression criteria thresholds to proceed to the definitive RCT were met. Areas for improvement were identified and protocol amendments were made to improve trial delivery.

The Potential of a Digital Weight Management Program to Support Specialist Weight Management Services in the UK National Health Service: Retrospective Analysis

BACKGROUND

Digital weight management interventions (DWMIs) have the potential to support existing specialist weight management services (SWMS) in the National Health Service (NHS) to increase access to treatment for people living with obesity and type 2 diabetes. At present, there is limited real-world evidence and long-term outcomes on the potential effectiveness of DWMIs to support such services.

OBJECTIVE

This study aimed to examine real-world data to evaluate the impact of Second Nature's 12-month DWMI for patients living with obesity with or without type 2 diabetes, referred from NHS primary care services, on sustained weight loss over a 2-year period.

METHODS

Retrospective data were extracted in August 2023 for participants who participated in the program between January 1, 2017, and January 8, 2021. Eligible participants were adults with a BMI ≥35 kg/m2, with or without type 2 diabetes. The primary outcomes were weight change in kilograms and percentage weight change at 2 years. Secondary outcomes were weight loss at 1 year, program engagement, and the proportion of participants who achieved >5% and >10% weight loss. Differences in weight loss between baseline and the 1- and 2-year follow-up points were compared using paired 2-tailed t tests. Linear regression models were used to examine whether participants' ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or program engagement were associated with weight loss at 1 year or 2 years.

RESULTS

A total of 1130 participants with a mean baseline BMI of 46.3 (SD 31.6) kg/m2 were included in the analysis. Of these participants, 65% (740/1130) were female (mean age 49.9, SD 12.0 years), 18.1% (205/339) were from Black, Asian, mixed, or other ethnicities, and 78.2% (884/1130) had type 2 diabetes. A total of 281 (24.9%) participants recorded weight readings at 2 years from baseline, with a mean weight loss of 13.8 kg (SD 14.2 kg; P<.001) or 11.8% (SD 10.9%; P<.001). A total of 204 (18.1%) participants achieved ≥5% weight loss, and 130 (11.5%) participants reached ≥10% weight loss. Weight loss did not significantly differ by ethnicity, indices of multiple deprivation, presence of type 2 diabetes, or engagement in the program.

CONCLUSIONS

The findings suggested that Second Nature's DWMI has the potential to support people living with obesity and type 2 diabetes remotely to achieve clinically significant and sustained weight loss at 2 years from baseline. Further research is needed to compare the intervention to standard care and assess integration with multidisciplinary clinical teams and pharmacotherapy in order to support this study's findings.

Pragmatic, feasibility randomized controlled trial of a recorded mental health recovery narrative intervention: narrative experiences online intervention for informal carers (NEON-C)

Introduction

Informal carers of people with mental health problems often have unmet support needs. Mental health recovery narratives are increasingly accessible, but their relevance to and effect on informal carers have been minimally investigated. The Narrative Experiences Online (NEON) Intervention is a first-in-field intervention that provides informal carers with access to a diverse collection of recorded mental health recovery narratives. This trial aimed to examine the feasibility and acceptability of the NEON Intervention for informal carers.

Methods

This study involved a two-arm feasibility randomized controlled trial. Carers were randomly assigned to receiving versus not receiving the NEON Intervention. The feasibility aspects investigated included the acceptability of the intervention and of randomization, trial processes, engagement rates, recruitment procedures, attrition, sample size estimation, identification of candidate primary and secondary outcomes, and the feasibility of conducting a definitive trial. A qualitative process evaluation was conducted.

Findings

A total of 121 carers were eligible, of whom 54 were randomized (intervention: 27, control: 27). Twelve-month follow-up data were available for 36 carers. Carers accessed a mean of 25 narratives over a 12-month period, and the intervention group, compared with the control group, reported a small effect on hope and a moderate effect on the presence of meaning in life. Five modifications were recommended to improve the user experience, applicability, and trial processes.

Discussion

The NEON Intervention is feasible and acceptable. Significant refinement of the NEON Intervention and trial processes is required to personalize and ensure applicability to carers. Further feasibility testing is recommended prior to a definitive trial.

Digital Health Interventions for Heart Failure Management in Underserved Rural Areas of the United States: A Systematic Review of Randomized Trials

BACKGROUND

Heart failure disproportionately affects individuals residing in rural areas, leading to worse health outcomes. Digital health interventions have been proposed as a promising approach for improving heart failure management. This systematic review aims to identify randomized trials of digital health interventions for individuals living in underserved rural areas with heart failure.

METHODS AND RESULTS

We conducted a systematic review by searching 6 databases (CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed; 2000-2023). A total of 30 426 articles were identified and screened. Inclusion criteria consisted of digital health randomized trials that were conducted in underserved rural areas of the United States based on the US Census Bureau's classification. Two independent reviewers screened the studies using the National Heart, Lung, and Blood Institute tool to evaluate the risk of bias. The review included 5 trials from 6 US states, involving 870 participants (42.9% female). Each of the 5 studies employed telemedicine, 2 studies used remote monitoring, and 1 study used mobile health technology. The studies reported improvement in self-care behaviors in 4 trials, increased knowledge in 2, and decreased cardiovascular mortality in 1 study. However, 3 trials revealed no change or an increase in health care resource use, 2 showed no change in cardiac biomarkers, and 2 demonstrated an increase in anxiety.

CONCLUSIONS

The results suggest that digital health interventions have the potential to enhance self-care and knowledge of patients with heart failure living in underserved rural areas. However, further research is necessary to evaluate their impact on clinical outcomes, biomarkers, and health care resource use.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022366923.

Mapping Respiratory Health Digital Interventions in South and Southeast Asia: Protocol for a Scoping Review

BACKGROUND

The last 2 decades have been a time of exponential growth and maturation for digital health, while the global burden of respiratory disease continues to grow worldwide. Leveraging digital health interventions (DHIs) to manage and mitigate respiratory disease and its adverse health effects presents itself as an obvious path forward.

OBJECTIVE

We aimed to understand the current digital landscape and enabling environment around respiratory health to reduce costs, avoid duplication, and understand the comprehensiveness of DHIs.

METHODS

This study will follow a scoping review methodology as outlined by Arksey and O'Malley, the Joanna Briggs Institute, and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, Web of Science, PakiMedNet, and MyMedR databases will be searched along with key websites, repositories, and gray literature databases. The terms "respiratory health," "digital health," "South Asia," and "Southeast Asia," as well as related terms will be searched. The results will be screened for duplicates and then against the inclusion and exclusion criteria. For the studies included, data will be extracted, collated, and analyzed.

RESULTS

The scoping review was started in July 2023 and will be finalized by February 2024. Results will be presented following the World Health Organization's classification of DHIs to categorize interventions in a standardized format and the mobile health evidence reporting and assessment checklist to report on the effectiveness of interventions. Further exposition of the evidence extracted will be presented through narrative synthesis.

CONCLUSIONS

As DHIs continue to proliferate, the need to understand the current landscape becomes more pertinent. In this scoping review, we will seek to more clearly understand what digital health tools and technologies are being used in the current landscape of digital health in South and Southeast Asia for respiratory health and to what extent they are addressing the respiratory health needs of the region. The results will inform recommendations on digital health tools for respiratory health in South and Southeast Asia will help funders and implementers of DHIs leverage existing technologies and accelerate innovations that address documented gaps in the studied countries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52517.

A Serious Game to Train Rhythmic Abilities in Children With Dyslexia: Feasibility and Usability Study

BACKGROUND

Rhythm perception and production are related to phonological awareness and reading performance, and rhythmic deficits have been reported in dyslexia. In addition, rhythm-based interventions can improve cognitive function, and there is consistent evidence suggesting that they are an efficient tool for training reading skills in dyslexia.

OBJECTIVE

This paper describes a rhythmic training protocol for children with dyslexia provided through a serious game (SG) called Mila-Learn and the methodology used to test its usability.

METHODS

We computed Mila-Learn, an SG that makes training remotely accessible and consistently reproducible and follows an educative agenda using Unity (Unity Technologies). The SG's development was informed by 2 studies conducted during the French COVID-19 lockdowns. Study 1 was a feasibility study evaluating the autonomous use of Mila-Learn with 2500 children with reading deficits. Data were analyzed from a subsample of 525 children who spontaneously played at least 15 (median 42) games. Study 2, following the same real-life setting as study 1, evaluated the usability of an enhanced version of Mila-Learn over 6 months in a sample of 3337 children. The analysis was carried out in 98 children with available diagnoses.

RESULTS

Benefiting from study 1 feedback, we improved Mila-Learn to enhance motivation and learning by adding specific features, including customization, storylines, humor, and increasing difficulty. Linear mixed models showed that performance improved over time. The scores were better for older children (P<.001), children with attention-deficit/hyperactivity disorder (P<.001), and children with dyslexia (P<.001). Performance improved significantly faster in children with attention-deficit/hyperactivity disorder (β=.06; t3754=3.91; P<.001) and slower in children with dyslexia (β=-.06; t3816=-5.08; P<.001).

