TY - JOUR AU - Seiterö, Anna AU - Henriksson, Pontus AU - Thomas, Kristin AU - Henriksson, Hanna AU - Löf, Marie AU - Bendtsen, Marcus AU - Müssener, Ulrika PY - 2025/4/22 TI - Effectiveness of a Mobile Phone-Delivered Multiple Health Behavior Change Intervention (LIFE4YOUth) in Adolescents: Randomized Controlled Trial JO - J Med Internet Res SP - e69425 VL - 27 KW - mHealth KW - multiple behavior KW - high school students KW - digital behavior change intervention KW - public health KW - telemedicine KW - randomized controlled trial N2 - Background: Although mobile health (mHealth) interventions have demonstrated effectiveness in modifying 1 or 2 health-risk behaviors at a time, there is a knowledge gap regarding the effects of stand-alone mHealth interventions on multiple health risk behaviors. Objective: This study aimed to estimate the 2- and 4-month effectiveness of an mHealth intervention (LIFE4YOUth) targeting alcohol consumption, diet, physical activity, and smoking among Swedish high school students, compared with a waiting-list control condition. Methods: A 2-arm parallel group, single-blind randomized controlled trial (1:1) was conducted from September 2020 to June 2023. Eligibility criteria included nonadherence to guidelines related to the primary outcomes, such as weekly alcohol consumption (standard drinks), monthly frequency of heavy episodic drinking (ie, ?4 standard drinks), daily intake of fruit and vegetables (100-g portions), weekly consumption of sugary drinks (33-cL servings), weekly duration of moderate to vigorous physical activity (minutes), and 4-week point prevalence of smoking abstinence. The intervention group had 16 weeks of access to LIFE4YOUth, a fully automated intervention including recurring screening, text message services, and a web-based dashboard. Intention-to-treat analysis was conducted on available and imputed 2- and 4-month self-reported data from participants at risk for each outcome respectively, at baseline. Effects were estimated using multilevel models with adaptive intercepts (per individual) and time by group interactions, adjusted for baseline age, sex, household economy, and self-perceived importance, confidence, and know-how to change behaviors. Bayesian inference with standard (half-)normal priors and null-hypothesis testing was used to estimate the parameters of statistical models. Results: In total, 756 students (aged 15-20, mean 17.1, SD 1.2 years; 69%, 520/756 females; 31%, 236/756 males) from high schools across Sweden participated in the trial. Follow-up surveys were completed by 71% (539/756) of participants at 2 months and 57% (431/756) of participants at 4 months. Most participants in the intervention group (219/377, 58%) engaged with the intervention at least once. At 2 months, results indicated positive effects in the intervention group, with complete case data indicating median between-group differences in fruit and vegetable consumption (0.32 portions per day, 95% CI 0.13-0.52), physical activity (50 minutes per week, 95% CI ?0.2 to 99.7), and incidence rate ratio for heavy episodic drinking (0.77, 95% CI 0.55-1.07). The odds ratio for smoking abstinence (1.09, 95% CI 0.34-3.64), incidence rate ratio for weekly alcohol consumption (0.69, 95% CI 0.27-1.83), and the number of sugary drinks consumed weekly (0.89, 95% CI 0.73-1.1) indicated inconclusive evidence for effects due to uncertainty in the estimates. At 4 months, a remaining effect was observed on physical activity only. Conclusions: Although underpowered, our findings suggest modest short-term effects of the LIFE4YOUth intervention, primarily on physical activity and fruit and vegetable consumption. Our results provide inconclusive evidence regarding weekly alcohol consumption and smoking abstinence. Trial Registration: ISRCTN Registry ISRCTN34468623; https://doi.org/10.1186/ISRCTN34468623 UR - https://www.jmir.org/2025/1/e69425 UR - http://dx.doi.org/10.2196/69425 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/69425 ER - TY - JOUR AU - Price, AB Jill AU - McCall, C. Hugh AU - Demyen, A. Sam AU - Spencer, M. Shaylee AU - Katz, MW Benjamin AU - Clairmont, P. Alyssa AU - Hadjistavropoulos, D. Heather PY - 2025/4/17 TI - Optimization of Internet-Delivered Cognitive Behavioral Therapy for Canadian Leaders Within Public Safety: Qualitative Study JO - J Med Internet Res SP - e72321 VL - 27 KW - first responders KW - public safety personnel KW - leadership KW - mental health KW - digital mental health interventions KW - internet-delivered cognitive behavioral therapy N2 - Background: Canadian public safety personnel (PSP) report high rates of mental health concerns and barriers to treatment. PSPNET is a clinical research unit that offers internet-delivered cognitive behavioral therapy (ICBT) that is free, confidential, and developed with and for PSP. Treatment outcomes are promising with clinically significant symptom improvement (eg, anxiety, depression, and posttraumatic stress) and favorable treatment satisfaction. While these results are promising, research has yet to explore ways to optimize therapist-guided ICBT for leaders within public safety. Optimizing ICBT for leaders is particularly important given their widespread organizational impact. Objective: This study aims to investigate (1) the perceived mental health stressors of Canadian leaders within public safety, (2) the degree to which leaders perceived existing therapist-guided ICBT courses tailored for PSP (ie, PSP Wellbeing Course and PSP PTSD Course) as suitable for their needs, and (3) ways to further optimize therapist-guided ICBT for public safety leaders. Methods: This study included 10 clients who self-identified as being in a supervisory or leadership position within their public safety organization and completed either the therapist-guided PSP Wellbeing Course or PSP PTSD Course. We used descriptive statistics to analyze demographics, mental health symptoms, treatment engagement, and treatment satisfaction. We also used a reflexive thematic analysis of semistructured interview transcripts to assess leaders? course perceptions and feedback. Results: Canadian leaders within public safety reported occupational and nonoccupational stressors and enrolled in ICBT to support their own or colleagues? mental health. Most clients enrolled in the PSP Wellbeing Course, accessed 4 of 5 lessons (n=7, 70%), engaged with therapist support (n=7, 70%), and identified as employed (n=8, 80%), White (n=8, 80%), and men (n=7, 70%) with an average age of 45 years. At pretreatment, 80% of clients endorsed clinically significant symptoms of one or more disorders; most often depression (n=7, 70%) and anger (n=6, 60%). Clients reported favorable attitudes toward the ICBT courses with most reporting that they were satisfied with the course (n=9, 90%). Feedback to further optimize ICBT content for leaders included the development of a leader case story (n=6, 60%) and new resources to help leaders apply skills learned in ICBT within the context of their leadership roles (n=4, 40%). Leaders also recommended optimizing ICBT delivery by improving the platform technology and incorporating more multimedia. Conclusions: Canadian leaders within public safety perceived therapist-guided ICBT developed with and for PSP as a suitable treatment option for their needs and identified ways to further optimize its content and delivery. Future research should investigate the impacts of these efforts and explore optimizing ICBT for other groups of clients. Trial Registration: ClinicalTrials.gov NCT04127032, https://www.clinicaltrials.gov/study/NCT04127032; ClinicalTrials.gov NCT04335487, https://clinicaltrials.gov/study/NCT04335487 UR - https://www.jmir.org/2025/1/e72321 UR - http://dx.doi.org/10.2196/72321 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/72321 ER - TY - JOUR AU - Six, Stephanie AU - Schlesener, Elizabeth AU - Hill, Victoria AU - Babu, V. Sabarish AU - Byrne, Kaileigh PY - 2025/4/11 TI - Impact of Conversational and Animation Features of a Mental Health App Virtual Agent on Depressive Symptoms and User Experience Among College Students: Randomized Controlled Trial JO - JMIR Ment Health SP - e67381 VL - 12 KW - depression KW - mental health app KW - virtual agents KW - cognitive behavioral therapy KW - conversational agents KW - virtual agent KW - animations KW - college student KW - CBT KW - ANOVA KW - randomized controlled trial KW - depressive symptoms KW - mental disorder KW - mental illness KW - user experience KW - mHealth KW - digital health N2 - Background: Numerous mental health apps purport to alleviate depressive symptoms. Strong evidence suggests that brief cognitive behavioral therapy (bCBT)-based mental health apps can decrease depressive symptoms, yet there is limited research elucidating the specific features that may augment its therapeutic benefits. One potential design feature that may influence effectiveness and user experience is the inclusion of virtual agents that can mimic realistic, human face-to-face interactions. Objective: The goal of the current experiment was to determine the effect of conversational and animation features of a virtual agent within a bCBT-based mental health app on depressive symptoms and user experience in college students with and without depressive symptoms. Methods: College students (N=209) completed a 2-week intervention in which they engaged with a bCBT-based mental health app with a customizable therapeutic virtual agent that varied in conversational and animation features. A 2 (time: baseline vs 2-week follow-up) × 2 (conversational vs non-conversational agent) × 2 (animated vs non-animated agent) randomized controlled trial was used to assess mental health symptoms (Patient Health Questionnaire-8, Perceived Stress Scale-10, and Response Rumination Scale questionnaires) and user experience (mHealth App Usability Questionnaire, MAUQ) in college students with and without current depressive symptoms. The mental health app usability and qualitative questions regarding users? perceptions of their therapeutic virtual agent interactions and customization process were assessed at follow-up. Results: Mixed ANOVA (analysis of variance) results demonstrated a significant decrease in symptoms of depression (P=.002; mean [SD]=5.5 [4.86] at follow-up vs mean [SD]=6.35 [4.71] at baseline), stress (P=.005; mean [SD]=15.91 [7.67] at follow-up vs mean [SD]=17.02 [6.81] at baseline), and rumination (P=.03; mean [SD]=40.42 [12.96] at follow-up vs mean [SD]=41.92 [13.61] at baseline); however, no significant effect of conversation or animation was observed. Findings also indicate a significant increase in user experience in animated conditions. This significant increase in animated conditions is also reflected in the user?s ease of use and satisfaction (F(1, 201)=102.60, P<.001), system information arrangement (F(1, 201)=123.12, P<.001), and usefulness of the application (F(1, 201)=3667.62, P<.001). Conclusions: The current experiment provides support for bCBT-based mental health apps featuring customizable, humanlike therapeutic virtual agents and their ability to significantly reduce negative symptomology over a brief timeframe. The app intervention reduced mental health symptoms, regardless of whether the agent included conversational or animation features, but animation features enhanced the user experience. These effects were observed in both users with and without depressive symptoms. Trial Registration: Open Science Framework B2HX5; https://doi.org/10.17605/OSF.IO/B2HX5 UR - https://mental.jmir.org/2025/1/e67381 UR - http://dx.doi.org/10.2196/67381 ID - info:doi/10.2196/67381 ER - TY - JOUR AU - Cho, Minseo AU - Park, Doeun AU - Choo, Myounglee AU - Han, Hyun Doug AU - Kim, Jinwoo PY - 2025/4/9 TI - Adolescent Self-Reflection Process Through Self-Recording on Multiple Health Metrics: Qualitative Study JO - J Med Internet Res SP - e62962 VL - 27 KW - self-recording KW - self-tracking KW - self-regulation KW - personal informatics KW - digital health KW - qualitative study KW - grounded theory KW - adolescents KW - teenagers KW - adolescent health KW - self-reflection KW - health metrics KW - behavior change KW - self-awareness KW - decision-making KW - mental health KW - behavioral health KW - health management KW - semi-structured interview N2 - Background: Self-recording is an effective behavior change technology that has long been used in diverse health contexts. Recent technological advancements have broadened its applications. While previous studies have explored its role and benefits in enhancing self-awareness and informed decision-making, relatively little attention has been given to its potential to address the multidimensional nature of health with various health metrics. Objective: This study investigates the process of self-recording in adolescent health, recognizing the connections between lifestyle behaviors and mental health. Specifically, we aim to incorporate both behavioral and emotional health metrics into the self-recording process. Grounded in self-regulation theory, we explore how adolescents record lifestyle behaviors and emotions, and how they inform and implement health management strategies. Methods: We conducted a qualitative study using the grounded theory methodology. Data were collected through individual semistructured interviews with 17 adolescents, who recorded their emotions and behaviors over 4 weeks using a prototype application. Analysis followed iterative phases of coding, constant comparison, and theme saturation. This process revealed how adolescents engage in self-recording for behaviors and emotions, as well as their failures and potential system support strategies. We further examined the relevance of the identified themes to theoretical constructs in self-regulation theory. Results: Under self-regulation theory, we gained insights into how adolescents manage their health through self-recording. The findings suggested variability in the self-recording process, in relation to specific health metrics of lifestyle behaviors and emotions. Adolescents focused on evaluating behaviors for management purposes while exploring the causes underlying emotional experiences. Throughout the health management, which involved modifying behavior or distancing from triggering factors, they monitored progress and outcomes, demonstrating a self-experimental approach. Uncertainty emerged as a barrier throughout the self-regulation process, suggesting that self-recording systems for adolescents should prioritize strategies to address these uncertainties. In addition, the self-recording system demonstrated interventional effects in aiding future planning and fostering a sense of relatedness among users. Conclusions: This study offers a theoretical framework for adolescents? self-recording process on diverse health metrics. By integrating self-regulation theory, we suggest a stepwise process from recording lifestyle behaviors and emotions to health management behaviors. Through exploring potential features and health-supportive effects, our findings contribute to the development of digital self-recording systems that address various health metrics in adolescent health. UR - https://www.jmir.org/2025/1/e62962 UR - http://dx.doi.org/10.2196/62962 UR - http://www.ncbi.nlm.nih.gov/pubmed/40202781 ID - info:doi/10.2196/62962 ER - TY - JOUR AU - Wróbel, Ewa Agata AU - Cash, Philip AU - Maier, Anja AU - Paulin Hansen, John PY - 2025/4/7 TI - Determining the Prioritization of Behavior Change Techniques for Long-Term Stroke Rehabilitation: Delphi Survey Study JO - Interact J Med Res SP - e59172 VL - 14 KW - behavior change KW - behavior change techniques KW - BCT KW - neuroscience KW - neurology KW - stroke KW - rehabilitation KW - adherence KW - Delphi method KW - Delphi KW - intervention design KW - intervention mapping N2 - Background: Stroke results in both physical disability and psychological distress. The impact can be minimized through rehabilitation, but it is a long-term process, making it difficult for patients to adhere to treatment. Thus, a better understanding of long-term behavior change interventions for patients with stroke is needed as well as how such interventions can support not only rehabilitation of motoric functions but also mental well-being. Objective: The aim of this study is to understand both the most important behavior change technique (BCT) clusters for long-term stroke rehabilitation in general as well as which are most relevant for each aspect of stroke rehabilitation: behavioral, cognitive, and emotional. Methods: We applied the 16 BCT clusters. The study used a 2-round Delphi survey, as reliable consensus was obtained among a group of 12 international experts. Experts represented three main backgrounds involved in behavioral intervention in the health context: (1) specialists in behavioral science (n=4), (2) behavioral designers (n=4), and (3) expert health care professionals (n=4). Experts were brought together in this way for the first time. In the first round, web-based questionnaires were used to collect data from the experts. This was followed by a personalized second round. Consensus was determined by statistically aggregating the responses and evaluating IQR and percentage consensus. BCT clusters reaching consensus (IQR ?1 and percentage ?50%) were then ranked. Results: In total, 12 of 16 BCT clusters reached consensus for general importance in stroke rehabilitation, with 11, 9, and 6 BCT clusters achieving consensus for, respectively, the behavioral, cognitive, and emotional aspects of rehabilitation. The overall most relevant BCT clusters were repetition and substitution, social support, feedback and monitoring, and self-belief, with similar outcomes for behavioral and cognitive rehabilitation. For emotional rehabilitation, social support and identity were emphasized. The least relevant BCT clusters were natural consequences, covert learning, and comparison of behavior. Conclusions: This expert panel study using a 2-round Delphi survey ranked the importance of BCT clusters for long-term stroke rehabilitation. The process yielded a number of novel insights highlighting differences in importance between general rehabilitation and that specifically focused on the behavioral, cognitive, and emotional aspects of stroke recovery. This provides a first but important step toward unlocking the prioritization of BCT clusters for long-term intervention contexts such as stroke rehabilitation and enables effective intervention mapping addressing long-term behavior change and treatment adherence. UR - https://www.i-jmr.org/2025/1/e59172 UR - http://dx.doi.org/10.2196/59172 ID - info:doi/10.2196/59172 ER - TY - JOUR AU - Chen, T. Annie AU - Wang, C. Lexie AU - Johnny, Shana AU - Wong, H. Sharon AU - Chaliparambil, K. Rahul AU - Conway, Mike AU - Glass, E. Joseph PY - 2025/3/26 TI - Stigma and Behavior Change Techniques in Substance Use Recovery: Qualitative Study of Social Media Narratives JO - JMIR Form Res SP - e57468 VL - 9 KW - stigma KW - substance use KW - transtheoretical model KW - behavior change techniques KW - social media N2 - Background: Existing literature shows that persons with substance use disorder (SUD) experience different stages of readiness to reduce or abstain from substance use, and tailoring intervention change strategies to these stages may facilitate recovery. Moreover, stigma may serve as a barrier to recovery by preventing persons with SUDs from seeking treatment. In recent years, the behavior change technique (BCT) taxonomy has increasingly become useful for identifying potential efficacious intervention components; however, prior literature has not addressed the extent to which these techniques may naturally be used to recover from substance use, and knowledge of this may be useful in the design of future interventions. Objective: We take a three-step approach to identifying strategies to facilitate substance use recovery: (1) characterizing the extent to which stages of change are expressed in social media data, (2) identifying BCTs used by persons at different stages of change, and (3) exploring the role that stigma plays in recovery journeys. Methods: We collected discussion posts from Reddit, a popular social networking site, and identified subreddits or discussion forums about 3 substances (alcohol, cannabis, and opioids). We then performed qualitative data analysis using a hybrid inductive-deductive method to identify the stages of change in social media authors? recovery journeys, the techniques that social media content authors used as they sought to quit substance use, and the role that stigma played in social media authors? recovery journeys. Results: We examined 748 posts pertaining to 3 substances: alcohol (n=316, 42.2%), cannabis (n=335, 44.8%), and opioids (n=135, 18%). Social media content representing the different stages of change was observed, with the majority (472/748, 63.1%) of narratives representing the action stage. In total, 11 categories of BCTs were identified. There were similarities in BCT use across precontemplation, contemplation, and preparation stages, with social support seeking and awareness of natural consequences being the most common. As people sought to quit or reduce their use of substances (action stage), we observed a variety of BCTs, such as the repetition and substitution of healthful behaviors and monitoring and receiving feedback on their own behavior. In the maintenance stage, reports of diverse BCTs continue to be frequent, but offers of social support also become more common than in previous stages. Stigma was present throughout all stages. We present 5 major themes pertaining to the manifestation of stigma. Conclusions: Patterns of BCT use and stigmatizing experiences are frequently discussed in social media, which can be leveraged to better understand the natural course of recovery from SUD and how interventions might facilitate recovery from substance use. It may be important to incorporate stigma reduction across all stages of the recovery journey. UR - https://formative.jmir.org/2025/1/e57468 UR - http://dx.doi.org/10.2196/57468 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57468 ER - TY - JOUR AU - Eguchi, Kana AU - Kubota, Takeaki AU - Koyanagi, Tomoyoshi AU - Muto, Manabu PY - 2025/3/25 TI - Real-World Data on Alcohol Consumption Behavior Among Smartphone Health Care App Users in Japan: Retrospective Study JO - Online J Public Health Inform SP - e57084 VL - 17 KW - alcohol consumption KW - individual behavior KW - mobile health KW - mobile health app KW - mobile health care app log-based survey KW - real-world data KW - RWD KW - RWD analysis KW - smartphone health care app KW - surveillance system KW - health care app N2 - Background: Although many studies have used smartphone apps to examine alcohol consumption, none have clearly delineated long-term (>1 year) consumption among the general population. Objective: The objective of our study is to elucidate in detail the alcohol consumption behavior of alcohol drinkers in Japan using individual real-world data. During the state of emergency associated with the COVID-19 outbreak, the government requested that people restrict social gatherings and stay at home, so we hypothesize that alcohol consumption among Japanese working people decreased during this period due to the decrease in occasions for alcohol consumption. This analysis was only possible with individual real-world data. We also aimed to clarify the effects of digital interventions based on notifications about daily alcohol consumption. Methods: We conducted a retrospective study targeting 5-year log data from January 1, 2018, to December 31, 2022, obtained from a commercial smartphone health care app (CALO mama Plus). First, to investigate the possible size of the real-world data, we investigated the rate of active users of this commercial smartphone app. Second, to validate the individual real-world data recorded in the app, we compared individual real-world data from 9991 randomly selected users with government-provided open data on the number of daily confirmed COVID-19 cases in Japan and with nationwide alcohol consumption data. To clarify the effects of digital interventions, we investigated the relationship between 2 types of notification records (ie, ?good? and ?bad?) and a 3-day daily alcohol consumption log following the notification. The protocol of this retrospective study was approved by the Ethics Committee of the Kyoto University Graduate School and Faculty of Medicine (R4699). UR - https://ojphi.jmir.org/2025/1/e57084 UR - http://dx.doi.org/10.2196/57084 UR - http://www.ncbi.nlm.nih.gov/pubmed/40131328 ID - info:doi/10.2196/57084 ER - TY - JOUR AU - Rooper, R. Isabel AU - Ortega, Adrian AU - Massion, A. Thomas AU - Lakhtakia, Tanvi AU - Kruger, Macarena AU - Parsons, M. Leah AU - Lipman, D. Lindsay AU - Azubuike, Chidiebere AU - Tack, Emily AU - Obleada, T. Katrina AU - Graham, K. Andrea PY - 2025/3/21 TI - Optimizing Testimonials for Behavior Change in a Digital Intervention for Binge Eating: Human-Centered Design Study JO - JMIR Form Res SP - e59691 VL - 9 KW - health behavior KW - health narratives KW - binge eating KW - user engagement KW - personalization KW - behavior change KW - digital health KW - intervention KW - human-centered design KW - behavioral health KW - preferences N2 - Background: Testimonials from credible sources are an evidence-based strategy for behavior change. Behavioral health interventions have used testimonials to promote health behaviors (eg, physical activity and healthy eating). Integrating testimonials into eating disorder (ED) interventions poses a nuanced challenge because ED testimonials can promote ED behaviors. Testimonials in ED interventions must therefore be designed carefully. Some optimal design elements of testimonials are known, but questions remain about testimonial speakers, messaging, and delivery, especially for ED interventions. Objective: We sought to learn how to design and deliver testimonials focused on positive behavior change strategies within our multisession digital binge eating intervention. Methods: We applied human-centered design methods to learn users? preferences for testimonial speakers, messaging, and delivery (modalities, over time, and as ?nudges? for selecting positive behavior change strategies they could practice). We recruited target users of our multisession intervention to complete design sessions. Adults (N=22, 64% self-identified as female; 32% as non-Hispanic Black, 41% as non-Hispanic White, and 27% as Hispanic) with recurrent binge eating and obesity completed individual interviews. Data were analyzed using methods from thematic analysis. Results: Most participants preferred designs with testimonials (vs without) for their motivation and validation of the intervention?s efficacy. A few distrusted testimonials for appearing too ?commercial? or personally irrelevant. For speakers, participants preferred sociodemographically tailored testimonials and were willing to report personal data in the intervention to facilitate tailoring. For messaging, some preferred testimonials with ?how-to? advice, whereas others preferred ?big picture? success stories. For delivery interface, participants were interested in text, video, and multimedia testimonials. For delivery over time, participants preferred testimonials from new speakers to promote engagement. When the intervention allowed users to choose between actions (eg, behavioral strategies), participants preferred testimonials to be available across all actions but said that selectively delivering a testimonial with one action could ?nudge? them to select it. Conclusions: Results indicated that intervention users were interested in testimonials. While participants preferred sociodemographically tailored testimonials, they said different characteristics mattered to them, indicating that interventions should assess users? most pertinent identities and tailor testimonials accordingly. Likewise, users? divided preferences for testimonial messaging (ie, ?big picture? vs ?how-to?) suggest that optimal messaging may differ by user. To improve the credibility of testimonials, which some participants distrusted, interventions could invite current users to submit testimonials for future integration in the intervention. Aligned with nudge theory, our findings indicate testimonials could be used as ?nudges? within interventions?a ripe area for further inquiry?though future work should test if delivering a testimonial only with the nudged choice improves its uptake. Further research is needed to validate these design ideas in practice, including evaluating their impact on behavior change toward improving ED behaviors. UR - https://formative.jmir.org/2025/1/e59691 UR - http://dx.doi.org/10.2196/59691 ID - info:doi/10.2196/59691 ER - TY - JOUR AU - Brinsley, Jacinta AU - O'Connor, J. Edward AU - Singh, Ben AU - McKeon, Grace AU - Curtis, Rachel AU - Ferguson, Ty AU - Gosse, Georgia AU - Willems, Iris AU - Marent, Pieter-Jan AU - Szeto, Kimberley AU - Firth, Joseph AU - Maher, Carol PY - 2025/3/20 TI - Effectiveness of Digital Lifestyle Interventions on Depression, Anxiety, Stress, and Well-Being: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e56975 VL - 27 KW - depression KW - anxiety KW - stress KW - well-being KW - mental health KW - lifestyle intervention KW - physical activity KW - sleep KW - diet KW - digital health KW - mobile phone N2 - Background: There is a growing body of robust evidence to show that lifestyle behaviors influence mental health outcomes. Technology offers an accessible and cost-effective implementation method for interventions, yet the study of the effectiveness of interventions to date has been specific to the mode of delivery, population, or behavior. Objective: The primary aim of this review was to comprehensively evaluate the effectiveness of digital lifestyle interventions for improving symptoms of depression, anxiety, stress, and well-being as coprimary outcomes in adults. The secondary aim was to explore the technological, methodological, intervention-specific, and population-specific characteristics that were associated with major changes in mental health outcomes. Methods: A systematic search was conducted across the MEDLINE, CINAHL, Embase, Emcare, PsycINFO, and Scopus databases to identify studies published between January 2013 and January 2023. Randomized controlled trials of lifestyle interventions (physical activity, sleep, and diet) that were delivered digitally; reported