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Digital health resources are being increasingly used to support women with substance use concerns. Although empirical research has demonstrated that these resources have promise, the available evidence for their benefit in women requires further investigation. Evidence supports the capacity of interventions that are sex-, gender-, and trauma-informed to improve treatment access and outcomes and to reduce health system challenges and disparities. Indeed, both sex- and gender-specific approaches are critical to improve health and gender equity. Violence and trauma are frequent among those with substance use concerns, but they disproportionately affect those who identify as female or women, further underscoring the need for trauma-informed care as well.
The objective of this investigation was to evaluate the evidence supporting the efficacy or effectiveness of online or mobile interventions for risky or harmful substance use in adults who identify as female or women, or who report a history of trauma.
This scoping review is based on an academic search in MEDLINE, APA PsycINFO, Embase, Cochrane Central, and CINAHL, as well as a grey literature search in US and Canadian government and funding agency websites. Of the 7807 records identified, 465 remained following title and abstract screening. Of these, 159 met all eligibility criteria and were reviewed and synthesized.
The 159 records reflected 141 distinct studies and 125 distinct interventions. Investigations and the interventions evaluated predominantly focused on alcohol use or general substance use. Evaluated digital health resources included multisession and brief-session interventions, with a wide range of therapeutic elements. Multisession online and mobile interventions exhibited beneficial effects in 86.1% (105/122) of studies. Single-session interventions similarly demonstrated beneficial effects in 64.2% (43/67) of study conditions. Most investigations did not assess gender identity or conduct sex- or gender-based analyses. Only 13 investigations that included trauma were identified.
Despite the overall promise of digital health interventions for substance use concerns, direct or quantitative evidence on the efficacy or effectiveness of interventions in females or women specifically is weak.
Despite the higher prevalence of substance misuse and substance use disorders in men compared with women, a substantial proportion of women do experience harms associated with substance use. Moreover, research suggests that substance use and associated harms have been increasing in women over time. For example, the frequency and volume of alcohol use in women increased substantially from the 2000s to 2010s [
Despite an increase in substance use among women, women are generally underrepresented in treatment settings [
Evidence supports the capacity of interventions that are sex-, gender-, and trauma-informed to improve treatment access and outcomes and to reduce health system challenges and disparities. Indeed, both sex- and gender-specific approaches are critical to improve health and gender equity, attending to the biological factors that impact the response to substances and biological treatments, as well as the gendered experiences of substance use challenges and their management [
Current evidence-based best practice guidelines have therefore highlighted the importance of gender- and trauma-informed treatments for substance use concerns in women. Gender-informed practices include integrated treatment approaches addressing a wide range of women’s needs (eg, physical, social, and mental health needs, and child-centered services such as prenatal services, parenting programs, and child care) and are associated with improvements in recovery, parenting skills, and emotional health [
It is notable then that the gender- and trauma-informed practices most appropriate to women with substance use difficulties primarily comprise integrated psychosocial interventions, most commonly provided in-person and in group formats. Yet, in many jurisdictions, this model of care delivery is not possible to maintain during the COVID-19 global pandemic. Similar to other health care settings, substance use treatment centers serving women are increasingly turning to digital health solutions to provide support, particularly while physical distancing measures are necessary to protect public health. Digital health solutions may in fact overcome numerous barriers to care experienced by women and provide a valuable addition to the health system even beyond the current crisis.
In a recent review, Nesvåg and McKay [
This review extends the foundational work in several ways. First, Hai et al [
The aim of this investigation was to evaluate the current evidence for digital health resources for substance use concerns, with a focus on resources that have been evaluated in females or women, or in those who report a history of trauma, regardless of sex or gender. Although current resources may not have been designed to fully incorporate gender- and trauma-based principles, their therapeutic benefit in these groups is nevertheless an important consideration in evaluating currently available resources, as well as identifying priorities for both clinical and research initiatives.
The methodology for this scoping review was based on the framework developed by Arksey and O’Malley [
The scoping review was conducted to answer the following research questions:
What digital health resources have been evaluated in those who identify as female/women or those reporting a history of trauma, regardless of sex or gender?
What digital health resources have empirical support for their efficacy/effectiveness in those who identify as female/women or those reporting a history of trauma, regardless of sex or gender?