CONCLUSIONS

Given these encouraging results, future work will focus on the clinical evaluation of Mila-Learn through a large double-blind randomized controlled trial comparing Mila-Learn and a placebo game.

Effectiveness and User Perception of an In-Vehicle Voice Warning for Hypoglycemia: Development and Feasibility Trial

BACKGROUND

Hypoglycemia is a frequent and acute complication in type 1 diabetes mellitus (T1DM) and is associated with a higher risk of car mishaps. Currently, hypoglycemia can be detected and signaled through flash glucose monitoring or continuous glucose monitoring devices, which require manual and visual interaction, thereby removing the focus of attention from the driving task. Hypoglycemia causes a decrease in attention, thereby challenging the safety of using such devices behind the wheel. Here, we present an investigation of a hands-free technology-a voice warning that can potentially be delivered via an in-vehicle voice assistant.

OBJECTIVE

This study aims to investigate the feasibility of an in-vehicle voice warning for hypoglycemia, evaluating both its effectiveness and user perception.

METHODS

We designed a voice warning and evaluated it in 3 studies. In all studies, participants received a voice warning while driving. Study 0 (n=10) assessed the feasibility of using a voice warning with healthy participants driving in a simulator. Study 1 (n=18) assessed the voice warning in participants with T1DM. Study 2 (n=20) assessed the voice warning in participants with T1DM undergoing hypoglycemia while driving in a real car. We measured participants' self-reported perception of the voice warning (with a user experience scale in study 0 and with acceptance, alliance, and trust scales in studies 1 and 2) and compliance behavior (whether they stopped the car and reaction time). In addition, we assessed technology affinity and collected the participants' verbal feedback.

RESULTS

Technology affinity was similar across studies and approximately 70% of the maximal value. Perception measure of the voice warning was approximately 62% to 78% in the simulated driving and 34% to 56% in real-world driving. Perception correlated with technology affinity on specific constructs (eg, Affinity for Technology Interaction score and intention to use, optimism and performance expectancy, behavioral intention, Session Alliance Inventory score, innovativeness and hedonic motivation, and negative correlations between discomfort and behavioral intention and discomfort and competence trust; all P<.05). Compliance was 100% in all studies, whereas reaction time was higher in study 1 (mean 23, SD 5.2 seconds) than in study 0 (mean 12.6, SD 5.7 seconds) and study 2 (mean 14.6, SD 4.3 seconds). Finally, verbal feedback showed that the participants preferred the voice warning to be less verbose and interactive.

CONCLUSIONS

This is the first study to investigate the feasibility of an in-vehicle voice warning for hypoglycemia. Drivers find such an implementation useful and effective in a simulated environment, but improvements are needed in the real-world driving context. This study is a kickoff for the use of in-vehicle voice assistants for digital health interventions.

Engagement with mHealth Alcohol Interventions: User Perspectives on an App or Chatbot-Delivered Program to Reduce Drinking

Research suggests participant engagement is a key mediator of mHealth alcohol interventions' effectiveness in reducing alcohol consumption among users. Understanding the features that promote engagement is critical to maximizing the effectiveness of mHealth-delivered alcohol interventions. The purpose of this study was to identify facilitators and barriers to mHealth alcohol intervention utilization among hazardous-drinking participants who were randomized to use either an app (Step Away) or Artificial Intelligence (AI) chatbot-based intervention for reducing drinking (the Step Away chatbot). We conducted semi-structured interviews from December 2019 to January 2020 with 20 participants who used the app or chatbot for three months, identifying common facilitators and barriers to use. Participants of both interventions reported that tracking their drinking, receiving feedback about their drinking, feeling held accountable, notifications about high-risk drinking times, and reminders to track their drinking promoted continued engagement. Positivity, personalization, gaining insight into their drinking, and daily tips were stronger facilitator themes among bot users, indicating these may be strengths of the AI chatbot-based intervention when compared to a user-directed app. While tracking drinking was a theme among both groups, it was more salient among app users, potentially due to the option to quickly track drinks in the app that was not present with the conversational chatbot. Notification glitches, technology glitches, and difficulty with tracking drinking data were usage barriers for both groups. Lengthy setup processes were a stronger barrier for app users. Repetitiveness of the bot conversation, receipt of non-tailored daily tips, and inability to self-navigate to desired content were reported as barriers by bot users. To maximize engagement with AI interventions, future developers should include tracking to reinforce behavior change self-monitoring and be mindful of repetitive conversations, lengthy setup, and pathways that limit self-directed navigation.

The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety.

DATA SOURCES

Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

STUDY ELIGIBILITY REQUIREMENTS

The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated.

RESULTS

Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I2=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I2=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]).

CONCLUSION

Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Effectiveness of an Occupational Well-being Intervention Among Nurse Educators: A Quasi-Experimental Study

BACKGROUND

Occupational well-being supports the retention of the nurse educator workforce and their ability to manage workload. There is a research gap regarding interventions promoting occupational well-being.

PURPOSE

To evaluate the effectiveness of an 8-workweek digital occupational well-being intervention using self-conducted exercises among nurse educators in secondary vocational nursing schools in Finland.

METHODS

A quasi-experimental study design was applied using an intervention group (n = 37) and a control group (n = 40). Data were collected at baseline, post, and 1-month follow-up using a questionnaire and a heart rate sensor to assess the resource-workload-balance and its associating and promoting factors.

RESULTS

This study found no statistical effects on the resource-workload-balance. Positive effects were found on associating factors (general well-being) and promoting factors (recovery experiences and self-regulation).

CONCLUSIONS

Self-Help INtervention for Educators (SHINE) has the potential to promote recovery experiences during working hours; however, the intervention needs more investigation.

Patient Acceptability of Symptom Screening and Patient Education Using a Chatbot for Autoimmune Inflammatory Diseases: Survey Study

BACKGROUND

Chatbots have the potential to enhance health care interaction, satisfaction, and service delivery. However, data regarding their acceptance across diverse patient populations are limited. In-depth studies on the reception of chatbots by patients with chronic autoimmune inflammatory diseases are lacking, although such studies are vital for facilitating the effective integration of chatbots in rheumatology care.

OBJECTIVE

We aim to assess patient perceptions and acceptance of a chatbot designed for autoimmune inflammatory rheumatic diseases (AIIRDs).

METHODS

We administered a comprehensive survey in an outpatient setting at a top-tier rheumatology referral center. The target cohort included patients who interacted with a chatbot explicitly tailored to facilitate diagnosis and obtain information on AIIRDs. Following the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework, the survey was designed to gauge the effectiveness, user acceptability, and implementation of the chatbot.

RESULTS

Between June and October 2022, we received survey responses from 200 patients, with an equal number of 100 initial consultations and 100 follow-up (FU) visits. The mean scores on a 5-point acceptability scale ranged from 4.01 (SD 0.63) to 4.41 (SD 0.54), indicating consistently high ratings across the different aspects of chatbot performance. Multivariate regression analysis indicated that having a FU visit was significantly associated with a greater willingness to reuse the chatbot for symptom determination (P=.01). Further, patients' comfort with chatbot diagnosis increased significantly after meeting physicians (P<.001). We observed no significant differences in chatbot acceptance according to sex, education level, or diagnosis category.

CONCLUSIONS

This study underscores that chatbots tailored to AIIRDs have a favorable reception. The inclination of FU patients to engage with the chatbot signifies the possible influence of past clinical encounters and physician affirmation on its use. Although further exploration is required to refine their integration, the prevalent positive perceptions suggest that chatbots have the potential to strengthen the bridge between patients and health care providers, thus enhancing the delivery of rheumatology care to various cohorts.

A Remotely Delivered, Semaglutide-Supported Specialist Weight Management Program: Preliminary Findings From a Retrospective Service Evaluation

BACKGROUND

Digital weight management interventions have the potential to increase access to novel pharmacotherapy for people living with obesity. At present, there is limited real-world evidence on the effectiveness, feasibility, and acceptability of this type of intervention.

OBJECTIVE

This retrospective service evaluation examines real-world data to evaluate the preliminary impact of Second Nature's 24-month, remotely delivered, semaglutide-supported weight management intervention for adults living with obesity at 12 weeks.

METHODS

Retrospective data were extracted in October 2023 for participants who started the intervention between June 8, 2023, and July 22, 2023. The primary outcomes were weight change (kg) and percentage of weight change at 12 weeks. The secondary outcomes were the proportion of participants who achieved ≥5% and ≥10% weight loss and the feasibility and acceptability of this type of intervention. Descriptive statistics were used to evaluate the baseline characteristics, retention, engagement, prevalence of side effects, and weight change. A paired 2-tailed t test was used to determine the significance of weight change. Content analysis was used to analyze the free-text questionnaire responses.