changes in symptoms of depression, anxiety, stress, or well-being in adults (aged ?18 years); and were published in English were included. Multiple authors independently extracted data, which was evaluated using the 2011 Levels of Evidence from the Oxford Centre for Evidence-Based Medicine. Inverse-variance random-effects meta-analyses were used for data analysis. The primary outcome was the change in symptoms of depression, anxiety, stress, and well-being as measured by validated self-report of clinician-administered outcomes from pre- to postintervention. Subgroup analyses were conducted to determine whether results differed based on the target lifestyle behavior, delivery method, digital features, design features, or population characteristics. Results: Of the 14,356 studies identified, 61 (0.42%) were included. Digital lifestyle interventions had a significant small-to-medium effect on depression (standardized mean difference [SMD] ?0.37; P<.001), a small effect on anxiety (SMD ?0.29; P<.001) and stress (SMD ?0.17; P=.04), and no effect on well-being (SMD 0.14; P=.15). Subgroup analyses generally suggested that effects were similar regardless of the delivery method or features used, the duration and frequency of the intervention, the population, or the lifestyle behavior targeted. Conclusions: Overall, these results indicate that delivering lifestyle interventions via a range of digital methods can have significant positive effects on depression (P<.001), anxiety (P<.001), and stress (P=.04) for a broad range of populations, while effects on well-being are inconclusive. Future research should explore how these interventions can be effectively implemented and embedded within health care with a concerted focus on addressing digital health equity. Trial Registration: PROSPERO CRD42023428908; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023428908 UR - https://www.jmir.org/2025/1/e56975 UR - http://dx.doi.org/10.2196/56975 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56975 ER - TY - JOUR AU - Kwon, Manjae AU - Moon, Un Daa AU - Kang, Minjae AU - Jung, Young-Chul PY - 2025/3/19 TI - A Brief Cognitive Behavioral Therapy?Based Digital Intervention for Reducing Hazardous Alcohol Use in South Korea: Development and Prospective Pilot Study JO - JMIR Form Res SP - e64459 VL - 9 KW - alcohol KW - hazardous alcohol use KW - digital intervention KW - cognitive behavioral therapy KW - mobile apps KW - prevention KW - therapy-based KW - cognitive behavioral KW - alcohol use KW - South Korea KW - prospective pilot study KW - pilot study KW - alcohol consumption KW - death KW - disability KW - chronic medical condition KW - digital health interventions KW - traditional treatment methods KW - Korean KW - hazardous drinking KW - acceptability KW - feasibility KW - smartphone app KW - alcohol use disorder KW - psychiatric symptoms KW - mobile phone N2 - Background: Alcohol consumption is a leading cause of death and disability worldwide, associated with numerous acute and chronic medical conditions. Digital health interventions offer a promising solution to overcome barriers associated with traditional treatment methods, providing accessible, scalable, and cost-effective means to support individuals in reducing hazardous drinking. Objective: This pilot study aims to evaluate the feasibility, acceptability, and preliminary efficacy of the Sober smartphone app in individuals with hazardous alcohol use. Methods: This single-group, pre- and postpilot study included 20 participants with risky alcohol use, identified using the Alcohol Use Disorder Identification Test. Participants used the Sober app for 4 weeks, incorporating cognitive behavioral therapy?based interventions. Feasibility was assessed by study and session completion rates, acceptability by participant satisfaction and perceived usefulness, and preliminary efficacy by changes in alcohol consumption and psychiatric symptoms. Semistructured interviews with participants and clinicians provided qualitative perspectives on the app?s usability, efficacy, and areas for improvement. Results: Of the 20 enrolled participants, 17 completed the study. The app demonstrated high feasibility with an 85% (17/20) study completion rate, and 59% (10/17) completed all cognitive behavioral therapy sessions. Participants reported positive acceptability, with average satisfaction and usefulness ratings of 3.8 and 3.7 of 5, respectively. Preliminary efficacy outcomes showed significant improvements: abstinence days increased from 67% to 85% (z=?3.17; P=.002), heavy drinking episodes decreased from 3.3 to 1.9 (t16=?2.97; P=.003), and total alcohol consumption reduced from 456.8 to 195.9 mL (t16=3.16; P=.002). Alcohol Use Disorder Identification Test scores dropped from 17.5 to 10.7 (t16=4.51; P<.001). Additionally, depression (Patient Health Questionnaire-9) scores decreased from 5.8 to 4.4 (t16=2.91; P=.01), and anxiety (Generalized Anxiety Disorder-7) scores from 3.4 to 2.1 (z=?2.80; P=.005). No adverse events were reported. Qualitative analysis found participants valued daily logging but noted usability issues, while clinicians called for tailored goals, enhanced communication features, and age-specific content. Conclusions: The mobile app Sober shows promise as an effective tool for reducing hazardous alcohol consumption and improving related psychiatric symptoms. The study demonstrated high feasibility and positive acceptability, with significant preliminary efficacy in reducing alcohol use. Qualitative findings provided actionable evidence for refining the app?s usability and clinical integration. Further research through a randomized controlled trial is warranted to confirm these findings and optimize the app?s features and content. Trial Registration: ClinicalTrials.gov NCT06502756; https://clinicaltrials.gov/study/NCT06502756 UR - https://formative.jmir.org/2024/1/e64459 UR - http://dx.doi.org/10.2196/64459 ID - info:doi/10.2196/64459 ER - TY - JOUR AU - Gomersall, R. Sjaan AU - Giguere, Y. Denis AU - Cotugno, Jacqueline AU - Munro, Joanna AU - Westbrook, J. Wallis AU - Littlewood, Robyn AU - Cairney, John AU - Winkler, AH Elisabeth AU - van der Vliet, M. Phillip AU - Goode, D. Ana AU - Alsop, Tahlia AU - Healy, Nissa Genevieve PY - 2025/3/10 TI - Development and Impact of a Community-Delivered, Multisectoral Lifestyle Management Service for People Living With Type 2 Diabetes (Logan Healthy Living): Protocol for a Pragmatic, Single-Arm Intervention Study JO - JMIR Res Protoc SP - e69477 VL - 14 KW - type 2 diabetes KW - lifestyle management KW - allied health KW - evaluation KW - protocol N2 - Background: Type 2 diabetes is the fastest-growing chronic condition in Australia, with higher prevalence in disadvantaged groups. Logan Healthy Living by UQ Health Care is a proof-of-concept, interprofessional allied health clinic focused on supporting people with and at risk of type 2 diabetes in Logan, a region in South East Queensland, Australia, with high levels of health inequity. Logan Healthy Living is supported by the Queensland Government through Health and Wellbeing Queensland and a broader multisectoral alliance including primary health care; tertiary hospital and health services; and government, community, and university sectors. Objective: This paper describes the establishment of Logan Healthy Living and outlines the evaluation protocol for the service?s type 2 diabetes lifestyle management program. Methods: The context and setting of Logan Healthy Living are presented, and the process for establishing the multisectoral partnerships, development and governance of the service, and the facility are described. The lifestyle management program is an 8-week, group-based program that includes 1 hour of education and 1 hour of supervised, individually tailored exercise each week. The theoretical underpinnings and the program are described in detail. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework will guide evaluation of the program and inform key questions regarding the number and characteristics of the clients (reach); diabetes-related distress, health behaviors (physical activity and diet), quality of life, self-management self-efficacy, loneliness, community involvement, anthropometric measures, hemoglobin A1c levels, physical function, and health care use (effectiveness); referral pathways (adoption); fidelity, appropriateness, acceptability, and costs (implementation); and long-term effectiveness (maintenance). Data will be drawn from a purposefully embedded minimum dataset and data registry, with the process for designing and embedding data collection into practice (via surveys, in-person measures, and client management software) described in detail. Results: Ethics approval has been obtained for the data registry. Logan Healthy Living is a 4-year proof of concept that concludes on December 31, 2024, with findings expected to be reported starting in 2025. Conclusions: While multisectoral responses are needed for complex community health challenges, the processes for achieving these are rarely documented, and the description of the development of Logan Healthy Living has the potential to inform future partnerships. The findings of the evaluation will provide important new knowledge on the impact of a community-delivered type 2 diabetes program on individuals, the community, and the health system in an area of high health inequity. International Registered Report Identifier (IRRID): DERR1-10.2196/69477 UR - https://www.researchprotocols.org/2025/1/e69477 UR - http://dx.doi.org/10.2196/69477 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/69477 ER - TY - JOUR AU - Zhou, Meng AU - Wang, Li AU - Deng, Ying AU - Ge, Jinjin AU - Zhao, Shiqi AU - You, Hua PY - 2025/3/10 TI - Effects of a Mobile Health Intervention Based on Behavioral Integrated Model on Cognitive and Behavioral Changes in Gestational Weight Management: Randomized Controlled Trial JO - J Med Internet Res SP - e55844 VL - 27 KW - cognition KW - health behavior KW - information-motivation-behavioral skills model KW - mobile health KW - psychological models KW - pregnant woman KW - randomized controlled trial KW - mobile phone N2 - Background: The key to gestational weight management intervention involves health-related behaviors, including dietary and exercise management. Behavioral theory-based interventions are effective in improving health-related behaviors. However, evidence for mobile health interventions based on specific behavioral theories is insufficient and their effects have not been fully elucidated. Objective: This study aimed to examine the effects of a gestational mobile health intervention on psychological cognition and behavior for gestational weight management, using an integrated behavioral model as the theoretical framework. Methods: This study was conducted in a tertiary maternity hospital and conducted as a single-blind randomized controlled trial (RCT) in Changzhou, Jiangsu Province, China. Using the behavioral model, integrated with the protection motivation theory and information?motivation?behavioral skills model (PMT-IMB model), the intervention group received a mobile health intervention using a self-developed app from 14 to 37 gestational weeks, whereas the control group received routine guidance through the application. Psychological cognition and behaviors related to weight management during pregnancy were the main outcomes, which were measured at baseline, and at the second and third trimesters of pregnancy using a self-designed questionnaire. Generalized estimation and regression equations were used to compare the outcome differences between the intervention and control groups. Results: In total, 302 (302/360, 83.9%) participants underwent all measurements at 3 time points (intervention group: n=150; control group: n=152). Compared with the control group, the intervention group had significantly higher scores for information, perceived vulnerability, response cost, and exercise management in the second trimester, while their scores for perceived vulnerability, response cost, and diet management were significantly higher in the third trimester. The results of repeated measures analysis revealed that, in psychological cognition, the information dimension exhibited both the time effects (T3 ?=3.235, 95% CI 2.859-3.611; P<.001) and the group effects (?=0.597, 95% CI 0.035-1.158; P=.04). Similarly, response costs demonstrated both the time effects (T3 ?=0.745, 95% CI 0.199-1.291; P=.008) and the group effects (?=1.034, 95% CI 0.367-1.700; P=.002). In contrast, perceived vulnerability solely exhibited the group effects (?=0.669, 95% CI 0.050-1.288; P=.03). Regarding weight management behaviors, both time (T3 ?=6, 95% CI 4.527-7.473; P<.001) and group (?=2.685, 95% CI 0.323-5.047; P=.03) had statistically significant impacts on the total points. Furthermore, the exercise management dimension also demonstrated both the time effects (T3 ?=3.791, 95% CI 2.999-4.584; P<.001) and the group effects (?=1.501, 95% CI 0.232-2.771; P=.02). Conclusions: The intervention program was effective in increasing psychological cognitions in terms of information, perceived vulnerability, and response costs, as well as promoting healthy behaviors among Chinese pregnant women. This study provides new evidence supporting the effectiveness of mobile intervention based on behavioral science theory in gestational weight management. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100043231; https://www.chictr.org.cn/showproj.html?proj=121736 UR - https://www.jmir.org/2025/1/e55844 UR - http://dx.doi.org/10.2196/55844 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55844 ER - TY - JOUR AU - Kuipers, M. Ellen A. AU - Timmerman, G. Josien AU - van Det, J. Marc AU - Vollenbroek-Hutten, R. Miriam M. PY - 2025/3/5 TI - Feasibility and Links Between Emotions, Physical States, and Eating Behavior in Patients After Metabolic Bariatric Surgery: Experience Sampling Study JO - JMIR Form Res SP - e60486 VL - 9 KW - feasibility KW - experience sampling methodology KW - metabolic bariatric surgery KW - eating behavior KW - positive and negative affect KW - physical states KW - contextual factors KW - mobile phone N2 - Background: Lifestyle modification is essential to achieve and maintain successful outcomes after metabolic bariatric surgery (MBS). Emotions, physical states, and contextual factors are considered important determinants of maladaptive eating behavior, emphasizing their significance in understanding and addressing weight management. In this context, experience sampling methodology (ESM) offers promise for measuring lifestyle and behavior in the patient?s natural environment. Nevertheless, there is limited research on its feasibility and association among emotions and problematic eating behavior within the population after MBS. Objective: This study aimed to examine the feasibility of ESM in the population after MBS regarding emotions, physical states, contextual factors, and problematic eating behavior, and to explore the temporal association among these variables. Methods: An experience sampling study was conducted in which participants rated their current affect (positive and negative), physical states (disgust, boredom, fatigue, and hunger), contextual factors (where, with whom, and doing what), and problematic eating behavior (ie, grazing, dietary relapse, craving, and binge eating) via smartphone-based ESM questionnaires at 6 semirandom times daily for 14 consecutive days. Feasibility was operationalized as the study?s participation rate and completion rate, compliance in answering ESM questionnaires, and response rates per day. At the end of the study period, patients reflected on the feasibility of ESM in semistructured interviews. Generalized estimation equations were conducted to examine the temporal association between emotions, physical states, contextual factors, and problematic eating behavior. Results: In total, 25 out of 242 participants consented to participate, resulting in a study participation rate of 10.3%. The completion rate was 83%. Overall compliance was 57.4% (1072/1868), varying from 13% (11/84) to 89% (75/84) per participant. Total response rates per day decreased from 65% (90/138) to 52% (67/130) over the 14-day study period. According to the interviews, ESM was considered feasible and of added value. Temporal associations were found for hunger and craving (odds ratio 1.04, 95% CI 1.00-1.07; P=.03), and for positive affect and grazing (odds ratio 1.61, 95% CI 1.03-2.51; P=.04). Conclusions: In this exploratory study, patients after MBS were not amenable to participate. Only a small number of patients were willing to participate. However, those who participated found it feasible and expressed satisfaction with it. Temporal associations were identified between hunger and craving, as well as between positive affect and grazing. However, no clear patterns were observed among emotions, physical states, context, and problematic eating behaviors. UR - https://formative.jmir.org/2025/1/e60486 UR - http://dx.doi.org/10.2196/60486 UR - http://www.ncbi.nlm.nih.gov/pubmed/40053719 ID - info:doi/10.2196/60486 ER - TY - JOUR AU - Kirchner-Krath, Jeanine AU - Schmidt-Kraepelin, Manuel AU - Schmähl, Katharina AU - Schütz, Christoph AU - Morschheuser, Benedikt AU - Sunyaev, Ali PY - 2025/2/20 TI - Behavior Change Support Systems for Self-Treating Procrastination: Systematic Search in App Stores and Analysis of Motivational Design Archetypes JO - J Med Internet Res SP - e65214 VL - 27 KW - procrastination KW - mobile apps KW - cluster analysis KW - motivational design KW - persuasive technology KW - behavior change support systems KW - behavior change techniques KW - mobile health KW - mHealth KW - mobile phone KW - artificial intelligence KW - AI N2 - Background: The phenomenon of procrastination refers to an individual?s conscious decision to postpone the completion of tasks despite being aware of its adverse consequences in the future. Extant research in this field shows that procrastination is associated with increased levels of anxiety and stress and the likelihood of developing depression and calls for the development of suitable interventions that support individuals in making lasting positive changes to their procrastination behaviors. In parallel, practice has produced a plethora of behavior change support systems (BCSSs) that aim to provide a low-threshold, accessible alternative to in-person therapeutic approaches. Most of these BCSSs can be considered motivational BCSSs that combine functional, utilitarian components with hedonic and eudaimonic design elements to empower self-treatment. Although early studies have suggested the potential benefits of such BCSSs, research on understanding their specific design characteristics and support of individuals in self-treating procrastination is still in its infancy. Objective: In response to this gap between practice and research, we aimed to analyze and systemize the multitude of practical design efforts in motivational BCSSs for the self-treatment of procrastination and identify the main design archetypes that have emerged. Methods: We conducted a 3-step research approach. First, we identified 127 behavior change support apps for procrastination through a systematic screening process in the German and US Apple App Store and Google Play Store. Second, we systematically coded the identified apps in terms of the behavior change techniques targeted by their functional design and hedonic or eudaimonic design elements. Third, we conducted a 2-step cluster analysis to identify archetypes of motivational design in behavior change support apps to combat procrastination. Results: A variety of motivational designs have been developed and implemented in practice, and our analysis identified five main archetypes: (1) structured progress monitor, (2) self-improvement guide, (3) productivity adventure, (4) emotional wellness coach, and (5) social focus companion. The identified archetypes target different psychological determinants of procrastination and successfully use a variety of hedonic and eudaimonic design elements that extend beyond the current state of research. Conclusions: The results of our study provide a foundation for future research endeavors that aim to examine the comparative effects of motivational design archetypes and develop more effective interventions tailored to individual needs. For practitioners, the findings reveal the contemporary design space of motivational BCSSs to support the self-treatment of procrastination and may serve as blueprints that can guide the design of future systems. For individuals seeking support and health professionals treating procrastination, our study systemizes the landscape of apps, thereby facilitating the selection of one that best aligns with the patient?s individual needs. UR - https://www.jmir.org/2025/1/e65214 UR - http://dx.doi.org/10.2196/65214 UR - http://www.ncbi.nlm.nih.gov/pubmed/39977017 ID - info:doi/10.2196/65214 ER - TY - JOUR AU - Allen, D. K. J. AU - Elliott, V. Matthew AU - Ronold, Haga Eivind AU - Mason, Liam AU - Rajgopal, Nandini AU - Hammar, Åsa AU - Johnson, L. Sheri PY - 2025/2/19 TI - Cognitive Training for Emotion-Related Impulsivity and Rumination: Protocol for a Pilot Randomized Waitlist-Controlled Trial JO - JMIR Res Protoc SP - e54221 VL - 14 KW - cognitive control KW - cognitive training KW - emotion regulation KW - emotional response inhibition KW - emotional working memory KW - executive function KW - impulsivity KW - rumination KW - transdiagnostic KW - urgency N2 - Background: Inhibitory deficits are common in psychopathology. Emotion-related impulsivity (ERI) and rumination are general risk factors for psychiatric distress that are similarly associated with dysfunctional inhibition?particularly in affective contexts. A number of cognitive remediation procedures have been developed to improve inhibitory control; however, most remediation programs focus on ?cold? cognition independent of affective processing. This pilot trial will gather preliminary evidence for a new cognitive training intervention targeting ?hot? affective control (ie, inhibitory functions during elevated emotional arousal) in a transdiagnostic sample of adults who report heightened emotion dysregulation. Objective: This manuscript describes a protocol for a pilot randomized waitlist-controlled trial to assess changes in ERI and rumination after neurobehavioral affective control training (N-ACT), an 8-week cognitive training intervention designed to improve emotional response inhibition and emotional working memory. Our primary aim is to evaluate the efficacy, feasibility, and acceptability of N-ACT in reducing rumination and ERI, which we respectively conceptualize as complementary cognitive and behavioral consequences of emotion dysregulation. Secondarily, we will examine whether N-ACT leads to improvements in inhibitory control and, more distally, psychopathology symptoms. Methods: The final sample will comprise 80 adults who report high ERI or rumination. Participants will be randomized to (1) begin the N-ACT program without delay or (2) join a waitlist condition and then complete N-ACT. Exclusion criteria include active alcohol or substance use disorders, psychosis, and suicide risk. At the baseline and postintervention time points, participants will complete measures of emotion dysregulation and psychiatric symptoms, as well as a neuropsychological assessment of inhibitory control. Individuals assigned to the control group will undergo an identical assessment before joining the waitlist, followed by parallel assessments before and after N-ACT. Results: This trial is funded by support from the University of California Board of Regents and the Peder Sather Foundation (funding period: October 2022-September 2025). Recruitment is scheduled to begin in spring 2025. We will begin data analysis once data collection is complete, which is planned to occur in fall 2025. Conclusions: This pilot randomized waitlist-controlled trial is designed to assess the initial efficacy, feasibility, and acceptability of N-ACT, a novel cognitive remediation approach developed to address 2 key contributors to psychopathology: ERI and rumination. The N-ACT program uses computerized adaptive behavioral tasks to strengthen the affective control processes theoretically and empirically linked to ERI and rumination. We hope this work will help inform future studies with sufficient statistical power to ascertain whether enhancing affective control through cognitive training (N-ACT) produces downstream reductions in psychiatric symptoms via improved emotion regulation. Trial Registration: ClinicalTrials.gov NCT06226467; https://www.clinicaltrials.gov/study/NCT06226467; Open Science Framework Registry rak5z; https://osf.io/rak5z International Registered Report Identifier (IRRID): PRR1-10.2196/54221 UR - https://www.researchprotocols.org/2025/1/e54221 UR - http://dx.doi.org/10.2196/54221 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54221 ER - TY - JOUR AU - Beckett, Darcy AU - Curtis, Rachel AU - Szeto, Kimberley AU - Maher, Carol PY - 2025/2/13 TI - Changing User Experience of Wearable Activity Monitors Over 7 Years: Repeat Cross-Sectional Survey Study JO - J Med Internet Res SP - e56251 VL - 27 KW - cross-sectional survey KW - activity tracker KW - user experience KW - physical activity KW - sleep KW - diet KW - health behaviour KW - wearable activity trackers KW - cohort KW - Apple KW - Fitbit KW - preferences KW - reliability KW - accessibility KW - lifestyle KW - mobile phone N2 - Background: Lifestyle behaviors, including physical inactivity, sedentary behavior, poor sleep, and unhealthy diet, significantly impact global population health. Wearable activity trackers (WATs) have emerged as tools to enhance health behaviors; however, their effectiveness and continued use depend on their user experience. Objective: This study aims to explore changes in user experiences, preferences, and perceived impacts of WATs from 2016 to 2023. Methods: We conducted a cross-sectional online survey among an international cohort of adults (n=475, comprising 387 current and 88 former WAT users). Results were compared with a 2016 cross-sectional online survey (n=237, comprising 200 current and 37 former WAT users) using descriptive statistics and chi-square tests. The survey examined brand preference, feature usefulness, motivations, perceived health behavior change, social sharing behaviors, and technical issues. Results: In 2023, Apple (210/475, 44%) and Fitbit (101/475, 21%) were the most commonly used devices, compared with the 2016 survey where Fitbit (160/237, 68%) and Garmin devices (39/237, 17%) were most common. The median usage duration in 2023 was 18 months, significantly longer than the 7 months reported in 2016, with most users planning ongoing use. Users in both survey years reported greater improvements in physical activity than diet or sleep, despite lower improvement in physical activity in 2023 compared with 2016, contrasted with greater perceived improvements in diet and sleep. Social media sharing of WAT data notably rose to 73% (283/387) in 2023 from 35% (70/200) in 2016. However, reports of technical issues and discomfort increased, alongside a decrease in overall positive experiences. There was also a noticeable shift in discontinuation reasons, from having learned everything possible in 2016 to dissatisfaction in 2023. Conclusions: The study highlights significant shifts in WAT usage, including extended use and evolving preferences for brands and features. The rise in social media sharing indicates a deeper integration of WATs into everyday life. However, user feedback points to a need for enhanced design and functionality despite technological progress. These findings illustrate WAT?s potential in health promotion, emphasizing the need for user-focused design in diverse populations to fully realize their benefits in enhancing health behaviors. UR - https://www.jmir.org/2025/1/e56251 UR - http://dx.doi.org/10.2196/56251 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56251 ER - TY - JOUR AU - Lunde, Pernille AU - Bye, Asta AU - Grimsmo, Jostein AU - Pripp, Hugo Are AU - Ritschel, Vibeke AU - Jarstad, Even AU - Nilsson, Blakstad Birgitta PY - 2025/2/13 TI - Effects of Individualized Follow-Up With an App Postcardiac Rehabilitation: Five-Year Follow-Up of a Randomized Controlled Trial JO - J Med Internet Res SP - e60256 VL - 27 KW - mHealth KW - cardiac rehabilitation KW - mobile phone app KW - smartphone KW - lifestyle N2 - Background: Adherence to healthy behaviors initiated or adapted during cardiac rehabilitation (CR) remains a significant challenge, with few patients meeting guideline standards for secondary prevention. The use of mobile health (mHealth) interventions has been proposed as a potential solution to improve adherence to healthy behaviors after CR. In particular, app-based interventions have shown promise due to their ability to provide monitoring and feedback anytime and anywhere. Growing evidence supports the use of apps in post-CR settings to enhance adherence. In 2020, we demonstrated that individualized follow-up via an app increased adherence to healthy behaviors 1 year after CR. However, it remains uncertain whether these effects persist once the follow-up is discontinued. Objective: This study aims to evaluate the long-term effects of individualized follow-up using an app, assessed 4 years after the intervention. Methods: A single-blinded multicenter randomized controlled trial was conducted. Patients were recruited from 2 CR centers in eastern Norway. The intervention group (IG) received individualized follow-up through an app for 1 year, while the control group (CG) received usual care. After the 1-year follow-up, the app-based follow-up was discontinued for the IG, and both groups were encouraged to maintain or improve their healthy behaviors based on their individual risk profiles. The primary outcome was the difference in peak oxygen uptake (VO2peak). The secondary outcomes included exercise performance, body weight, blood pressure, lipid profile, exercise habits, health-related quality of life, health status, cardiac events, and physical activity. Linear mixed models for repeated measurements were used to analyze differences between groups. All tests were 2-sided, and P values ?0.05 were considered statistically significant. Results: At the 5-year follow-up, 101 out of the initial 113 randomized participants were