For the purpose of this study, a scoping review was defined as a type of research synthesis that aims to “map the literature” on a particular topic or research area and provide an opportunity to identify key concepts; gaps in the research; and types and sources of evidence to inform practice, policymaking, and research [
A comprehensive search strategy was developed by a librarian (RB) in consultation with the research team. The following databases were searched from inception: MEDLINE (including Epub ahead of print, in-process, and other nonindexed citations), APA PsycINFO, Embase, Cochrane Central, and CINAHL. No language limits were applied at this stage. For the searches, combinations of controlled vocabulary in the form of database-specific subject headings and relevant free-text keywords were included. The database searches were conducted in June 2020. The full MEDLINE search strategy is available for viewing in
In addition, nonpeer reviewed (grey) literature was also retrieved. The research team conducted a web search of Canadian and US Government and Funding Agencies in Canada and the United States using Google from July to August 2020. These searches were conducted using variations of the following (including but not limited to): “substance use,” “drug use,” “alcohol use,” or “addiction;” “online intervention,” “digital health,” “eHealth,” or “mobile health;” and “women” or “female.”
Studies were selected according to the following eligibility criteria:
Language: We included articles in English.
Date: We included articles from database inception to the date of extraction (June 30, 2020).
Publication type: We only considered original research articles, including secondary analyses. Dissertations, commentaries, conference proceedings, letters, editorials, and reviews were excluded to ensure presence of sufficient methodology and data needed to map and evaluate the nature of the evidence.
Sample: We considered adults aged 18 years or older, who endorsed or exhibited risky or harmful substance use. Similar to previous reviews [
Setting: We considered all settings (eg, health care, forensic, and educational).
Design: We included all prospective designs (eg, single vs multiple arms and augmentation vs stand-alone intervention). Randomization or a comparison/control group was not required.
Intervention: We considered web- or mobile-based interventions targeting substance use or substance use disorder symptoms. All theoretical orientations and durations of treatments were included; however, formats that were computer-based, but not online, or that were interactive were excluded (eg, telephone, video, and text-based interactive psychosocial interventions with a clinician and social networking/platforms such as peer support discussion boards).
Outcomes: We considered substance use or substance use disorder symptoms. Outcomes that were focused only on acceptability or feasibility were excluded.
Following the initial extraction and removal of duplicates, two research staff independently (1) screened the titles and abstracts of all unique records, (2) conducted full-text reviews for all records not excluded, and (3) extracted data from included studies. Team members demonstrated substantial agreement during title and abstract screening (96% agreement; κ=0.74) and during the full-text review (92% agreement; κ=0.84). Discrepancies were resolved by consensus, with the support of a member of the investigation team as needed (LQ).
Procedures were consistent with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) guidelines [
The Cochrane Risk of Bias Tool was used to evaluate bias at the study level across the following six domains: sequence generation, allocation concealment, blinding, incomplete data, selective reporting, and overall risk [
The study selection process is illustrated in
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
The study characteristics are provided in
Characteristics of the included studies (N=159).
Parameters and characteristics | Studies, n (%)a | |||
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Randomized controlled trial | 122 (76.3%) | |
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Secondary analyses | 18 (11.3%) | |
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Single-arm studies | 19 (11.9%) | |
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United States | 94 (58.4%) | |
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Canada | 7 (4.4%) | |
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European Union | 38 (23.6%) | |
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United Kingdom | 7 (4.4%) | |
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South America | 1 (0.6%) | |
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Australia and New Zealand | 11 (6.8%) | |
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Asia | 3 (1.9%) | |
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≤100 | 41 (25.6%) | |
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101-500 | 66 (41.3%) | |
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501-1000 | 39 (24.4%) | |
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>1000 | 14 (8.8%) | |
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Mean age (years)c | 31.83 | ||
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≤10% | 3 (1.9%) | |
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11%-50% | 95 (59.4%) | |
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51%-99% | 54 (33.8%) | |
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100% | 8 (5.0%) | |
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Alcohol | 110 (69.2%) | |
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Cannabis | 12 (7.6%) | |
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Opioids | 4 (2.5%) | |
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Any substance | 28 (17.6%) | |
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Other substances | 5 (3.1%) | |
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Yes | 27 (17.0%) | |
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No | 123 (77.3%) | |
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N/Ad | 9 (5.7%) | |
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Yes | 19 (12.0%) | |
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No | 140 (88.0%) | |
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Yes | 13 (9.1%) | |
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No | 147 (90.9%) | |
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English | 150 (79.0%) | |
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Spanish | 3 (1.6%) | |
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Swedish | 15 (7.9%) | |
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German | 6 (3.2%) | |
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Norwegian | 2 (1.1%) | |
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Multiple | 6 (3.2%) | |
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Other | 5 (2.6%) | |
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Single-session intervention | 68 (35.8%) | |
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Multisession intervention | 122 (64.2%) | |
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Mobile (app) | 27 (14.2%) | |
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Mobile (text) | 13 (6.8%) | |
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Online | 148 (77.9%) | |
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Combined (online + mobile) | 2 (1.1%) |
aPercentages were rounded and may not sum to 100.
bNumbers do not add up to 159 as two studies were conducted in multiple locations.
cMean age was not reported in nine studies.
dN/A: not applicable.