RESULTS

A total of 113 participants with a mean baseline BMI of 38.4 kg/m2 (SD 7.3) were included in the analysis (n=102, 90.4% women, mean age 46.6, SD 11.1 years). Over 12 weeks, 23% (n=26) of participants withdrew from the intervention. A total of 70.8% (n=80) of participants provided weight data at 12 weeks. The average weight loss observed over this 12-week period was 6.5 (SD 4.4) kg (P<.001) or 6.4% (SD 4.2%) of their starting weight (P<.001). Of the 80 participants who recorded weight readings, 62.5% (n=50) achieved ≥5% weight loss, and 11.3% (n=9) achieved ≥10% weight loss. Engagement with the app-based program declined from a mean of 131 (SD 142.6) home screen views in week 0 to 35 (SD 57.1) in week 11. Common side effects reported over 12 weeks included feeling more tired than usual, constipation, and feeling sick. However, a significant proportion of participants reported no side effects. Most participants (n=106, 93.8%) did not experience any difficulties in medication administration. Qualitative data showed that most participants had a positive or neutral experience of the intervention, with some reporting perceived benefits as early as 4 weeks. Most participants did not feel that improvements in the intervention were needed; however, some participants faced issues with medication shipping or logistics.

CONCLUSIONS

This retrospective preliminary service evaluation suggests that a remotely delivered semaglutide-supported weight management intervention has the potential to be effective, feasible, and acceptable for self-paying consumer adults with obesity in the United Kingdom. Areas for further improvement were highlighted, including user engagement in an app-based program. A full-service evaluation at the end of the 24-month intervention with a larger sample size is required to support these early findings.

Factors influencing participation in an online national diabetes prevention programme: A qualitative study with attenders and educators

AIM

To explore factors affecting participation in the pilot of the synchronous online national diabetes prevention programme (NDPP) in Ireland from the perspectives of those who attended and the educators who recruited for and delivered the programme.

METHODS

A qualitative study involving semi-structured interviews and focus groups with NDPP attenders (attended the assessment and at least one session) and educators (dietitians) on the programme. The Framework Method using the Theoretical Domains Framework (TDF) guided the analysis.

RESULTS

Thirteen attenders took part in two online focus groups and five online or phone interviews. Eight educators took part. Four themes which cut across the TDF domains were identified as factors influencing participation; (i) lack of awareness of prediabetes and fear of diabetes, relating to attenders' fear of diabetes and lack of knowledge of prediabetes and diabetes prevention; (ii) perceived need for programme support to change health behaviour, concerning attenders' and educators' recognition of the need for the NDPP; (iii) trust in healthcare professionals (HCPs), relating to trust in HCPs to convey the seriousness of prediabetes and the value of diabetes prevention programmes (DPPs) and (iv) practical and personal ease of joining online, relating to the flexibility and accessibility of the synchronous online group format, the IT skills of attenders and educators and apprehension about group education.

CONCLUSIONS

Raising awareness of prediabetes and the need for prevention programmes should be a priority for health services and HCPs. The synchronous online group format was seen as less daunting to join than a face-to-face programme and may be a useful option to encourage participation.

Feasibility, Adherence, and Effectiveness of Blended Psychotherapy for Severe Mental Illnesses: Scoping Review

BACKGROUND

Blended psychotherapy (bPT) combines face-to-face psychotherapy with digital interventions to enhance the effectiveness of mental health treatment. The feasibility and effectiveness of bPT have been demonstrated for various mental health issues, although primarily for patients with higher levels of functioning.

OBJECTIVE

This scoping review aims to investigate the feasibility, adherence, and effectiveness of bPT for the treatment of patients with severe mental illnesses (SMIs).

METHODS

Following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines, we conducted searches in PubMed, MEDLINE, Embase, PsycINFO, and PsycArticles for studies published until March 23, 2023.

RESULTS

Out of 587 screened papers, we incorporated 25 studies encompassing 23 bPT interventions, involving a total of 2554 patients with SMI. The intervention formats and research designs exhibited significant variation. Our findings offer preliminary evidence supporting the feasibility of bPT for SMI, although there is limited research on adherence. Nevertheless, the summarized studies indicated promising attrition rates, spanning from 0% to 37%, implying a potential beneficial impact of bPT on adherence to SMI treatment. The quantity of evidence on the effects of bPT for SMI was limited and challenging to generalize. Among the 15 controlled trials, 4 concluded that bPT interventions were effective compared with controls. However, it is noteworthy that 2 of these studies used the same study population, and the control groups exhibited significant variations.

CONCLUSIONS

Overall, our review suggests that while bPT appears promising as a treatment method, further research is necessary to establish its effectiveness for SMI. We discuss considerations for clinical implementation, directions, and future research.

Development of a Virtual Human for Supporting Tobacco Cessation During the COVID-19 Pandemic

People who consume tobacco are at greater risk of developing severe COVID-19. Unfortunately, the COVID-19 pandemic reduced the accessibility of tobacco cessation services as a result of necessary social restrictions. Innovations were urgently needed to support tobacco cessation during the pandemic. Virtual humans are artificially intelligent computer agents with a realistic, humanlike appearance. Virtual humans could be a scalable and engaging way to deliver tobacco cessation information and support. Florence, a virtual human health worker, was developed in collaboration with the World Health Organization to remotely support people toward tobacco cessation during the COVID-19 pandemic. Florence delivers evidence-based information, assists with making quit plans, and directs people to World Health Organization-recommended cessation services in their country. In this viewpoint, we describe the process of developing Florence. The development was influenced by a formative evaluation of data from 115 early users of Florence from 49 countries. In general, Florence was positively perceived; however, changes were requested to aspects of her design and content. In addition, areas for new content were identified (eg, for nonsmoker support persons). Virtual health workers could expand the reach of evidence-based tobacco cessation information and personalized support. However, as they are a new innovation in tobacco cessation, their efficacy, feasibility, and acceptability in this application needs to be evaluated, including in diverse populations.

Implementing Telemedicine in Clinical Practice in the First Digital Hematology Unit: Feasibility Study

BACKGROUND

Currently, there are no telemedicine models that fully integrate all areas of hematology into daily practice.

OBJECTIVE

The objectives of this feasibility study were to assess the practicality of implementing telemedicine into our clinical practice in the first Digital Hematology Unit and propose an innovative integrative design for clinical practice.

METHODS

We designed the Digital Hematology Unit, which is a specific physical space dedicated to carrying out telemedicine and monitoring patients in a holistic way. Also, a satisfaction questionnaire was performed and health care indicators were measured.

RESULTS

In 2021, there were 1331 first visits and 7534 follow-up visits. Of the first visits, 12.2% (n=163) were face-to-face and 87.8% (n=1168) were telematic. For follow-up visits, 29.9% (n=2251) were face-to-face and 70.1% (n=5283) were telematic. The health care management indicators showed that we had a waiting time of less than 4 days and took less than 4 hours to answer interconsultations among specialists. Moreover, patients reported a high level of satisfaction with the services provided.

CONCLUSIONS

Our Digital Hematology Unit, as a case of success, serves as an example of how innovative digital solutions can contribute to the quality of care and excellence in health care achieved through a digital transformation process led by hematologists.

The acceptability and preliminary effectiveness of a brief, online parenting program: Expanding access to Evidence-Based parenting intervention content

Parenting interventions are a promising means for preventing and treating a variety of child behavior and conduct problems; yet, many families lack access to such services. Online parenting programs offer an opportunity to mitigate many barriers to intervention access by extending service delivery options. The purpose of the present study was to evaluate the acceptability and preliminary effectiveness of a brief, online parenting program. We developed a new online parenting program based on foundational content from the evidence-based GenerationPMTO intervention and used a mixed-methods, single-arm open trial (pre-post) design to perform a preliminary evaluation. The combined results from the quantitative and qualitative data provide initial support for the acceptability and preliminary effectiveness of the online program, based on participant self-report data from program completers. Participants indicated high levels of acceptability for the program topics and videos. They also reported statistically significant improvements from baseline to 4 weeks postintervention in parental efficacy, parenting practices, and child behavior problems. The qualitative data corroborated and expanded these findings. We go on to discuss important accessibility and sustainability considerations addressed by this online parenting program as well as to suggest implications for intervention research and mental health practice.

The Multidomain Metaverse Cancer Care Digital Platform: Development and Usability Study

BACKGROUND

As cancer treatment methods have diversified and the importance of self-management, which lowers the dependence rate on direct hospital visits, has increased, effective cancer care education and management for health professionals and patients have become necessary. The metaverse is in the spotlight as a means of digital health that allows users to engage in cancer care education and management beyond physical constraints. However, it is difficult to find a multipurpose medical metaverse that can not only be used in the field but also complements current cancer care.

OBJECTIVE

This study aimed to develop an integrated metaverse cancer care platform, Dr. Meta, and examine its usability.