reassessed. Intention-to-treat analyses, using a mixed model for repeated measurements, revealed a statistically significant difference (P=.04) in exercise habits in favor of the IG, with a mean difference of 0.67 (95% CI 0.04-1.29) exercise sessions per week. Statistically significant differences were also observed in triglycerides (mean difference 0.40, 95% CI 0.00-0.79 mmol/l, P=.048) and walking (P=.03), but these were in favor of the CG. No differences were found between the groups for other evaluated outcomes. Conclusions: Most of the benefits derived from the app-based follow-up diminished by 4 years after the intervention. Although the IG reported statistically significantly higher levels of exercise, this did not translate into improved VO2peak or exercise performance. Our study highlights the need for follow-up from health care providers to enhance adherence to healthy behaviors in the long term following CR. Trial Registration: ClinicalTrials.gov NCT03174106; https://clinicaltrials.gov/ct2/show/NCT03174106 (original study protocol) and NCT05697120; https://clinicaltrials.gov/ct2/show/NCT05697120 (updated study protocol) UR - https://www.jmir.org/2025/1/e60256 UR - http://dx.doi.org/10.2196/60256 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60256 ER - TY - JOUR AU - Henry, M. Lauren AU - Blay-Tofey, Morkeh AU - Haeffner, E. Clara AU - Raymond, N. Cassandra AU - Tandilashvili, Elizabeth AU - Terry, Nancy AU - Kiderman, Miryam AU - Metcalf, Olivia AU - Brotman, A. Melissa AU - Lopez-Guzman, Silvia PY - 2025/2/11 TI - Just-In-Time Adaptive Interventions to Promote Behavioral Health: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e58917 VL - 14 KW - just-in-time adaptive interventions KW - JITAI KW - behavioral health KW - systematic review KW - behavior change KW - health outcomes KW - accessibility KW - digital treatment delivery KW - mobile phone N2 - Background: The goal of just-in-time adaptive interventions (JITAIs) is to use mobile, digital tools to provide individuals with personalized interventions at the optimal time and in the optimal context. Accordingly, JITAIs are promising for advancing accessible, equitable, and evidence-based treatment for behavioral health. To guide future inquiry in this space, a review of the literature is needed to describe the state of research on JITAIs for behavioral health. Objective: This study aims to systematically review the literature to describe the landscape of existing JITAIs for behavioral health at any stage of intervention development. In addition, conditional upon a sufficiently homogeneous literature, we will conduct meta-analyses to investigate the effectiveness of JITAIs for promoting distal outcomes (here, aspects of behavioral health) and proximal outcomes (eg, emotion regulation). Methods: This systematic review is being conducted in accordance with the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols). We developed our search strategy and executed the literature search in collaboration with biomedical librarians; 5 databases (PubMed, Embase, Cochrane Library, Web of Science: Core Collection, and APA PsycINFO) were searched, and results were managed using EndNote 20 (Clarivate). We are screening (title, abstract, and full text) all records in duplicate in Covidence according to eligibility criteria. Data items will be extracted, and risk of bias will be assessed in duplicate from the included articles in Covidence. We will summarize JITAI characteristics in tables and text. We will conduct meta-analyses for the distal and proximal outcomes conditional upon sufficient homogeneity in subgroups. Moderation (conditional upon sufficient heterogeneity of outcomes) and mediation (ie, whether changes in proximal outcomes mediate the relation between JITAIs and distal outcomes) will be conducted as appropriate. We will investigate publication bias and use the Grading of Recommendations Assessment, Development and Evaluation to characterize the quality of evidence of our estimates. Results: The search strategy was developed between July 2023 and November 2023. The literature search was executed between November 2023 and December 2023. Title and abstract screening began in December 2023, and full-text screening began in May 2024. Data extraction and analyses have not begun. Conclusions: Here, we propose a systematic review to assess the state of the literature on JITAIs for behavioral health. The insights derived from this study will describe the literature on JITAIs in promoting behavioral health, reinforce JITAI definitions, clarify JITAI elements, and inform the next steps in JITAI research. International Registered Report Identifier (IRRID): PRR1-10.2196/58917 UR - https://www.researchprotocols.org/2025/1/e58917 UR - http://dx.doi.org/10.2196/58917 UR - http://www.ncbi.nlm.nih.gov/pubmed/39932763 ID - info:doi/10.2196/58917 ER - TY - JOUR AU - Kennedy, Fiona AU - Smith, Susan AU - Beeken, J. Rebecca AU - Buck, Caroline AU - Williams, Sarah AU - Martin, Charlene AU - Lally, Phillippa AU - Fisher, Abi PY - 2025/2/10 TI - An App-Based Intervention With Behavioral Support to Promote Brisk Walking in People Diagnosed With Breast, Prostate, or Colorectal Cancer (APPROACH): Process Evaluation Study JO - JMIR Cancer SP - e64747 VL - 11 KW - cancer KW - physical activity KW - process evaluation KW - randomized controlled trial KW - intervention KW - app KW - habit N2 - Background: The APPROACH pilot study explored the feasibility and acceptability of an app (NHS Active 10) with brief, habit-based, behavioral support calls and print materials intended to increase brisk walking in people diagnosed with cancer. Objective: Following UK Medical Research Council guidelines, this study assessed the implementation of the intervention, examined the mechanisms of impact, and identified contextual factors influencing engagement. Methods: Adults (aged ?18 y) with breast, prostate, or colorectal cancer who reported not meeting the UK guidelines for moderate-to-vigorous physical activity (?150 min/wk) were recruited from a single hospital site in Yorkshire, United Kingdom. They were randomly assigned to the intervention or control (usual care) arm and assessed via quantitative surveys at baseline (time point 0 [T0]) and 3-month follow-up (time point 1 [T1]) and qualitative exit interviews (36/44, 82%) at T1. The process evaluation included intervention participants only (n=44). Implementation was assessed using data from the T1 questionnaire exploring the use of the intervention components. The perceived usefulness of the app, leaflet, and behavioral support call was rated from 0 to 5. Behavioral support calls were recorded, and the fidelity of delivery of 25 planned behavior change techniques was rated from 0 to 5 using an adapted Dreyfus scale. Mechanisms of impact were identified by examining T0 and T1 scores on the Self-Reported Behavioural Automaticity Index and feedback on the leaflet, app, call, and planner in the T1 questionnaire and qualitative interviews. Contextual factors influencing engagement were identified through qualitative interviews. Results: The implementation of the intervention was successful: 98% (43/44) of the participants received a behavioral support call, 78% (32/41) reported reading the leaflet, 95% (39/41) reported downloading the app, and 83% (34/41) reported using the planners. The mean perceived usefulness of the app was 4.3 (SD 0.8) in participants still using the app at T1 (n=33). Participants rated the leaflet (mean 3.9, SD 0.6) and the behavioral support call (mean 4.1, SD 1) as useful. The intended behavior change techniques in the behavioral support calls were proficiently delivered (overall mean 4.2, SD 1.2). Mechanisms of impact included habit formation, behavioral monitoring, and support and reassurance from the intervention facilitator. Contextual factors impacting engagement included barriers, such as the impact of cancer and its treatment, and facilitators, such as social support. Conclusions: The APPROACH intervention was successfully implemented and shows promise for increasing brisk walking, potentially through promoting habit formation and enabling self-monitoring. Contextual factors will be important to consider when interpreting outcomes in the larger APPROACH randomized controlled trial. International Registered Report Identifier (IRRID): RR2-10.1186/s40814-022-01028-w UR - https://cancer.jmir.org/2025/1/e64747 UR - http://dx.doi.org/10.2196/64747 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/64747 ER - TY - JOUR AU - Monreal-Bartolomé, Alicia AU - Castro, Adoración AU - Pérez-Ara, Ángeles M. AU - Gili, Margalida AU - Mayoral, Fermín AU - Hurtado, Magdalena María AU - Varela Moreno, Esperanza AU - Botella, Cristina AU - García-Palacios, Azucena AU - Baños, M. Rosa AU - López-Del-Hoyo, Yolanda AU - García-Campayo, Javier AU - Montero-Marin, Jesus PY - 2025/2/10 TI - Efficacy of a Blended Low-Intensity Internet-Delivered Psychological Program in Patients With Multimorbidity in Primary Care: Randomized Controlled Trial JO - J Med Internet Res SP - e56203 VL - 27 KW - multimorbidity KW - depression KW - type 2 diabetes KW - low back pain KW - primary care KW - blended KW - internet KW - randomized controlled trial KW - RCT N2 - Background: Multimorbidity is a highly prevalent phenomenon whose presence causes a profound physical, psychological, and economic impact. It hinders help seeking, diagnosis, quality of care, and adherence to treatment, and it poses a significant dilemma for present-day health care systems. Objective: This study aimed to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression and type 2 diabetes or low back pain) in primary care settings. Methods: A 2-armed, parallel-group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to ?intervention + iTAU? (combining a face-to-face intervention with a supporting web-based program) or ?iTAU? alone. The main outcome consisted of a standardized composite score to consider (1) severity of depressive symptoms and (2a) diabetes control or (2b) pain intensity and physical disability 3 months after the end of treatment as the primary end point. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity and openness to the future. Results: At 3-month follow-up, the intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B=?0.34, 95% CI ?0.64 to ?0.04; Hedges g=0.39) as well as in depression and negative affect and improvements in perceived health, positive affect, and openness to the future. Similar positive effects were observed after the intervention, including improvements in physical disability. No significant differences were found in glycosylated hemoglobin, pain intensity, or disability at 3-month follow-up (P=.60; P=.79; and P=.43, respectively). Path analyses revealed that the intervention had a significant impact on the primary outcome, mediated by both positive and negative affect (positive affect: indirect effect=?0.15, bootstrapped 95% CI ?0.28 to ?0.03; negative affect: indirect effect=?0.14, bootstrapped 95% CI ?0.28 to ?0.02). Conclusions: This study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in primary care. It justifies the exploration of the conceptualization of depression in type 2 diabetes as well as the analysis of the implementation of such interventions in routine clinical practice. Trial Registration: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709 International Registered Report Identifier (IRRID): RR2-10.1186/S12888-019-2037-3 UR - https://www.jmir.org/2025/1/e56203 UR - http://dx.doi.org/10.2196/56203 UR - http://www.ncbi.nlm.nih.gov/pubmed/39928931 ID - info:doi/10.2196/56203 ER - TY - JOUR AU - Tjernberg, Johanna AU - Helgesson, Sara AU - Håkansson, Anders AU - Hansson, Helena PY - 2025/1/31 TI - Exploring the Users? Perspective of the Nationwide Self-Exclusion Service for Gambling Disorder, ?Spelpaus?: Qualitative Interview Study JO - JMIR Hum Factors SP - e66045 VL - 12 KW - gambling disorder KW - gambling addiction KW - behavioral addiction KW - harm reduction KW - self-exclusion KW - voluntary self-exclusion KW - Spelpaus KW - lived experience KW - human factors KW - usability KW - qualitative study N2 - Background: Problem gambling and gambling disorder cause severe social, psychiatric, and financial consequences, and voluntary self-exclusion is a common harm reduction tool used by individuals with gambling problems. Objective: The aim of this study was to explore users? experience of a novel nationwide, multioperator gambling self-exclusion service, ?Spelpaus,? in Sweden and to inform stakeholders and policy makers in order to improve harm reduction tools against gambling problems. Methods: Semistructured interviews were conducted with 15 individuals who reported self-perceived gambling problems and who had experience of having used the self-exclusion service Spelpaus in Sweden. Interviews were transcribed and analyzed through qualitative content analysis. Results: We identified 3 categories and 8 subcategories. The categories were (1) reasons for the decision to self-exclude, (2) positive experiences, and (3) suggestions for improvement. The subcategories identified a number of reasons for self-exclusion, such as financial reasons and family reasons, and positive experiences described as a relief from gambling; in addition, important suggestions for improvement were cited, such as a more gradual return to gambling post?self-exclusion, better ways to address loopholes in the system, and transfer from self-exclusion to treatment. Conclusions: Voluntary self-exclusion from gambling, using a nationwide multioperator service, remains an appreciated harm-reducing tool. However, transfer from self-exclusion to treatment should be facilitated by policy making, and loopholes allowing for breaching of the self-exclusion need to be counteracted. UR - https://humanfactors.jmir.org/2025/1/e66045 UR - http://dx.doi.org/10.2196/66045 UR - http://www.ncbi.nlm.nih.gov/pubmed/39888656 ID - info:doi/10.2196/66045 ER - TY - JOUR AU - Duffy, Daniel AU - Richards, Derek AU - Hisler, Garrett AU - Timulak, Ladislav PY - 2025/1/28 TI - Implementing Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety in Adults: Systematic Review JO - J Med Internet Res SP - e47927 VL - 27 KW - mixed methods systematic review KW - internet-delivered cognitive behavioral therapy KW - iCBT KW - implementation science KW - implementation research KW - depression KW - anxiety N2 - Background: Scientific implementation findings relevant to the implementation of internet-delivered cognitive behavioral therapy (iCBT) for depression and anxiety in adults remain sparse and scattered across different sources of published information. Identifying evidence-based factors that influence the implementation of iCBT is key to successfully using iCBT in real-world clinical settings. Objective: This systematic review evaluated the following: (1) aspects that research articles postulate as important for the implementation of iCBT and (2) aspects relevant to the day-to-day running of iCBT services. A mixed methods systematic review using a convergent synthesis design was conducted to bring together evidence across this sparse literature consisting of divergent scientific article types to investigate the implementation of iCBT for