Digital health resources included multisession interventions (122/190, 64.2%) with multiple components or modules, such as screening and assessment, motivational enhancement, psychoeducation, and cognitive and behavioral skills building. Multisession interventions were available online (82/122, 67.2%), on mobile devices (mobile apps [25/122, 20.5%] and text [13/122, 10.7%]), and in a combination of both online and mobile methods (2/122, 1.6%). A substantial minority comprised single-session interventions (68/190, 35.8%), which were primarily available online (67/68, 99%) rather than on mobile devices (mobile apps [1/68, 2%]). There were no single-session interventions that were provided over text or that comprised a combination of both online and mobile methods. Each of these broad categories of digital health resources will be discussed in turn below. The digital health intervention duration ranged from one session (n=68) to 12 months, with other frequent durations including 4 weeks (n=7), 8 weeks (n=10), and 12 weeks (n=28). A substantial minority did not report or include a follow-up period (n=35). Follow-up durations ranged from 2 weeks to 2 years, with the most frequent periods including 1 month (n=37), 3 months (n=49), and 6 months (n=52). Overall, interventions were primarily in the English language (150/190, 78.9%), although others were available in multiple languages (6/190, 3.2%) or other specific languages such as Swedish (15/190, 7.9%) and others (German [6/190, 3.2%], Norwegian [2/190, 1.1%], Spanish [3/190, 1.6%], other [5/190, 2.6%]; all <4%). In line with the study focus as reviewed above, the majority of interventions themselves targeted alcohol use, risks, and/or harms (95/124, 76.6%) in their content, with a substantial minority including a treatment targeting multiple substances or any substance (15/124, 12.1%), cannabis specifically (11/124, 8.9%), or other specific substances or substance combinations (<2% each).
Overall, the majority of studies were found to exhibit features associated with some concerns of bias (93/160, 58.1%), with 11.9% (19/160) associated with high bias and 30.0% (48/160) associated with low bias, according to the Cochrane Risk of Bias Tool (
Risk of bias distributions.
Domain 2 examined the risk of bias due to deviations from the intended interventions. Approximately 48% (76/160, 47.5%) of studies were evaluated as having some concerns of bias in this domain, mostly due to the use of analyses that were not appropriate to estimate the effect of assignment to the intervention, or the lack of adequate information regarding deviations from the planned protocol. The 22.5% (36/160) of studies with high bias tended to have issues regarding both of these points, whereas the 30.0% (48/160) of studies with low bias used intention-to-treat analyses to estimate the effect of assignment and had adequate blinding measures in place.
Domain 3 examined risk of bias due to missing outcome data, with 71.9% (115/160) of studies being evaluated as having low bias. Low bias in this domain signified that outcome data were available for nearly all participants or that adequate measures were put in place to evaluate bias due to missing outcome data. The 12.5% (20/160) of studies with some concerns were evaluated as such if it was possible that the results were biased by missing outcome data, such that study withdrawal occurred due to participants’ health status, whereas the 15.6% (25/160) of studies with high bias were evaluated as such if it was
Domain 4 examined risk of bias in measurement of the outcome variables. Approximately 77% (123/160, 76.9%) of studies were evaluated to have low bias in this section, due to appropriate outcome measures being used and appropriate blinding if outcomes were assessed by outcome assessors or participant blinding if outcomes were assessed using self-report measures. The 17.5% (28/160) of studies evaluated as having some concerns in this domain were characterized by some likelihood that measures of outcomes could have been influenced by the intervention received, and the 5.6% (9/160) of studies rated as having high bias in this domain were found to have inadequate information in this regard.