METHODS

We conducted a multicenter, cross-sectional survey between November and December 2021. A descriptive analysis was performed to examine users' experiences with Dr. Meta. In addition, a supplementary open-ended question was used to ask users for their suggestions and improvements regarding the platform.

RESULTS

Responses from 70 Korean participants (male: n=19, 27% and female: n=51, 73%) were analyzed. More than half (n=37, 54%) of the participants were satisfied with Dr. Meta; they responded that it was an interesting and immersive platform (n=50, 72%). Less than half perceived no discomfort when using Dr. Meta (n=34, 49%) and no difficulty in wearing and operating the device (n=30, 43%). Furthermore, more than half (n=50, 72%) of the participants reported that Dr. Meta would help provide non-face-to-face and noncontact services. More than half also wanted to continue using this platform in the future (n=41, 59%) and recommended it to others (n=42, 60%).

CONCLUSIONS

We developed a multidomain metaverse cancer care platform that can support both health professionals and patients in non-face-to-face cancer care. The platform was uniquely disseminated and implemented in multiple regional hospitals and showed the potential to perform successful cancer care.

A Brief, Digital Music-Based Mindfulness Intervention for Black Americans With Elevated Race-Based Anxiety and Little-to-No Meditation Experience ("healing attempt"): Replication and Extension Study

BACKGROUND

Race-based anxiety is a critical health issue within the Black community. Mindfulness interventions hold promise for treating race-based anxiety in Black Americans; however, there are many barriers that prevent Black Americans from using these treatments, such as low cultural relevance, significant time burdens, and excessive costs.

OBJECTIVE

This study is a replication and extension of findings that "healing attempt"-a brief (<60-minute), digital, music-based mindfulness intervention-is a feasible and acceptable intervention for race-based anxiety in Black Americans. In this study, we tested this research question among those with little-to-no meditation experience.

METHODS

The participants were 4 Black American adults with elevated race-based trait anxiety and little-to-no meditation experience. We used a series of multiple-baseline single-case experiments and conducted study visits on Zoom (Zoom Video Communications) to assess whether the intervention can decrease state anxiety and increase mindfulness and self-compassion in Black Americans. We also assessed feasibility and acceptability using quantitative and qualitative scales.

RESULTS

In line with our hypotheses, "healing attempt" increased mindfulness/self-compassion (Tau-U range: 0.57-0.86; P<.001) and decreased state anxiety (Tau-U range: -0.93 to -0.66; P<.001), with high feasibility and acceptability (the average likelihood of recommending "healing attempt" was 88 out of 100).

CONCLUSIONS

"healing attempt" may represent a feasible intervention for race-based anxiety in Black Americans with elevated race-based anxiety and little or no mindfulness experience. Future between-subjects randomized feasibility trials can assess whether the intervention can give rise to lasting improvements in race-based anxiety, mindfulness, and self-compassion.

TRIAL REGISTRATION

OSF Registries osf.io/k5m93; https://osf.io/k5m93.

The Impact of WhatsApp as a Health Education Tool in Albinism: Interventional Study

BACKGROUND

Oculocutaneous albinism is a congenital disorder that causes hypopigmentation of the skin, hair, and eyes due to a lack of melanin. People with albinism are at increased risk of developing skin complications, such as solar keratosis and skin cancers, leading to higher morbidity. As education is crucial in managing albinism, leveraging information technology, such as WhatsApp, can provide an effective intervention for digital health education.

OBJECTIVE

This study aims to assess the impact of WhatsApp as a tool for providing health education among people with albinism.

METHODS

The design of the study was interventional. The intervention consisted of weekly health education sessions conducted in a WhatsApp group for the duration of 4 weeks. The topics discussed were knowledge of albinism, sun protection practices, the use of sunscreen, and myths about albinism. They were all covered in 4 WhatsApp sessions held in 4 separate days. A web-based questionnaire was filled out before and after the intervention by the participants. Mann-Whitney U test was used to compare the pre- and postknowledge scores. Spearman correlation was used to correlate data.

RESULTS

The mean age of the study participants was 28.28 (SD 11.57) years. The number of participants was 140 in the preintervention period and 66 in the postintervention period. A statistically significant increase in overall knowledge (P=.01), knowledge of sunscreen (P=.01), and knowledge of sun protection (P<.01) was observed following the intervention. Before the intervention, a positive correlation was observed between age (r=0.17; P=.03) and education level (r=0.19; P=.02) with participants' overall knowledge. However, after the intervention, there was no significant correlation between knowledge and age or education level. A percentage increase of 5.23% was observed in the overall knowledge scores following the intervention.

CONCLUSIONS

WhatsApp is an effective tool for educating people with albinism and can act as an alternative to the conventional methods of health education. It shows promising outcomes irrespective of the health literacy level of people with albinism. This educational intervention can positively impact behavior change and translate to consistent sun protection practices. The limitations of this study include the possibility of social desirability bias and data security.

Behavioral Mechanisms That Mediate Mental and Physical Health Improvements in People With Chronic Pain Who Receive a Digital Health Intervention: Prospective Cohort Pilot Study

BACKGROUND

Preliminary evidence suggests that digital mental health intervention (Wysa for Chronic Pain) can improve mental and physical health in people with chronic musculoskeletal pain and coexisting symptoms of depression or anxiety. However, the behavioral mechanisms through which this intervention acts are not fully understood.

OBJECTIVE

The purpose of this study was to identify behavioral mechanisms that may mediate changes in mental and physical health associated with use of Wysa for Chronic Pain during orthopedic management of chronic musculoskeletal pain. We hypothesized that improved behavioral activation, pain acceptance, and sleep quality mediate improvements in self-reported mental and physical health.

METHODS

In this prospective cohort, pilot mediation analysis, adults with chronic (≥3 months) neck or back pain received the Wysa for Chronic Pain digital intervention, which uses a conversational agent and text-based access to human counselors to deliver cognitive behavioral therapy and related therapeutic content. Patient-reported outcomes and proposed mediators were collected at baseline and 1 month. The exposure of interest was participants' engagement (ie, total interactions) with the digital intervention. Proposed mediators were assessed using the Behavioral Activation for Depression Scale-Short Form, Chronic Pain Acceptance Questionnaire, and Athens Insomnia Scale. Outcomes included Patient-Reported Outcomes Measurement Information System Anxiety, Depression, Pain Interference, and Physical Function scores. A mediation analysis was conducted using the Baron and Kenny method, adjusting for age, sex, and baseline mediators and outcome values. P<.20 was considered significant for this pilot study.

RESULTS

Among 30 patients (mean age 59, SD 14, years; 21 [70%] female), the mediation effect of behavioral activation on the relationship between increased intervention engagement and improved anxiety symptoms met predefined statistical significance thresholds (indirect effect -0.4, 80% CI -0.7 to -0.1; P=.13, 45% of the total effect). The direction of mediation effect was generally consistent with our hypothesis for all other proposed mediator or outcome relationships, as well.

CONCLUSIONS

In a full-sized randomized controlled trial of patients with chronic musculoskeletal pain, behavioral activation, pain acceptance, and sleep quality may play an important role in mediating the relationship between use of a digital mental health intervention (Wysa for Chronic Pain) and improved mental and physical health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05194722; https://clinicaltrials.gov/ct2/show/NCT05194722.

Effectiveness of a 5-Week Virtual Reality Telerehabilitation Program for Children With Duchenne and Becker Muscular Dystrophy: Prospective Quasi-Experimental Study

Background

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are neuromuscular diseases. DMD is the most prevalent in children. It affects dystrophin production, reducing the patient's mobility and quality of life. New technologies have become a part of physical therapy in DMD and BMD. During the COVID-19 pandemic, conducting telerehabilitation through virtual reality-based games could help these children maintain their physical abilities.

Objective

This study examined if the use of a virtual platform in a multimodal intervention program changes the results of the 6-minute walk test (6MWT) in children with DMD and BMD. The main objective was to test whether children with DMD and BMD obtain different results on the 6MWT after completing 10 telerehabilitation treatment sessions. The secondary objective was to measure whether other specific motor scales also produce different results after the 10 defined sessions.

Methods

This was a descriptive, open, and quasi-experimental study with a prospective A-B (control-intervention) design. A sample of 12 participants who fulfilled the inclusion criteria followed the program for 5 weeks with 10 telerehabilitation sessions. During the sessions, the participants used virtual reality glasses to train for the treatment goals. All participants were assessed in person before and after the intervention. Analysis was performed using R software according to the different functional assessments performed for each test.

Results

The participants showed a 19.55-meter increase in the 6MWT. Motor function also remained stable according to other scales used to assess it. The North Start Ambulatory Assessment scores were stable in both treatment conditions (P=.20). Furthermore, the timed up and go test results were 0.1 seconds faster in the telerehabilitation condition, and the Motor Function Measure in all of the 3 dimensions showed no significant differences (P=.08). Finally, the Effort Perception Infant scale showed that during the training, fatigue increased in the middle and decreased by the end of the sessions, but the perception throughout the sessions was lower even as the exercise intensity increased.