depression and anxiety in adults. Methods: We searched the PsycINFO, PsycArticles, MEDLINE, CINAHL Complete, and Embase databases for any published peer-reviewed scientific articles that report on the implementation of iCBT for depression or anxiety disorders in adults. A total of 40 articles spanning the case study, commentary, meta-analysis, mixed methods study, pilot randomized controlled trial, randomized controlled trial, qualitative study, quantitative study, review, and systematic review article types were identified as eligible for this mixed methods review. Data were analyzed qualitatively using the descriptive-interpretive approach. Results: The first domain highlighted the impact of therapist and patient attitudes when implementing iCBT, the superiority of guided iCBT over unguided iCBT, its noninferiority to equivalent face-to-face treatments, and its utility outside of the original target of mild-to-moderate depression and anxiety. In total, 3 subdomains were identified under the second domain: (1) the management of iCBT in the workplace, detailing the importance of managing the iCBT service, related staff, and their motivations for using it; (2) the practice of iCBT in the workplace, describing the therapeutic aspects of iCBT provision, such as the provision of support, the background of supporters, and screening procedures; and (3) contextual considerations, detailing the impact of governmental legislation on therapy conducted over the internet, the lack of an iCBT workforce as a limiting factor, and the cost estimates associated with iCBT provision. Conclusions: Broadly, the findings describe several aspects that should be taken into account when researchers or practitioners implement iCBT as part of their work. However, the findings should be interpreted with caution, as the articles reviewed spanned many article types, and few of the included studies were directly focused on evaluating the implementation of iCBT. While findings provide insight into important factors to consider during iCBT implementation, these findings and their limitations highlight the need for more implementation-specific research in this area. UR - https://www.jmir.org/2025/1/e47927 UR - http://dx.doi.org/10.2196/47927 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/47927 ER - TY - JOUR AU - Daniels, Kim AU - Vonck, Sharona AU - Robijns, Jolien AU - Quadflieg, Kirsten AU - Bergs, Jochen AU - Spooren, Annemie AU - Hansen, Dominique AU - Bonnechère, Bruno PY - 2025/1/27 TI - Exploring the Feasibility of a 5-Week mHealth Intervention to Enhance Physical Activity and an Active, Healthy Lifestyle in Community-Dwelling Older Adults: Mixed Methods Study JO - JMIR Aging SP - e63348 VL - 8 KW - mobile health KW - mHealth KW - feasibility KW - physical activity KW - older adults KW - health promotion KW - usability KW - mobile phone N2 - Background: Advancements in mobile technology have paved the way for innovative interventions aimed at promoting physical activity (PA). Objective: The main objective of this feasibility study was to assess the feasibility, usability, and acceptability of the More In Action (MIA) app, designed to promote PA among older adults. MIA offers 7 features: personalized tips, PA literacy, guided peer workouts, a community calendar, a personal activity diary, a progression monitor, and a chatbot. Methods: Our study used a mixed methods approach to evaluate the MIA app?s acceptability, feasibility, and usability. First, a think-aloud method was used to provide immediate feedback during initial app use. Participants then integrated the app into their daily activities for 5 weeks. Behavioral patterns such as user session duration, feature use frequency, and navigation paths were analyzed, focusing on engagement metrics and user interactions. User satisfaction was assessed using the System Usability Scale, Net Promoter Score, and Customer Satisfaction Score. Qualitative data from focus groups conducted after the 5-week intervention helped gather insights into user experiences. Participants were recruited using a combination of web-based and offline strategies, including social media outreach, newspaper advertisements, and presentations at older adult organizations and local community services. Our target group consisted of native Dutch-speaking older adults aged >65 years who were not affected by severe illnesses. Initial assessments and focus groups were conducted in person, whereas the intervention itself was web based. Results: The study involved 30 participants with an average age of 70.3 (SD 4.8) years, of whom 57% (17/30) were female. The app received positive ratings, with a System Usability Scale score of 77.4 and a Customer Satisfaction Score of 86.6%. Analysis showed general satisfaction with the app?s workout videos, which were used in 585 sessions with a median duration of 14 (IQR 0-34) minutes per day. The Net Promoter Score was 33.34, indicating a good level of customer loyalty. Qualitative feedback highlighted the need for improvements in navigation, content relevance, and social engagement features, with suggestions for better calendar visibility, workout customization, and enhanced social features. Overall, the app demonstrated high usability and satisfaction, with near-daily engagement from participants. Conclusions: The MIA app shows significant potential for promoting PA among older adults, evidenced by its high usability and satisfaction scores. Participants engaged with the app nearly daily, particularly appreciating the workout videos and educational content. Future enhancements should focus on better calendar visibility, workout customization, and integrating social networking features to foster community and support. In addition, incorporating wearable device integration and predictive analytics could provide real-time health data, optimizing activity recommendations and health monitoring. These enhancements will ensure that the app remains user-friendly, relevant, and sustainable, promoting sustained PA and healthy behaviors among older adults. Trial Registration: ClinicalTrials.gov NCT05650515; https://clinicaltrials.gov/study/NCT05650515 UR - https://aging.jmir.org/2025/1/e63348 UR - http://dx.doi.org/10.2196/63348 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63348 ER - TY - JOUR AU - Johnson, A. Jillian AU - Zawadzki, J. Matthew AU - Sliwinski, J. Martin AU - Almeida, M. David AU - Buxton, M. Orfeu AU - Conroy, E. David AU - Marcusson-Clavertz, David AU - Kim, Jinhyuk AU - Stawski, S. Robert AU - Scott, B. Stacey AU - Sciamanna, N. Christopher AU - Green, A. Paige AU - Repka, M. Emily AU - Toledo, L. Meynard John AU - Sturges, L. Nicole AU - Smyth, M. Joshua PY - 2025/1/22 TI - Adaptive Just-in-Time Intervention to Reduce Everyday Stress Responses: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e58985 VL - 14 KW - stress KW - stress responses KW - stress management KW - just-in-time adaptive intervention KW - sleep KW - physical activity KW - behavior change KW - experimental medicine approach N2 - Background: Personalized approaches to behavior change to improve mental and physical health outcomes are needed. Reducing the intensity, duration, and frequency of stress responses is a mechanism for interventions to improve health behaviors. We developed an ambulatory, dynamic stress measurement approach that can identify personalized stress responses in the moments and contexts in which they occur; we propose that intervening in these stress responses as they arise (ie, just in time; JIT) will result in positive impacts on health behaviors. Objective: This study aims to (1) use an experimental medicine approach to evaluate the impact of a smartphone-delivered JIT stress management intervention on the frequency and intensity of person-specific stress responses (ie, stress reactivity, nonrecovery, and pileup); (2) evaluate the impact of the JIT intervention on the enactment of health behaviors in everyday life (physical activity and sleep); and (3) explore whether changes in stress responses mediate the interventions? effects on health behaviors. Methods: In a 2-arm phase 2 clinical trial, we will enroll 210 adults in either a JIT stress management intervention or an active control condition. For 4 weeks, participants will complete 8 brief smartphone surveys each day and wear devices to assess sleep and physical activity. After a 1-week run-in period, participants will be randomized into the JIT intervention or an active control condition for 2 weeks. Participants in the JIT intervention will receive very brief stress management activities when reporting greater than typical stress responses, whereas control participants will receive no personalized stress management activities. Participants enrolled in both conditions will engage in self-monitoring for the entire study period and have access to a general stress management education module. Self-report outcomes will be assessed again 1 month after the intervention. We will use mixed-effects models to evaluate differences in person-specific stress responses between the intervention and control groups. We will conduct parallel analyses to evaluate whether the intervention is associated with improvement in health behavior enactment (ie, sleep and physical activity). The Pennsylvania State University Institutional Review Board approved all study procedures (STUDY00012740). Results: Initial participant recruitment for the trial was initiated on August 15, 2022, and enrollment was completed on June 9, 2023. A total of 213 participants were enrolled in this period. Data are currently being processed; analyses have not yet begun. Conclusions: We anticipate that this research will contribute to advancing stress measurement, thereby enhancing understanding of health behavior change mechanisms and, more broadly, providing a conceptual roadmap to advance JIT interventions aimed at improving stress management and health behaviors. Trial Registration: Clinicaltrials.gov NCT05502575; https://clinicaltrials.gov/study/NCT05502575 International Registered Report Identifier (IRRID): DERR1-10.2196/58985 UR - https://www.researchprotocols.org/2025/1/e58985 UR - http://dx.doi.org/10.2196/58985 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58985 ER - TY - JOUR AU - March, Sonja AU - Spence, H. Susan AU - Myers, Larry AU - Ford, Martelle AU - Smith, Genevieve AU - Donovan, L. Caroline PY - 2025/1/22 TI - Integrating Videoconferencing Therapist Guidance Into Stepped Care Internet-Delivered Cognitive Behavioral Therapy for Child and Adolescent Anxiety: Noninferiority Randomized Controlled Trial JO - JMIR Ment Health SP - e57405 VL - 12 KW - internet-delivered cognitive behavioral therapy KW - ICBT KW - anxiety KW - child KW - adolescent KW - stepped care KW - videoconferencing N2 - Background: Self-guided internet-delivered cognitive behavioral therapy (ICBT) achieves greater reach than ICBT delivered with therapist guidance, but demonstrates poorer engagement and fewer clinical benefits. Alternative models of care are required that promote engagement and are effective, accessible, and scalable. Objective: This randomized trial evaluated whether a stepped care approach to ICBT using therapist guidance via videoconferencing for the step-up component (ICBT-SC[VC]) is noninferior to ICBT with full therapist delivery by videoconferencing (ICBT-TG[VC]) for child and adolescent anxiety. Methods: Participants included 137 Australian children and adolescents aged 7 to 17 years (male: n=61, 44.5%) with a primary anxiety disorder who were recruited from participants presenting to the BRAVE Online website. This noninferiority randomized trial compared ICBT-SC[VC] to an ICBT-TG[VC] program, with assessments conducted at baseline, 12 weeks, and 9 months after treatment commencement. All ICBT-TG[VC] participants received therapist guidance (videoconferencing) after each session for all 10 sessions. All ICBT-SC[VC] participants completed the first 5 sessions online without therapist guidance. If they demonstrated response to treatment after 5 sessions (defined as reductions in anxiety symptoms to the nonclinical range), they continued sessions without therapist guidance. If they did not respond, participants were stepped up to receive supplemental therapist guidance (videoconferencing) for the remaining sessions. The measures included a clinical diagnostic interview (Anxiety Disorders Interview Schedule) with clinician-rated severity rating as the primary outcome and parent- and child-reported web-based surveys assessing anxiety and anxiety-related interference (secondary outcomes). Results: Although there were no substantial differences between the treatment conditions on primary and most secondary outcome measures, the noninferiority of ICBT-SC[VC] compared to ICBT-TG[VC] could not be determined. Significant clinical benefits were evident for participants in both treatments, although this was significantly higher for the ICBT-TG[VC] participants. Of the 89 participants (38 in ICBT-SC[VC] and 51 in ICBT-TG[VC]) who remained in the study, 26 (68%) in ICBT-SC[VC] and 45 (88%) in ICBT-TG[VC] were free of their primary anxiety diagnosis by the 9-month follow-up. For the intention-to-treat sample (N=137), 41% (27/66) ICBT-SC[VC], and 69% (49/71) ICBT-TG[VC] participants were free of their primary anxiety diagnosis. Therapy compliance was lower for the ICBT-SC[VC] participants (mean 7.39, SD 3.44 sessions) than for the ICBT-TG[VC] participants (mean 8.73, SD 3.08 sessions), although treatment satisfaction was moderate to high in both conditions. Conclusions: This study provided further support for the benefits of low-intensity ICBT for children and adolescents with a primary anxiety disorder and highlighted the excellent treatment outcomes that can be achieved through therapist-guided ICBT delivered via videoconferencing. Although noninferiority of the stepped care adaptive approach could not be determined, it was acceptable to families, produced good outcomes, and could assist in increasing access to evidence-based care. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618001418268; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001418268 UR - https://mental.jmir.org/2025/1/e57405 UR - http://dx.doi.org/10.2196/57405 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57405 ER - TY - JOUR AU - Guhan, Pooja AU - Awasthi, Naman AU - McDonald, Kathryn AU - Bussell, Kristin AU - Reeves, Gloria AU - Manocha, Dinesh AU - Bera, Aniket PY - 2025/1/20 TI - Developing a Machine Learning?Based Automated Patient Engagement Estimator for Telehealth: Algorithm Development and Validation Study JO - JMIR Form Res SP - e46390 VL - 9 KW - machine learning KW - mental health KW - telehealth KW - engagement detection KW - patient engagement N2 - Background: Patient engagement is a critical but challenging public health priority in behavioral health care. During telehealth sessions, health care providers need to rely predominantly on verbal strategies rather than typical nonverbal cues to effectively engage patients. Hence, the typical patient engagement behaviors are now different, and health care provider training on telehealth patient engagement is unavailable or quite limited. Therefore, we explore the application of machine learning for estimating patient engagement. This can assist psychotherapists in the development of a therapeutic relationship with the patient and enhance patient engagement in the treatment of mental health conditions during tele?mental health sessions. Objective: This study aimed to examine the ability of machine learning models to estimate patient engagement levels during a tele?mental health session and understand whether the machine learning approach could support therapeutic engagement between the client and psychotherapist. Methods: We proposed a multimodal learning-based approach. We uniquely leveraged latent vectors corresponding to affective and cognitive features frequently used in psychology literature to understand a person?s level of engagement. Given the labeled data constraints that exist in health care, we explored a semisupervised learning solution. To support the development of similar technologies for telehealth, we also plan to release a dataset called Multimodal Engagement Detection in Clinical Analysis (MEDICA). This dataset includes 1229 video clips, each lasting 3 seconds. In addition, we present experiments conducted on this dataset, along with real-world tests that demonstrate the effectiveness of our method. Results: Our algorithm reports a 40% improvement in root mean square error over state-of-the-art methods for engagement estimation. In our real-world tests on 438 video clips from psychotherapy sessions with 20 patients, in comparison to prior methods, positive correlations were observed between psychotherapists? Working Alliance Inventory scores and our mean and median engagement level estimates. This indicates the potential of the proposed model to present patient engagement estimations that align well with the engagement measures used by psychotherapists. Conclusions: Patient engagement has been identified as being important to improve therapeutic alliance. However, limited research has been conducted to measure this in a telehealth setting, where the therapist lacks conventional cues to make a confident assessment. The algorithm developed is an attempt to model person-oriented engagement modeling theories within machine learning frameworks to estimate the level of engagement of the patient accurately and reliably in telehealth. The results are encouraging and emphasize the value of combining psychology and machine learning to understand patient engagement. Further testing in the real-world setting is necessary to fully assess its usefulness in helping therapists gauge patient engagement during online sessions. However, the proposed approach and the creation of the new dataset, MEDICA, open avenues for future research and the development of impactful tools for telehealth. UR - https://formative.jmir.org/2025/1/e46390 UR - http://dx.doi.org/10.2196/46390 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/46390 ER - TY - JOUR AU - Bonneterre, Solenne AU - Zerhouni, Oulmann AU - Boffo, Marilisa PY - 2025/1/20 TI - Immersive Virtual Reality for Health Promotion and Primary Prevention in Psychology: Scoping Review JO - JMIR XR Spatial Comput SP - e49923 VL - 2 KW - virtual reality KW - health psychology KW - prevention psychology KW - health promotion N2 - Background: Virtual reality (VR) has emerged as a promising tool in health promotion and prevention psychology. Its ability to create immersive, engaging, and standardized environments offers unique opportunities for interventions and assessments. However, the scope of VR applications in this field remains unclear. Objective: This scoping review aims to identify and map the applications of VR in health promotion and prevention psychology, focusing on its uses, outcomes, and challenges. Methods: A systematic search was conducted across 3 electronic databases (PubMed, PsycINFO, and Scopus) for studies published between 2010 and 2024. Eligibility criteria included empirical studies using immersive VR for health promotion and prevention, while studies using nonimmersive VR, lacking health-related applications, or focusing on clinical interventions were excluded. The review followed PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews) guidelines, and 4295 records were initially identified, with 51 studies included after screening. Data were synthesized qualitatively to identify key applications, limitations, and emerging trends. Results: VR was primarily used in three areas: (1) delivering interventions (eg, pilot testing, skills training), (2) exploring fundamental research questions, and (3) assessing outcomes such as behavioral or psychological responses. Although VR demonstrated potential for enhancing user engagement and replicating ecological scenarios, its effectiveness compared to nonimmersive methods varied. Most studies were pilot or feasibility studies with small, nonrepresentative samples, short follow-up periods, and limited methodological standardization. Conclusions: VR offers a versatile and promising tool for health promotion and prevention but its applications are still in the early stages. The evidence is limited by methodological weaknesses and variability in outcomes. Future research should prioritize replication, longitudinal designs, and standardized methodologies to strengthen the evidence base and expand the applicability of VR interventions. UR - https://xr.jmir.org/2025/1/e49923 UR - http://dx.doi.org/10.2196/49923 ID - info:doi/10.2196/49923 ER - TY - JOUR AU - Vermeir, F. Julie AU - White, J. Melanie AU - Johnson, Daniel AU - Crombez, Geert AU - Van Ryckeghem, L. Dimitri M. PY - 2025/1/16 TI - Gamified Web-Delivered Attentional Bias Modification Training for Adults With Chronic Pain: Randomized, Double-Blind, Placebo-Controlled Trial JO - JMIR Serious Games SP - e50635 VL - 13 KW - chronic pain KW - cognition KW - attentional bias KW - gamification KW - motivation KW - randomized controlled trial KW - web-based intervention KW - pain management KW - digital intervention KW - digital health N2 - Background: Attentional bias to pain-related information has been implicated in pain chronicity. To date, research investigating attentional bias modification training (ABMT) procedures in people with chronic pain has found variable success, perhaps because training paradigms are typically repetitive and monotonous, which could negatively affect engagement and adherence. Increasing engagement through the gamification (ie, the use of game elements) of ABMT may provide the opportunity to overcome some of these barriers. However, ABMT studies applied to the chronic pain field have not yet incorporated gamification elements. Objective: This study aimed to investigate the effects of a gamified web-delivered ABMT intervention in a sample of adults with chronic pain via a randomized, double-blind, placebo-controlled trial. Methods: A final sample of 129 adults with chronic musculoskeletal pain, recruited from clinical (hospital outpatient waiting list) and nonclinical (wider community) settings, were included in this randomized, double-blind, placebo-controlled, 3-arm trial. Participants were randomly assigned to complete 6 web-based sessions of nongamified standard ABMT (n=43), gamified ABMT (n=41), or a control condition (nongamified sham ABMT; n=45) over a period of 3 weeks. Active ABMT conditions trained attention away from pain-related words. The gamified task included a combination of 5 game elements. Participant outcomes were assessed before training, during training, immediately after training, and at 1-month follow-up. Primary outcomes included self-reported and behavioral engagement, pain intensity, and pain interference. Secondary outcomes included anxiety, depression, cognitive biases, and perceived improvement. Results: Results of the linear mixed model analyses suggest that across all conditions, there was an overall small to medium decline in self-reported task-related engagement between sessions 1 and 2 (P<.001; Cohen d=0.257; 95% CI 0.13-0.39), sessions 1 and 3 (P<.001; Cohen d=0.368; 95% CI 0.23-0.50), sessions 1 and 4 (P<.001; Cohen d=0.473; 95% CI 0.34-0.61), sessions 1 and 5 (P<.001; Cohen d=0.488; 95% CI 0.35-0.63), and sessions 1 and 6 (P<.001; Cohen d=0.596; 95% CI 0.46-0.73). There was also an overall small decrease in depressive symptoms from baseline to posttraining assessment (P=.007; Cohen d=0.180; 95% CI 0.05-0.31) and in pain intensity (P=.008; Cohen d=0.180; 95% CI 0.05-0.31) and pain interference (P<.001; Cohen d=0.237; 95% CI 0.10-0.37) from baseline to follow-up assessment. However, no differential effects were observed over time between the 3 conditions on measures of engagement, pain intensity, pain interference, attentional bias, anxiety, depression, interpretation bias, or perceived improvement (all P values>.05). Conclusions: These findings suggest that gamification, in this context, was not effective at enhancing engagement, and they do not support the widespread clinical use of web-delivered ABMT in treating individuals with chronic musculoskeletal pain. The implications of these findings are discussed, and future directions for research are suggested. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000803998; https://anzctr.org.au/ACTRN12620000803998.aspx International Registered Report Identifier (IRRID): RR2-10.2196/32359 UR - https://games.jmir.org/2025/1/e50635 UR - http://dx.doi.org/10.2196/50635 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50635 ER - TY - JOUR AU - Sanchez Ortuño, Montserrat María AU - Pecune, Florian AU - Coelho, Julien AU - Micoulaud-Franchi, Arthur Jean AU - Salles, Nathalie AU - Auriacombe, Marc AU - Serre, Fuschia AU - Levavasseur, Yannick AU - De Sevin, Etienne AU - Sagaspe, Patricia AU - Philip, Pierre PY - 2025/1/15 TI - Determinants of Dropout From a Virtual Agent?Based App for Insomnia Management in a Self-Selected Sample of Users With Insomnia Symptoms: Longitudinal Study JO - JMIR Ment Health SP - e51022 VL - 12 KW - insomnia KW - digital behavioral therapy KW - mobile health KW - dropout KW - virtual agent?based app KW - virtual agent KW - user KW - digital intervention KW - smartphone KW - mental health KW - implementation KW - cognitive behavioral therapy KW - CBT N2 - Background: Fully automated digital interventions delivered via smartphone apps have proven efficacious for a wide variety of mental health outcomes. An important aspect is that they are accessible at a low cost, thereby increasing their potential public impact and reducing disparities. However, a major challenge to their successful implementation is the phenomenon of users dropping out early. Objective: The purpose of this study was to pinpoint the factors influencing early dropout in a sample of self-selected users of a virtual agent (VA)?based behavioral intervention for managing insomnia, named KANOPEE, which is freely available in France. Methods: From January 2021 to December 2022, of the 9657 individuals, aged 18 years or older, who downloaded and completed the KANOPEE screening interview and had either subclinical or clinical insomnia symptoms, 4295 (44.5%) dropped out (ie, did not return to the app to continue filling in subsequent assessments). The primary outcome was a binary variable: having dropped out after completing the screening assessment (early dropout) or having completed all the treatment phases (n=551). Multivariable logistic regression analysis was used to identify predictors of dropout among a set of sociodemographic, clinical, and sleep diary variables, and users? perceptions of the treatment program, collected during the screening interview. Results: The users? mean age was 47.95 (SD 15.21) years. Of those who dropped out early and those who completed the treatment, 65.1% (3153/4846) were women and 34.9% (1693/4846) were men. Younger age (adjusted odds ratio [AOR] 0.98, 95% CI 0.97?0.99), lower education level (compared to middle school; high school: AOR 0.56, 95% CI 0.35?0.90; bachelor?s degree: AOR 0.35, 95% CI 0.23?0.52; master?s degree or higher: AOR 0.35, 95% CI 0.22?0.55), poorer nocturnal sleep (sleep efficiency: AOR 0.64, 95% CI 0.42?0.96; number of nocturnal awakenings: AOR 1.13, 95% CI 1.04?1.23), and more severe depression symptoms (AOR 1.12, 95% CI 1.04?1.21) were significant predictors of dropping out. When measures of perceptions of the app were included in the model, perceived benevolence and credibility of the VA decreased the odds of dropout (AOR 0.91, 95%?CI 0.85?0.97). Conclusions: As in traditional face-to-face cognitive behavioral therapy for insomnia, the presence of significant depression symptoms plays an important role in treatment dropout. This variable represents an important target to address to increase early engagement with fully automated insomnia management programs. Furthermore, our results support the contention that a VA can provide relevant user stimulation that will eventually pay out in terms of user engagement. Trial Registration: ClinicalTrials.gov NCT05074901; https://clinicaltrials.gov/study/NCT05074901?a=1 UR - https://mental.jmir.org/2025/1/e51022 UR - http://dx.doi.org/10.2196/51022 ID - info:doi/10.2196/51022 ER - TY - JOUR AU - Li, Min AU - Gu, Dongxiao AU - Li, Rui AU - Gu, Yadi AU - Liu, Hu AU - Su, Kaixiang AU - Wang, Xiaoyu AU - Zhang, Gongrang PY - 2025/1/14 TI - The Impact of Linguistic Signals on Cognitive Change in Support Seekers in Online Mental Health Communities: Text Analysis and Empirical Study JO - J Med Internet Res SP - e60292 VL - 27 KW - mental health KW - online communities KW - cognitive change KW - signaling theory KW - text analysis N2 - Background: In online mental health communities, the interactions among members can significantly reduce their psychological distress and enhance their mental well-being. The overall quality of support from others varies due to differences in people?s capacities to help others. This results in some support seekers? needs being met, while others remain unresolved. Objective: This study aimed to examine which characteristics of the comments posted to provide support can make support seekers feel better (ie, result in cognitive change). Methods: We used signaling theory to model the factors affecting cognitive change and used consulting strategies from the offline, face-to-face psychological counseling process to construct 6 characteristics: intimacy, emotional polarity, the use of first-person words, the use of future-tense words, specificity, and language style. Through text mining and natural language processing (NLP) technology, we identified linguistic features in online text and conducted an empirical analysis using 12,868 online mental health support reply data items from Zhihu to verify the effectiveness of those features. Results: The findings showed that support comments are more likely to alter support seekers? cognitive processes if those comments have lower intimacy (?intimacy=?1.706, P<.001), higher positive emotional polarity (?emotional_polarity=.890, P<.001), lower specificity (?specificity=?.018, P<.001), more first-person words (?first-person=.120, P<.001), more future- and present-tense words (?future-words=.301, P<.001), and fewer function words (?linguistic_style=?.838, P<.001). The result is consistent with psychotherapists? psychotherapeutic strategy in offline counseling scenarios. Conclusions: Our research