Domain 5 examined risk of bias in the selection of the reported results. Approximately 61% (98/160, 61.3%) of studies were rated as having some concerns in this domain, particularly due to lack of prespecified analysis plans. The 37.5% (60/160) of studies with low risk of bias were found to have prespecified analysis plans and report all outcome measures and analyses in accordance with these plans. The 1.3% (2/160) of studies evaluated as having high risk of bias were found to be potentially selective in reporting outcome measurements and analyses, based on the results. All domains were coded according to a standardized scoring algorithm. Detailed information regarding the risk of bias for each study is presented in
Overall, studies concluded that digital health resources for substance use or associated harms were efficacious or effective (155/190, 81.6%). The proportion of participants who identified as female or women ranged from 7% to 100% (mean 48%, median 46%; six studies were below 20%, but were eligible as over 20% endorsed trauma). In the vast majority of cases, participants identified as female, as only 16 studies explicitly assessed gender identity. Many studies appeared to use the terms sex and gender interchangeably (n=41). For example, indicating that gender was assessed (rather than sex) and specifying that reported genders were female and male. Sex- and gender-based analyses were conducted in only 17.0% (27/159) of studies, with 77.4% (123/159) of studies not conducting such analyses and 5.7% (9/159) not applicable (ie, no females or women were included in the sample, or the sample included only females or women). Thus, although digital health resources were found to be efficacious or effective in general, this was quantitatively confirmed for females or women in only 13.7% (26/190) of studies, with 81.1% (154/190) of studies not reporting relevant analyses and 5.3% (10/190) finding that the intervention was not effective for female or women participants. Only 13 of the studies reported that at least 20% of participants had a trauma history, and only seven of these reported that at least 20% of participants were female or women,
A total of 122 study conditions comprised online multisession interventions, primarily targeting alcohol (n=53) or any substance (n=19), although more targeted interventions for cannabis and opioids were present as well. These interventions included both openly available and commercial products, which varied in their provision of screening, assessment, or monitoring; however, most included psychoeducation, goal setting, cognitive and behavioral skills training, and links to resources. Primary outcomes were most frequently substance consumption, although substance use harms or substance use disorder symptoms were also included. Overall, 87% (73/84) of these relatively intensive interventions exhibited acute impacts on primary outcomes following up to 8 or 12 weeks of treatment; in some cases, these were retained in subsequent follow-up assessments.
Mobile interventions included both apps (n=27) and text-based messaging interventions (n=13). Mobile apps targeted alcohol (n=21) and any substance (n=4) or cannabis (n=3), and 87% (73/84) of these apps demonstrated improvements in the primary outcomes after approximately 4 to 12 weeks of use. Text-based messaging interventions targeted alcohol (n=9) or cannabis (n=1), and 85% (11/13) demonstrated benefits following 2 to 12 weeks of use.
A total of 67 study conditions evaluated brief interventions, which were primarily delivered online (n=66) as compared to via a mobile device (n=1). The majority of these brief interventions addressed harmful or risky alcohol use, with only a small number addressing general drug use (n=10) or cannabis use (n=3). These brief interventions frequently took the form of noncommercial programs that provided initial screening and personalized normative feedback, as well as psychoeducation and resources. The primary outcome was most frequently substance consumption, primarily quantity or frequency (eg, number of standard alcoholic drinks per week and binge or heavy drinking frequency). Approximately 64% (43/67) of these brief interventions did exhibit short-term impacts on the primary outcomes.
The empirical investigations of the efficacy or effectiveness of digital health resources for adults who identify as female or women, or who report a history of trauma, appear to be principally conducted in the United States and Europe, with the majority in the English language. These investigations and the interventions evaluated predominantly focused on alcohol use or associated harms/risks, although a substantial minority of investigations was broadly applicable to substance use in general. The majority of studies randomized participants to study conditions, with a range of active and control conditions evident across studies. Similar to other reviews of psychosocial interventions, a substantial proportion of investigations was judged to have some concerns associated with bias, primarily related to participant or assessor blinding, lack of intent-to-treat analysis, or lack of a reported prespecified or registered analytical plan. Lower bias was evident regarding randomization, missing data, and outcome measurement.
The digital health resources evaluated included multisession and brief (ie, single) session interventions, with a wide range of therapeutic elements. Across all interventions, the primary outcome was most frequently substance use quantity and frequency. More intensive online and mobile interventions, frequently several months or more in duration and including numerous therapeutic components, exhibited moderate to strong effects in the vast majority of studies. Brief interventions, which consisted of a single session of varied duration (but most commonly less than 1 hour), demonstrated efficacy in most studies, although it was notable that these effects decreased over longer follow-ups in many studies.