Conclusions

There were no differences between conventional and telerehabilitation treatments, so the telerehabilitation tool could be used without harming children with DMD and BMD, facilitating their access to therapies and stimulating learning to maintain their functional capacity. Therefore, telerehabilitation in general may be helpful in maintaining motor function in children with DMD and BMD. The learning effect helped reduce the feeling of fatigue in the children during the program.

Personalized Coaching via Texting for Behavior Change to Understand a Healthy Lifestyle Intervention in a Naturalistic Setting: Mixed Methods Study

BACKGROUND

Digital health interventions, such as personalized SMS coaching, are considered affordable and scalable methods to support healthy lifestyle changes. SMS, or texting, is a readily available service to most people in Sweden, and personalized SMS coaching has shown great promise in supporting behavior changes.

OBJECTIVE

This study aims to explore the effectiveness of highly personalized SMS coaching for behavior change according to the Capability, Opportunity, Motivation-Behavior (COM-B) model on a sample of physically inactive adults in a nonprofit fitness organization in Sweden.

METHODS

The study used a mixed methods design in which clients acted as their own controls. The participants were clients (n=28) and fitness consultants (n=12). Three types of data were collected: (1) quantitative data at baseline and after the SMS intervention and the waitlist from the clients, (2) qualitative data from semistructured interviews with the fitness consultants, and (3) pseudonymized texting conversations between the fitness consultants and clients.

RESULTS

Overall, the results showed that personalized SMS coaching was effective in supporting the clients' behavior changes. The quantitative analysis showed how the clients' capabilities (Cohen d=0.50), opportunities (Cohen d=0.43), and relationship with the fitness consultants (Cohen d=0.51) improved during the SMS intervention in comparison with baseline. Furthermore, the qualitative analysis revealed how personalized texts added value to existing work methods (eg, increasing continuity and flexibility) and how the relationship between the clients and fitness consultants changed during the intervention, which helped motivate the clients.

CONCLUSIONS

Personalized SMS coaching is an effective method for supporting healthy behavior changes. The human connection that emerged in this study needs to be further explored to fully understand the effectiveness of a digital health intervention.

The role of smart devices and mobile application on the change in peak VO2 in patients with high cardiovascular risk: a sub-study of the LIGHT randomised clinical trial

BACKGROUND

This investigation aims to assess the influence of a mobile application and smart devices on cardiopulmonary exercise testing (CPET) over a one-year period in individuals who have high risk for cardiovascular disease.

METHODS

This is a post-hoc subgroup analysis of Lifestyle Intervention Using Mobile Technology in Patients with High Cardiovascular Risk: A Pragmatic Randomised Clinical Trial (LIGHT). In the intervention plus standard care standard standard care arms, 138 and 103 patients were recruited, respectively. The 1-year VO2 measurements were adjusted to the baseline VO2 measurements as the study's endpoint. VO2 measurements were taken for each subject during the randomisation and final CPET examinations.

RESULTS

The intervention plus standard care improved VO2 measurements by 1.1 (adjusted treatment effect 1.1, 95% confidence interval (CI): 0.8, 1.4, p < 0.001) compared to standard care following 1-year follow-up.

CONCLUSION

At a 1-year follow-up, the smart device and mobile application technologies increased VO2 measurements in individuals with high cardiovascular risk compared to conventional treatment alone.

Use of the Smart Excretion Care System Linked to Electronic Medical Records to Alleviate Nursing Burden and Enhance Patient Convenience: Mixed Methods Study

BACKGROUND

The surge in older demographics has inevitably resulted in a heightened demand for health care, and a shortage of nursing staff is impending. Consequently, there is a growing demand for the development of nursing robots to assist patients with urinary and bowel elimination. However, no study has examined nurses' opinions of smart devices that provide integrated nursing for patients' urinary and bowel elimination needs.

OBJECTIVE

This study aimed to evaluate the feasibility of the Smart Excretion Care System tethered to electronic medical records in a tertiary hospital and community care setting and discuss the anticipated reductions in the burden of nursing care.

METHODS

Focus group interviews were conducted using the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. The interviews were conducted in March 2021 and involved 67 nurses who had worked at Seoul National University Bundang Hospital for more than 1 year and had experience in assisting patients with excretion care. Data were collected using purposive and snowball sampling methods.

RESULTS

A total of four themes relevant to the Smart Excretion Care System were found: (1) expected reductions in the burden of nursing care, (2) applicable indications (by departments and diseases), (3) preferred features/functions, and (4) expected benefits of using the Smart Excretion Care System in clinical facilities. Nurses from comprehensive nursing care wards had the highest burden when it came to excretion care. It was a common opinion that the Smart Excretion Care System would be very useful in intensive care units and should be applied first to patients with stroke or dementia.

CONCLUSIONS

Excretion care is one of the most burdensome tasks for nurses, increasing their workload. The development of the Smart Excretion Care System as a digital health intervention could help improve nurses' work efficiency, reduce their burden, and extend to caregivers and guardians.

Effectiveness of a Theory-Based Digital Animated Video Intervention to Reduce Intention and Willingness to Sext Among Diploma Students: Cluster Randomized Controlled Trial

BACKGROUND

Sexting refers to the exchange of sexually explicit digital content in the form of texts, photos, or videos. In recent years, sexting has become a public health concern. Surveys in Malaysia show a high prevalence of young adults engaged in sexting. Given that sexting is associated with sexual risk behavior, cyberbullying, and mental health issues, this behavior needs intervention to alleviate the resulting public health burden. However, there is a scarcity of theory-based intervention programs on the prevention of intention and willingness to sext among young adults.

OBJECTIVE

This study aimed to develop and implement a sexting intervention module guided by the prototype willingness model (PWM), delivered using web-based animated video, and evaluate its effectiveness among diploma students from a public higher educational institution. The primary outcomes were intention and willingness to sext, while the secondary outcomes were knowledge, attitude, perceived norms, and prototype perceptions of sexting.

METHODS

This 2-armed, parallel, single-blinded cluster randomized controlled trial was conducted in a public higher educational institution in the state of Melaka, Malaysia. Diploma students from 12 programs were randomly allocated into intervention and control groups. Both groups answered a self-administered web-based questionnaire assessing the outcomes at the baseline. The intervention group received a newly developed intervention module based on the PWM in the form of 5 animated videos posted on a private YouTube platform, while the control group was put on the waitlist. The intervention group was encouraged to discuss any issues raised with the researchers via WhatsApp private chat after viewing the videos. All participants were observed immediately and 3 months postintervention. Data analysis was performed with SPSS (version 26; IBM Corp). A generalized linear mixed model was used to determine the effectiveness of the intervention.

RESULTS

There were a total of 300 participants with an attrition rate of 8.3% (n=25). After adjusting for age, sex, relationship status, and the amount of time spent on the web, there were significant differences in the intention to sext (β=-.12; P=.002; Cohen d=0.23), willingness to sext (β=-.16; P<.001; Cohen d=0.40), knowledge (β=.12; P<.001; Cohen d=0.39), attitude (β=-.11; P=.001; Cohen d=0.31), perceived norms (β=-.06; P=.04; Cohen d=0.18), and prototype perceptions (β=-.11; P<.001; Cohen d=0.35) between the intervention and control groups over 3 months.

CONCLUSIONS

In this study, the sexting intervention module using the PWM that was delivered via web-based animated videos was effective in reducing intention and willingness to sext as well as in improving knowledge of sexting, attitudes, perceived norms, and prototype perceptions. Therefore, relevant agencies involved in the promotion of sexual and reproductive health among young adults in Malaysia can consider the implementation of this module.

TRIAL REGISTRATION

Thai Clinical Trial Registry TCTR20201010002; https://www.thaiclinicaltrials.org/show/TCTR20201002001.

A Digital Music-Based Mindfulness Intervention ("healing attempt") for Race-Based Anxiety in Black Americans

This study replicates and extends findings that "healing attempt"-a brief digital music-based mindfulness intervention-represents a feasible and potentially effective intervention for race-based anxiety in the Black community.

Building a Chatbot in a Pandemic

Easy access to evidence-based information on COVID-19 within an infodemic has been a challenging task. Chatbots have been introduced in times of emergency, when human resources are stretched thin and individuals need a user-centered resource. The World Health Organization Regional Office for Europe and UNICEF (United Nations Children's Fund) Europe and Central Asia came together to build a chatbot, HealthBuddy+, to assist country populations in the region to access accurate COVID-19 information in the local languages, adapted to the country context. Working in close collaboration with thematic technical experts, colleagues and counterparts at the country level allowed the project to be tailored to a diverse range of subtopics. To ensure that HealthBuddy+ was relevant and useful in countries across the region, the 2 regional offices worked closely with their counterparts in country offices, which were essential in partnering with national authorities, engaging communities, promoting the tool, and identifying the most relevant communication channels in which to embed HealthBuddy+. Over the past 2 years, the project has expanded from a web-based chatbot in 7 languages to a multistream, multifunction chatbot available in 16 regional languages, and HealthBuddy+ continues to expand and adjust to meet emerging health emergency needs.

Identifying factors associated with user retention and outcomes of a digital intervention for substance use disorder: a retrospective analysis of real-world data

Objectives

Successful delivery of digital health interventions is affected by multiple real-world factors. These factors may be identified in routinely collected, ecologically valid data from these interventions. We propose ideas for exploring these data, focusing on interventions targeting complex, comorbid conditions.

Materials and Methods

This study retrospectively explores pre-post data collected between 2016 and 2019 from users of digital cognitive behavioral therapy (CBT)-containing psychoeducation and practical exercises-for substance use disorder (SUD) at UK addiction services. To identify factors associated with heterogenous user responses to the technology, we employed multivariable and multivariate regressions and random forest models of user-reported questionnaire data.

Results

The dataset contained information from 14 078 individuals of which 12 529 reported complete data at baseline and 2925 did so again after engagement with the CBT. Ninety-three percent screened positive for dependence on 1 of 43 substances at baseline, and 73% screened positive for anxiety or depression. Despite pre-post improvements independent of user sociodemographics, women reported more frequent and persistent symptoms of SUD, anxiety, and depression. Retention-minimum 2 use events recorded-was associated more with deployment environment than user characteristics. Prediction accuracy of post-engagement outcomes was acceptable (Area Under Curve [AUC]: 0.74-0.79), depending non-trivially on user characteristics.

Discussion

Traditionally, performance of digital health interventions is determined in controlled trials. Our analysis showcases multivariate models with which real-world data from these interventions can be explored and sources of user heterogeneity in retention and symptom reduction uncovered.

Conclusion

Real-world data from digital health interventions contain information on natural user-technology interactions which could enrich results from controlled trials.

Specifying the Efficacy of Digital Therapeutic Tools for Depression and Anxiety: Retrospective, 2-Cohort, Real-World Analysis

BACKGROUND

Depression and anxiety are the main sources of work and social disabilities as well as health-related problems around the world. Digital therapeutic solutions using cognitive behavioral therapy have demonstrated efficacy in depression and anxiety. A common goal of digital health apps is to increase user digital engagement to improve outcomes. However, there is a limited understanding of the association between digital platform components and clinical outcomes.

OBJECTIVE

The aim of the study is to investigate the contribution of specific digital engagement tools to mental health conditions. We hypothesized that participation in coaching sessions and breathing exercises would be associated with a reduction in depression and anxiety.

METHODS

Depression and general anxiety symptoms were evaluated in real-world data cohorts using the digital health platform for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform-based treatment followed two cohorts of people: (1) users who started with moderate levels of depression and completed at least 2 depression assessments (n=519) and (2) users who started with moderate levels of anxiety and completed at least 2 anxiety assessments (n=474). Levels of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) were tracked throughout the first 16 weeks. A piecewise mixed-effects model was applied to model the trajectories of the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 mean scores in 2 segments (1-6 weeks and 7-16 weeks). Finally, simple slope analysis was used for the interpretation of the interactions probing the moderators: coaching sessions and breathing exercises in both depression and anxiety cohorts.

RESULTS

Analysis revealed a significant decrease in depression symptoms (β=-.37, 95% CI -0.46 to 0.28; P≤.001) during the period of weeks 1-6 of app use, which was maintained during the period of 7-16 weeks. Coach interaction significantly moderated the reduction in depression symptoms during the period of weeks 1-6 (β=-.03, 95% CI -0.05 to -0.001; P=.02). A significant decrease in anxiety symptoms (β=-.41, 95% CI -0.50 to -0.33; P≤.001) was revealed during the period of 1-6 weeks, which was maintained during the period of 7-16 weeks. Breathing exercises significantly moderated the reduction in anxiety symptoms during the period of 1-6 weeks (β=-.07, 95% CI -0.14 to -0.01; P=.04).

CONCLUSIONS

This study demonstrated general improvement followed by a period of stability of depression and anxiety symptoms associated with cognitive behavioral therapy-based digital intervention. Interestingly, engagement with a coaching session but not a breathing exercise was associated with a reduction in depression symptoms. Moreover, breathing exercise but not engagement with a coaching session was associated with a reduction of anxiety symptoms. These findings emphasize the importance of using a personalized approach to behavioral health during digital health interventions.

The Effects of Dose, Practice Habits, and Objects of Focus on Digital Meditation Effectiveness and Adherence: Longitudinal Study of 280,000 Digital Meditation Sessions Across 103 Countries

BACKGROUND

The efficacy of digital meditation is well established. However, the extent to which the benefits remain after 12 weeks in real-world settings remains unknown. Additionally, findings related to dosage and practice habits have been mixed, and the studies were conducted on small and homogeneous samples and used a limited range of analytical procedures and meditation techniques. Findings related to the predictors of adherence are also lacking and may help inform future meditators and meditation programs on how to best structure healthy sustainable practices.

OBJECTIVE

This study aimed to measure outcome change across a large and globally diverse population of meditators and meditations in their naturalistic practice environments, assess the dose-response relationships between practice habits and outcome change, and identify predictors of adherence.

METHODS

We used ecological momentary assessment to assess participants' well-being over a 14-month period. We engineered outcomes related to the variability of change over time (equanimity) and recovery following a drop in mood (resilience) and established the convergent and divergent validity of these outcomes using a validated scale. Using linear mixed-effects and generalized additive mixed-effects models, we modeled outcome changes and patterns of dose-response across outcomes. We then used logistic regression to study the practice habits of participants in their first 30 sessions to derive odds ratios of long-term adherence.

RESULTS

Significant improvements were observed in all outcomes (P<.001). Generalized additive mixed models revealed rapid improvements over the first 50-100 sessions, with further improvements observed until the end of the study period. Outcome change corresponded to 1 extra day of improved mood for every 5 days meditated and half-a-day-faster mood recovery compared with baseline. Overall, consistency of practice was associated with the largest outcome change (4-7 d/wk). No significant differences were observed across session lengths in linear models (mood: P=.19; equanimity: P=.10; resilience: P=.29); however, generalized additive models revealed significant differences over time (P<.001). Longer sessions (21-30 min) were associated with the largest magnitude of change in mood from the 20th session onward and fewer sessions to recovery (increased resilience); midlength sessions (11-20 min) were associated with the largest decreases in recovery; and mood stability was similar across session lengths (equanimity). Completing a greater variety of practice types was associated with significantly greater improvements across all outcomes. Adhering to a long-term practice was best predicted by practice consistency (4-7 d/wk), a morning routine, and maintaining an equal balance between interoceptive and exteroceptive meditations.

CONCLUSIONS

Long-term real-world digital meditation practice is effective and associated with improvements in mood, equanimity, and resilience. Practice consistency and variety rather than length best predict improvement. Long-term sustainable practices are best predicted by consistency, a morning routine, and a practice balanced across objects of focus that are internal and external to the body.

Impact of a Combined Continuous Glucose Monitoring-Digital Health Solution on Glucose Metrics and Self-Management Behavior for Adults With Type 2 Diabetes: Real-World, Observational Study

BACKGROUND

The BlueStar (Welldoc) digital health solution for people with diabetes incorporates data from multiple devices and generates coaching messages using artificial intelligence. The BlueStar app syncs glucose data from the G6 (Dexcom) real-time continuous glucose monitoring (RT-CGM) system, which provides a glucose measurement every 5 minutes.

OBJECTIVE

The objective of this real-world study of people with type 2 diabetes (T2D) using the digital health solution and RT-CGM was to evaluate change in glycemic control and engagement with the program over 3 months.

METHODS

Participants were current or former enrollees in an employer-sponsored health plan, were aged 18 years or older, had a T2D diagnosis, and were not using prandial insulin. Outcomes included CGM-based glycemic metrics and engagement with the BlueStar app, including logging medications taken, exercise, food details, blood pressure, weight, and hours of sleep.

RESULTS

Participants in the program that met our analysis criteria (n=52) were aged a mean of 53 (SD 9) years; 37% (19/52) were female and approximately 50% (25/52) were taking diabetes medications. The RT-CGM system was worn 90% (SD 8%) of the time over 3 months. Among individuals with suboptimal glycemic control at baseline, defined as mean glucose >180 mg/dL, clinically meaningful improvements in glycemic control were observed, including reductions in a glucose management indicator (-0.8 percentage points), time above range 181-250 mg/dL (-4.4 percentage points) and time above range >250 mg/dL (-14 percentage points; all P<.05). Time in range 70-180 mg/dL also increased by 15 percentage points (P=.016) in this population, which corresponds to an increase of approximately 3.5 hours per day in the target range. Over the 3-month study, 29% (15/52) of participants completed at least one engagement activity per week. Medication logging was completed most often by participants (23/52, 44%) at a rate of 12.1 (SD 0.8) events/week, and this was closely followed by exercise and food logging.