Overall, studies that included a substantial proportion of adults who identified as female or women concluded that digital health resources for substance use or associated harms were efficacious or effective (155/190, 81.6%). A minimum threshold of 20% of the sample identifying as female or women, or endorsing trauma, was implemented to ensure the relevance of evidence reviewed to the research question. This eligibility requirement resulted in the exclusion of a limited number of records (n=17), which shared many of the study and intervention features described above. Notably, in many contexts, a much higher proportion would be required to conduct sex- or gender-based analyses and to support generalizability to our target populations. In fact, the majority of studies did include 40% or more of participants who were female or women, with larger proportions more common in community and trainee samples. Yet, most investigations did not assess gender identity, and many used sex and gender terms interchangeably. Further, sex- or gender-based analyses were not conducted in the majority of studies (n=113); thus, direct or quantitative evidence for the efficacy or effectiveness of interventions in females or women specifically is weak.
Evidence for adults reporting a history of trauma was even more limited. Only 13 studies were found that met this liberal inclusion criterion, and even then, the association between trauma history and clinical outcomes was not evaluated. There is a critical need to assess and report trauma in the evaluation of digital health resources in this context to identify those most likely to be of benefit to adults with a trauma history. Of note, the current results appear unlikely to be the result of lower access to individuals with past or current experiences of violence and trauma. Among women presenting to treatment, significantly higher rates of sexual abuse have been observed in comparison to community samples of women meeting criteria for the diagnosis of substance use disorders, suggesting that experiences of trauma may play a role in the process of treatment initiation [
Similar to the current investigation, previous systematic reviews and meta-analyses have highlighted the large number of digital interventions for alcohol, with a preponderance of brief interventions with small immediate benefits but low evidence for longer-term clinically significant effects [
The most recent and focused investigation of digital health resources for women with substance use disorders focused on the childbearing age. Notably, the current broader synthesis noted that, in fact, there appears to be a dearth of studies in older adult samples as well as studies in other important groups. For example, studies in samples across the lifespan, across racial backgrounds, and with other important social determinants of health and those who face barriers to care (eg, rural communities, homeless or houseless individuals, forensic samples, and adults of varied physical and mental abilities) are critical to conduct. Thus, although a range of sample types was evident in the current review, future research would benefit from extending across the lifespan and including other types of samples with more varied demographic and clinical features.
This investigation focused on a specific category of digital health resources, which necessarily limits its scope. The consideration of virtual psychotherapy, digital recovery support networks, and other forms of resources would be a valuable extension of this work. Similarly, this investigation focused on adults reporting or exhibiting substance use risks or harms, and interventions targeting substance use or associated risks or harms, which would preclude larger-scale population health interventions targeting a broader range of lower-risk individuals as well as interventions with lifestyle or health/wellness foci. Focused reviews of these broader groups and interventions would benefit a range of stakeholders. This review focused on adults who identify as female or women and neglected other sex and gender groups. Thus, increased attention to treatment outcomes across the gender continuum is needed. Finally, the incorporation of other key identity features, particularly those related to race, culture, and ethnicity, is critical to examine how the intersections of these different components of identity are linked to treatment outcomes. Very limited research in this area has been conducted to date, highlighting this key gap.
This project represents a synthesis of available evidence for digital health resources for adults who identify as female or women with substance use concerns. Although substance use has been increasing in these individuals, adults who identify as female or women are underrepresented in in-person clinical services and exhibit unique treatment barriers, preferences, and needs. Importantly, trauma is elevated in this group, highlighting the clinical priority of interventions that are sensitive to not only gender-specific psychoeducation and skills building, but also trauma-informed approaches. Although this synthesis simultaneously provides promising support for the therapeutic benefit of digital health resources for this priority population, it also highlights critical clinical and research priorities. Increased assessments of both sex and gender identities, and the implementation of sex- and gender-based analyses are critical in future empirical investigations of digital health resources. Increased integration of trauma and other key participant features is also needed to contribute to the further development of these interventions. Trauma, intersectionality, and key social determinants of health are critical to understand not only the value of these resources but also how to successfully implement them in varied geographical regions and health systems.
Search strategy for MEDLINE.
Study demographic characteristics.
Study design characteristics.
Intervention characteristics.
Risk of bias.
References for articles included in the scoping review.
This project was supported by operating funds from the Canadian Institutes of Health Research (CIHR), who approved the research proposal, including the objectives and methodology, but had no involvement in the research design, conduct, analysis, interpretation, or reporting.
None declared.