CONCLUSIONS

The combination of an artificial intelligence-powered digital health solution and RT-CGM helped people with T2D improve their glycemic outcomes and diabetes self-management behaviors.

The effect of nurse-led digital health interventions on blood pressure control for people with hypertension: A systematic review and meta-analysis

PURPOSE

Nurse-led digital health interventions (DHIs) for people with chronic disease are increasing. However, the effect of nurse-led DHIs on blood pressure control and hypertension self-management remains unclear. This study aimed to identify the characteristics of nurse-led DHIs for people with hypertension and compared the effect size of nurse-led DHIs with that of usual care to establish evidence for the development of effective nursing interventions using technologies.

DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews of Intervention (PRISMA) guidelines and registered the protocol in PROSPERO. Studies published from 2000 to August 5, 2021, were searched using the international databases: PubMed; Embase; Cochrane Central Register of Controlled Trials; Web of Science; CINAHL; Korean databases: RISS, KISS, KMBASE; and NDSL. Risk of bias 2.0 was used for evaluating the quality of studies. The primary outcome was blood pressure control. The secondary outcomes were self-management, medication adherence, and diet adherence. Publication bias was assessed using the funnel plot and Egger's regression tests.

FINDINGS

The systematic review included 26 studies. A meta-analysis of 21 studies was conducted to calculate the effect size and identify heterogeneity among the included studies. In our meta-analysis, we observed that nurse-led DHIs reduced systolic blood pressure by 6.49 mmHg (95% confidence interval [CI]: -8.52 to -4.46, I2  = 75.4%, p < 0.05) and diastolic blood pressure by 3.30 mmHg (95% CI: -4.58 to -2.01, I2  = 70.3%, p < 0.05) when compared with usual care. Concerning secondary outcomes, the effect size on self-management, medication adherence, and diet adherence was 0.98 (95% CI: 0.58 to 1.37, I2  = 63.2%, p < 0.05), 1.05 (95% CI: 0.41 to 1.69, I2  = 92.5%, p < 0.05), and 0.80 (95% CI: 0.17 to 1.42, I2  = 80.5%, p < 0.05), respectively.

CONCLUSION

Nurse-led DHIs were more effective in reducing blood pressure and enhancing self-management than usual care among people with hypertension. Therefore, as new technologies are being rapidly developed and applied in healthcare systems, further studies and policy support are needed to utilize the latest digital innovations with nursing interventions.

CLINICAL RELEVANCE

This study could be used to identify that nurse-led interventions may take advantage of real-time communication by employing digital technologies for improving blood control and self-management behaviors such as medication adherence and diet adherence. Using nurse-led DHIs allows nurses to provide patient-centered interventions such as reflecting on patients' needs and shared decision-making without space constraints and limited treatment time.

Effects of Increased Standing and Light-Intensity Physical Activity to Improve Postprandial Glucose in Sedentary Office Workers: Protocol for a Randomized Crossover Trial

BACKGROUND

Prolonged bouts of sedentary time, independent from the time spent in engaging in physical activity, significantly increases cardiometabolic risk. Nonetheless, the modern workforce spends large, uninterrupted portions of the day seated at a desk. Previous research suggests-via improved cardiometabolic biomarkers-that this risk might be attenuated by simply disrupting sedentary time with brief breaks of standing or moving. However, this evidence is derived from acute, highly controlled laboratory experiments and thus has low external validity.

OBJECTIVE

This study aims to investigate if similar or prolonged cardiometabolic changes are observed after a prolonged (2-week) practice of increased brief standing and moving behaviors in real-world office settings.

METHODS

This randomized crossover trial, called the WorkWell Study, will compare the efficacy of two 2-week pilot intervention conditions designed to interrupt sitting time in sedentary office workers (N=15) to a control condition. The intervention conditions use a novel smartphone app to deliver real-time prompts to increase standing (STAND) or moving (MOVE) by an additional 6 minutes each hour during work. Our primary aim is to assess intervention-associated improvements to daily postprandial glucose using continuous glucose monitors. Our secondary aim is to determine whether the interventions successfully evoke substantive positional changes and light-intensity physical activity (LPA). Other outcomes include the feasibility and acceptability of the intervention conditions, fasting blood glucose concentration, femoral artery flow-mediated dilation (f-FMD), and systolic and diastolic blood pressure.

RESULTS

The trial is ongoing at the time of submission.

CONCLUSIONS

This study is a novel, randomized crossover trial designed to extend a laboratory-based controlled study design into the free-living environment. By using digital health technologies to monitor and prompt participants in real time, we will be able to rigorously test the effects of breaking up sedentary behavior over a longer period of time than is seen in traditional laboratory-based studies. Our innovative approach will leverage the strengths of highly controlled laboratory and free-living experiments to achieve maximal internal and external validity. The research team's multidisciplinary expertise allows for a broad range of biological measures to be sampled, providing robust results that will extend knowledge of both the acute and chronic real-life effects of increased standing and LPA in sedentary office workers. The WorkWell Study uses a rigorous transdisciplinary protocol that will contribute to a more comprehensive picture of the beneficial effects of breaking up sitting behavior.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04269070; https://clinicaltrials.gov/study/NCT04269070.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45133.

Comparing Digital to Conventional Physical Therapy for Chronic Shoulder Pain: Randomized Controlled Trial

BACKGROUND

Chronic shoulder pain (CSP) is a common condition with various etiologies, including rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. It is associated with substantial disability and psychological distress, resulting in poor productivity and quality of life. Physical therapy constitutes the mainstay treatment for CSP, but several barriers exist in accessing care. In recent years, telerehabilitation has gained momentum as a potential solution to overcome such barriers. It has shown numerous benefits, including improving access and convenience, promoting patient adherence, and reducing costs. However, to date, no previous randomized controlled trial has compared fully remote digital physical therapy to in-person rehabilitation for nonoperative CSP.

OBJECTIVE

The aim of this study is to compare clinical outcomes between digital physical therapy and conventional in-person physical therapy in patients with CSP.

METHODS

We conducted a single-center, parallel-group, randomized controlled trial involving 82 patients with CSP referred for outpatient physical therapy. Participants were randomized into digital or conventional physical therapy (8-week interventions). The digital intervention consisted of home exercise, education, and cognitive behavioral therapy (CBT), using a device with movement digitalization for biofeedback and asynchronous physical therapist monitoring through a cloud-based portal. The conventional group received in-person physical therapy, including exercises, manual therapy, education, and CBT. The primary outcome was the change (baseline to 8 weeks) in function and symptoms using the short-form of Disabilities of the Arm, Shoulder, and Hand questionnaire. Secondary outcome measures included self-reported pain, surgery intent, analgesic intake, mental health, engagement, and satisfaction. All questionnaires were delivered electronically.

RESULTS

A total of 90 participants were randomized into digital or conventional physical therapy, with 82 receiving the allocated intervention. Both groups experienced significant improvements in function measured by the short-form of the Disabilities of the Arm, Shoulder, and Hand questionnaire, with no differences between groups (-1.8, 95% CI -13.5 to 9.8; P=.75). For secondary outcomes, no differences were observed in surgery intent, analgesic intake, and mental health or worst pain. Higher reductions were observed in average and least pain in the conventional group, which, given the small effect sizes (least pain 0.15 and average pain 0.16), are unlikely to be clinically meaningful. High adherence and satisfaction were observed in both groups, with no adverse events.

CONCLUSIONS

This study shows that fully remote digital programs can be viable care delivery models for CSP given their scalability and effectiveness, assessed through comparison with high-dosage in-person rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04636528); https://clinicaltrials.gov/study/NCT04636528.

A Digital Music-Based Mindfulness Intervention for Black Americans With Elevated Race-Based Anxiety: A Multiple-Baseline Pilot Study

BACKGROUND

Race-based anxiety is a substantial health issue for the Black community. Although mindfulness interventions have demonstrated efficacy for alleviating anxiety, three central barriers prevent Black Americans from accessing existing mindfulness treatments: high costs, excessive time commitments, and limited cultural relevance. There is a need for novel mindfulness interventions for the Black community that can overcome these barriers.

OBJECTIVE

The goal of this web-based study was to examine the preliminary efficacy, feasibility, and acceptability of a novel digital music-based mindfulness intervention for middle-to-low-income Black Americans with elevated race-based anxiety.

METHODS

This study used a nonconcurrent multiple-baseline design (n=5). The intervention featured contributions from Lama Rod Owens (a world-renowned meditation teacher and LA Times best-selling author) and Terry Edmonds (the former chief speechwriter for President Bill Clinton). We examined the effect of the intervention on state anxiety and assessed its feasibility and acceptability using quantitative and qualitative measures.

RESULTS

Results revealed that administration of the intervention led to significant decreases in state anxiety (Tau-U range -0.75 to -0.38; P values<.001). Virtually all feasibility and acceptability metrics were high (ie, the average likelihood of recommending the intervention was 98 out of 100).

CONCLUSIONS

This study offers preliminary evidence that a digital music-based mindfulness intervention can decrease race-based anxiety in Black Americans. Future research is needed to replicate these results, test whether the intervention can elicit lasting changes in anxiety, assess mechanisms of change, and explore the efficacy of the intervention in real-world contexts.

Use of a Smartphone-Based Medication Adherence Platform to Improve Outcomes in Uncontrolled Type 2 Diabetes Among Veterans: Prospective Case-Crossover Study

BACKGROUND

Medication nonadherence is a problem that impacts both the patient and the health system.

OBJECTIVE

The objective of this study was to evaluate the impact of a novel smartphone app with patient-response-directed clinical intervention on medication adherence and blood glucose control in noninsulin-dependent patients with type 2 diabetes mellitus (T2DM).

METHODS

We enrolled 50 participants with T2DM not on insulin with smartphones from a rural health care center in Northern Nevada for participation in this case-crossover study. Participants underwent a standard of care arm and an intervention arm. Each study arm was 3 months long, for a total of 6 months of follow-up. Participants had a hemoglobin A1c (HbA1c) lab draw at enrollment, 3 months, and 6 months. Participants had monthly "medication adherence scores" (MAS) and "Self-Efficacy for Appropriate Medication Use Scale" (SEAMS) questionnaires completed at baseline and monthly for the duration of the study. Our primary outcomes of interest were the changes in HbA1c between study arms. Secondary outcomes included the evaluation of the difference in the proportion of participants achieving a clinically meaningful reduction in HbA1c and the difference in the number of participants requiring diabetes therapy escalation between study arms. Exploratory outcomes included the analysis of the variation in medication possession ratio (MPR), MAS, and SEAMS during each study arm.

RESULTS

A total of 30 participants completed both study arms and were included in the analysis. Dropouts were higher in participants enrolled in the standard of care arm first (9/25, 36% vs 4/25, 16%). Participants had a median HbA1c of 9.1%, had been living with T2DM for 6 years, had a median age of 66 years, and had a median of 8.5 medications. HbA1c reduction was 0.69% in the intervention arm versus 0.35% in the standard of care arm (P=.30). A total of 70% (21/30) of participants achieved a clinically meaningful reduction in HbA1c of 0.5% in the app intervention arm versus 40% (12/30) in the standard of care arm (odds ratio 2.29, 95% CI 0.94-5.6; P=.09). Participants had higher odds of a therapy escalation while in the standard of care arm (18/30, 60% vs 5/30, 16.7%, odds ratio 4.3, 95% CI 1.2-15.2; P=.02). The median MPR prior to enrollment was 109%, 112% during the study's intervention arm, and 102% during the standard of care arm. The median real-time MAS was 93.2%. The change in MAS (1 vs -0.1; P=.02) and SEAMS (1.9 vs -0.2; P<.001) from baseline to month 3 was higher in the intervention arm compared to standard of care.

CONCLUSIONS

A novel smartphone app with patient-response-directed provider intervention holds promise in the ability to improve blood glucose control in complex non-insulin-dependent T2DM and is worthy of additional study.

The Complexity of Transferring Remote Monitoring and Virtual Care Technology Between Countries: Lessons From an International Workshop

International deployment of remote monitoring and virtual care (RMVC) technologies would efficiently harness their positive impact on outcomes. Since Canada and the United Kingdom have similar populations, health care systems, and digital health landscapes, transferring digital health innovations between them should be relatively straightforward. Yet examples of successful attempts are scarce. In a workshop, we identified 6 differences that may complicate RMVC transfer between Canada and the United Kingdom and provided recommendations for addressing them. These key differences include (1) minority groups, (2) physical geography, (3) clinical pathways, (4) value propositions, (5) governmental priorities and support for digital innovation, and (6) regulatory pathways. We detail 4 broad recommendations to plan for sustainability, including the need to formally consider how highlighted country-specific recommendations may impact RMVC and contingency planning to overcome challenges; the need to map which pathways are available as an innovator to support cross-country transfer; the need to report on and apply learnings from regulatory barriers and facilitators so that everyone may benefit; and the need to explore existing guidance to successfully transfer digital health solutions while developing further guidance (eg, extending the nonadoption, abandonment, scale-up, spread, sustainability framework for cross-country transfer). Finally, we present an ecosystem readiness checklist. Considering these recommendations will contribute to successful international deployment and an increased positive impact of RMVC technologies. Future directions should consider characterizing additional complexities associated with global transfer.

Technologies in Home-Based Digital Rehabilitation: Scoping Review

BACKGROUND

Due to growing pressure on the health care system, a shift in rehabilitation to home settings is essential. However, efficient support for home-based rehabilitation is lacking. The COVID-19 pandemic has further exacerbated these challenges and has affected individuals and health care professionals during rehabilitation. Digital rehabilitation (DR) could support home-based rehabilitation. To develop and implement DR solutions that meet clients' needs and ease the growing pressure on the health care system, it is necessary to provide an overview of existing, relevant, and future solutions shaping the constantly evolving market of technologies for home-based DR.

OBJECTIVE

In this scoping review, we aimed to identify digital technologies for home-based DR, predict new or emerging DR trends, and report on the influences of the COVID-19 pandemic on DR.

METHODS

The scoping review followed the framework of Arksey and O'Malley, with improvements made by Levac et al. A literature search was performed in PubMed, Embase, CINAHL, PsycINFO, and the Cochrane Library. The search spanned January 2015 to January 2022. A bibliometric analysis was performed to provide an overview of the included references, and a co-occurrence analysis identified the technologies for home-based DR. A full-text analysis of all included reviews filtered the trends for home-based DR. A gray literature search supplemented the results of the review analysis and revealed the influences of the COVID-19 pandemic on the development of DR.

RESULTS

A total of 2437 records were included in the bibliometric analysis and 95 in the full-text analysis, and 40 records were included as a result of the gray literature search. Sensors, robotic devices, gamification, virtual and augmented reality, and digital and mobile apps are already used in home-based DR; however, artificial intelligence and machine learning, exoskeletons, and digital and mobile apps represent new and emerging trends. Advantages and disadvantages were displayed for all technologies. The COVID-19 pandemic has led to an increased use of digital technologies as remote approaches but has not led to the development of new technologies.

CONCLUSIONS

Multiple tools are available and implemented for home-based DR; however, some technologies face limitations in the application of home-based rehabilitation. However, artificial intelligence and machine learning could be instrumental in redesigning rehabilitation and addressing future challenges of the health care system, and the rehabilitation sector in particular. The results show the need for feasible and effective approaches to implement DR that meet clients' needs and adhere to framework conditions, regardless of exceptional situations such as the COVID-19 pandemic.

Mobile Apps and Quality of Life in Patients With Breast Cancer and Survivors: Systematic Literature Review

BACKGROUND

Side effects of breast cancer treatment may persist long into survivorship, reducing quality of life (QOL) in patients with breast cancer and survivors. There is growing evidence for the use of digital health technologies, such as mobile apps, to support self-management, decrease symptom burden, and improve QOL in patients with cancer. However, an updated overview of the effects of mobile apps on QOL and well-being in patients with breast cancer and survivors is needed.

OBJECTIVE

The aim of this review was to provide an overview of breast cancer-specific, mobile app-driven lifestyle or behavioral interventions in patient care through to survivorship and their impact on QOL and mental well-being.

METHODS

A systematic search of PubMed, Scopus, and Web of Science was conducted to identify relevant studies. The inclusion criteria were limited to original studies involving a trial of a mobile app-driven lifestyle or behavioral intervention for patients with breast cancer or survivors and using QOL or well-being measures. The results of the studies that met the inclusion criterion were then synthesized in text and table format. The quality of the evidence was assessed with the Cochrane risk-of-bias tool.

RESULTS

A total of 17 studies with the number of participants ranging from 23 to 356 met the inclusion criterion. Of the 17 reviewed studies, 7 (41%) delivered an app-only intervention, and 10 (59%) combined an app with additional supporting materials, such as SMS text messaging, telecoaching, wearables, or printed materials. Among the 17 reviewed studies, 6 (35%) focused on aiding patients with breast cancer during the active treatment phase (excluding ongoing hormone therapy), whereas the remaining 11 (65%) focused on survivorship. The majority of the studies (14/17, 82%) observed some positive effects on QOL or well-being measures.

CONCLUSIONS

The results of the review indicate that mobile apps are a promising avenue for improving QOL and well-being in breast cancer care. Positive effects were observed in patients undergoing active treatment in all reviewed studies, but effects were less clear after chemotherapy and in long-term survivors. Although lifestyle and behavioral digital interventions are still being developed, and further research should still be pursued, the available data suggest that current mobile health apps aid patients with breast cancer and survivors.