contributes to both theory and practice by proposing a model to reveal the factors that make support seekers feel better. The findings have significance for support providers. Additionally, our study offers pointers for managing and designing online communities for mental health. UR - https://www.jmir.org/2025/1/e60292 UR - http://dx.doi.org/10.2196/60292 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60292 ER - TY - JOUR AU - Szinay, Dorothy AU - Cameron, A. Rory AU - Jones, Andy AU - Whitty, A. Jennifer AU - Chadborn, Tim AU - Brown, Jamie AU - Naughton, Felix PY - 2025/1/14 TI - Eliciting Preferences for the Uptake of Smoking Cessation Apps: Discrete Choice Experiment JO - J Med Internet Res SP - e37083 VL - 27 KW - discrete choice experiment KW - uptake, engagement KW - mHealth KW - smartphone app KW - smoking cessation KW - health app KW - behavior change KW - TDF KW - theoretical domains framework KW - mobile phone N2 - Background: If the most evidence-based and effective smoking cessation apps are not selected by smokers wanting to quit, their potential to support cessation is limited. Objective: This study sought to determine the attributes that influence smoking cessation app uptake and understand their relative importance to support future efforts to present evidence-based apps more effectively to maximize uptake. Methods: Adult smokers from the United Kingdom were invited to participate in a discrete choice experiment. Participants made 12 choices between two hypothetical smoking cessation app alternatives, with five predefined attributes reflecting domains from the theoretical domains framework: (1) monthly price of the app (environmental resources), (2) credible source as app developer (social influence), (3) social proof as star rating (social influence), (4) app description type (beliefs about consequences), and (5) images shown (beliefs about consequences); or opting out (choosing neither app). Preferences and the relative importance of attributes were estimated using mixed logit modeling. Willingness to pay and predicted uptake of the most and least preferred app were also calculated. Results: A total of 337 adult smokers completed the survey (n=168, 49.8% female; mean age 35, SD 11 years). Participants selected a smoking cessation app rather than opting out for 90% of the choices. Relative to other attributes, a 4.8-star user rating, representing social proof, was the strongest driver of app selection (mean preference parameter 2.27, SD 1.55; 95% CI 1.95-2.59). Participants preferred an app developed by health care?orientated trusted organization (credible source) over a hypothetical company (mean preference parameter 0.93, SD 1.23; 95% CI 0.72-1.15), with a logo and screenshots over logo only (mean preference parameter 0.39, SD 0.96; 95% CI 0.19-0.59), and with a lower monthly cost (mean preference parameter ?0.38, SD 0.33; 95% CI ?0.44 to ?0.32). App description did not influence preferences. The uptake estimate for the best hypothetical app was 93% and for the worst, 3%. Participants were willing to pay a single payment of up to an additional US $6.96 (UK £5.49) for 4.8-star ratings, US $3.58 (UK £2.82) for 4-star ratings, and US $2.61(UK £2.06) for an app developed by a trusted organization. Conclusions: On average, social proof appeared to be the most influential factor in app uptake, followed by credible source, one perceived as most likely to provide evidence-based apps. These attributes may support the selection of evidence-based apps. UR - https://www.jmir.org/2025/1/e37083 UR - http://dx.doi.org/10.2196/37083 UR - http://www.ncbi.nlm.nih.gov/pubmed/39808479 ID - info:doi/10.2196/37083 ER - TY - JOUR AU - Shmueli-Scheuer, Michal AU - Silverman, Yedidya AU - Halperin, Israel AU - Gepner, Yftach PY - 2025/1/13 TI - Analysis of Reddit Discussions on Motivational Factors for Physical Activity: Cross-Sectional Study JO - J Med Internet Res SP - e54489 VL - 27 KW - motivation KW - physical activity KW - social media KW - Reddit KW - adherence N2 - Background: Despite the ample benefits of physical activity (PA), many individuals do not meet the minimum PA recommended by health organizations. Structured questionnaires and interviews are commonly used to study why individuals perform PA and their strategies to adhere to PA. However, certain biases are inherent to these tools that limit what can be concluded from their results. Collecting data from social media channels can complement these studies and provide a more comprehensive overview of PA motives and adherence strategies. Objective: This study aims to investigate motives for engaging in PA, as well as the associated strategies to achieve these goals, as stated by a large number of people on a social media site. Methods: We searched for users? responses regarding PA motives and adherence strategies in Reddit forums dedicated to PA and analyzed the data using (1) unsupervised clustering to identify topics from the textual comments and (2) supervised classification to classify the comments into the detected topics. A panel of experts participated in both steps for annotation and validation purposes. Results: We analyzed 1577 unique user comments (representing 1577 individual users); of those, 1247 were linked to physical appearance (mentioned in 298/1247, 23.9% of the comments) and improving physical (235/1247, 18.9%) and mental health (211/1247, 16.9%), indicating these as the main motivational factors. The main strategies people used to adhere to PA were habit formation (373/1247, 30%), goal setting (173/1247, 13.9%), enjoyable activities (151/1247, 12.1%), socializing (121/1247, 9.7%), using media (111/1247, 8.9%), using different apps to monitor PA (35/1247, 2.8%), and financial commitment (32/1247, 2.5%). Conclusions: This study presented a novel approach using a language model to investigate why people engage in PA and the strategies they use to adhere to PA using wide-scale, self-disclosed content from popular social media channels. UR - https://www.jmir.org/2025/1/e54489 UR - http://dx.doi.org/10.2196/54489 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54489 ER - TY - JOUR AU - Liu, Shiyu AU - Ma, Jingru AU - Sun, Meichen AU - Zhang, Chao AU - Gao, Yujing AU - Xu, Jinghong PY - 2025/1/13 TI - Mapping the Landscape of Digital Health Intervention Strategies: 25-Year Synthesis JO - J Med Internet Res SP - e59027 VL - 27 KW - digital health interventions KW - intervention strategies KW - behavior change KW - mHealth KW - eHealth KW - randomized controlled trial N2 - Background: Digital health interventions have emerged as promising tools to promote health behavior change and improve health outcomes. However, a comprehensive synthesis of strategies contributing to these interventions is lacking. Objective: This study aims to (1) identify and categorize the strategies used in digital health interventions over the past 25 years; (2) explore the differences and changes in these strategies across time periods, countries, populations, delivery methods, and senders; and (3) serve as a valuable reference for future researchers and practitioners to improve the effectiveness of digital health interventions. Methods: This study followed a systematic review approach, complemented by close reading and text coding. A comprehensive search for published English academic papers from PubMed, Web of Science, and Scopus was conducted. The search employed a combination of digital health and intervention-related terms, along with database-specific subject headings and filters. The time span covered 25 years, from January 1, 1999, to March 10, 2024. Sample papers were selected based on study design, intervention details, and strategies. The strategies were identified and categorized based on the principles of Behavior Change Techniques and Behavior Strategies. Results: A total of 885 papers involving 954,847 participants met the eligibility criteria. We identified 173 unique strategies used in digital health interventions, categorized into 19 themes. The 3 most frequently used strategies in the sample papers were ?guide? (n=492, 55.6%), ?monitor? (n=490, 55.4%), and ?communication? (n=392, 44.3%). The number of strategies employed in each paper ranged from 1 to 32. Most interventions targeted clients (n=844, 95.4%) and were carried out in hospitals (n=268, 30.3%). High-income countries demonstrated a substantially higher number and diversity of identified strategies than low- and middle-income countries, and the number of studies targeting the public (n=647, 73.1%) far exceeded those focusing on vulnerable groups (n=238, 26.9%). Conclusions: Digital health interventions and strategies have undergone considerable development over the past 25 years. They have evolved from simple approaches to sophisticated, personalized techniques and are trending toward multifaceted interventions, leveraging advanced technologies for real-time monitoring and feedback. Future studies should focus on rigorous evaluations, long-term effectiveness, and tailored approaches for diverse populations, and more attention should be given to vulnerable groups. UR - https://www.jmir.org/2025/1/e59027 UR - http://dx.doi.org/10.2196/59027 UR - http://www.ncbi.nlm.nih.gov/pubmed/39804697 ID - info:doi/10.2196/59027 ER - TY - JOUR AU - Holley, Dan AU - Brooks, Amanda AU - Hartz, Matthew AU - Rao, Sudhir AU - Zaubler, Thomas PY - 2025/1/10 TI - mHealth-Augmented Care for Reducing Depression Symptom Severity Among Patients With Chronic Pain: Exploratory, Retrospective Cohort Study JO - JMIR Mhealth Uhealth SP - e52764 VL - 13 KW - mHealth KW - mobile health KW - app KW - behavioral health care KW - depression KW - mental health KW - screening KW - pain KW - chronic pain KW - psychiatric screenings KW - digital health care KW - psychiatry KW - psychiatric KW - longitudinal KW - assessment KW - behavioral KW - self-help KW - integrated KW - comorbidity KW - augmented care N2 - Background: Depression and chronic pain are commonly comorbid, mutually reinforcing, and debilitating. Emerging approaches to mobile behavioral health care (mHealth) promise to improve outcomes for patients with comorbid depression and chronic pain by integrating with existing care models to bolster support and continuity between clinical visits; however, the evidence base supporting the use of mHealth to augment care for this patient population is limited. Objective: To develop an evidence base that sets the stage for future research, we aimed to explore the associations between changes in depression severity and various integrated care models, with and without mHealth augmentation, among patients with comorbid depression and nonmalignant chronic pain. Methods: Our team leveraged retrospective, real-world data from 3837 patients with comorbid depression and nonmalignant chronic pain who received integrated behavioral health care (IBH) at a subspecialty pain clinic. We analyzed one IBH-only, non-mHealth cohort (n=2765), an mHealth-augmented cohort (n=844), and a collaborative care (CoCM)+mHealth cohort (n=136), which were supported by the NeuroFlow mHealth platform, and a pre-CoCM mHealth cohort (n=92), which was supported by the mHealth platform for 3 months prior to beginning the chronic pain treatment. We evaluated changes in depression severity between treatment cohorts via longitudinal analyses of both clinician- and mHealth-administered Patient Health Questionnaire-9 (PHQ-9) assessments. Results: mHealth-augmented integrated care led to significantly greater proportions of patients reaching clinical benchmarks for reduction (725/844, 86% vs 2112/2765, 76%), response (689/844, 82% vs 2027/2765, 73%), and remission (629/844, 75% vs 1919/2765, 69%) compared with integrated care alone. Furthermore, hierarchical regression modeling revealed that patients who received mHealth-augmented psychiatric CoCM experienced the greatest sustained reductions in on-average depression severity compared with other cohorts, irrespective of clinical benchmarks. In addition, patients who engaged with an mHealth platform before entering CoCM experienced a 7.2% reduction in average depression severity before starting CoCM treatment. Conclusions: Our findings suggest that mHealth platforms have the potential to improve treatment outcomes for patients with comorbid chronic pain and depression by providing remote measurement?based care, tailored interventions, and improved continuity between appointments. Moreover, our study set the stage for further research, including randomized controlled trials to evaluate causal relationships between mHealth engagement and treatment outcomes in integrated care settings. UR - https://mhealth.jmir.org/2025/1/e52764 UR - http://dx.doi.org/10.2196/52764 ID - info:doi/10.2196/52764 ER - TY - JOUR AU - Law, Vivienne AU - Afolalu, F. Esther AU - Abetz-Webb, Linda AU - Wemyss, Andrew Lee AU - Turner, Andrew AU - Chrea, Christelle PY - 2025/1/2 TI - International Expert Consensus on Relevant Health and Functioning Concepts to Assess in Users of Tobacco and Nicotine Products: Delphi Study JO - JMIR Form Res SP - e58614 VL - 9 KW - Delphi study KW - expert consensus KW - outcome measures KW - health and functioning KW - tobacco and/or nicotine products N2 - Background: A Delphi study was conducted to reach a consensus among international clinical and health care experts on the most important health and functioning self-reported concepts when evaluating a switch from smoking cigarettes to using smoke-free tobacco and/or nicotine products (sf-TNPs). Objective: The aim of this research was to identify concepts considered important to measure when assessing the health and functioning status of users of tobacco and/or nicotine products. Methods: Experts (n=105), including health care professionals, researchers, and policy makers, from 26 countries with professional experience and knowledge of sf-TNPs completed a 3-round, adapted Delphi panel. Online surveys combining quantitative (MaxDiff best-worst scaling and latent class analysis) and qualitative assessments were used to rank and achieve alignment on the importance of 69 health and functioning concepts. All experts participating in round I completed round II, and 101 (95%) completed round III. Results: The round I analysis identified 36 (52%) out of 69 concepts that were refined for the round II assessment. The highest-ranked concepts reflected health-related impacts, while the lowest-ranked ranked concepts were related to aesthetics and social impacts. Round II ranking reinforced the importance of concepts relating to health impacts, and the analysis resulted in 20 concepts retained for round III assessment. In round III, the 4 highest-ranked concepts were cardiovascular symptoms, shortness of breath, chest pain, and worry about smoking-related diseases and impact on general health, and they made up 50% of the total score in the MaxDiff analysis. Experts reported likelihood of seeing measurable levels of change in the final 20 concepts with a switch to an sf-TNP. The majority of experts felt it was ?likely? or ?extremely likely? to observe changes in concepts such as gum problems (74/101, 73%), phlegm or mucus while coughing or not coughing (72/101, 71%), general perception of well-being (72/101, 71%), and throat irritation or sore throat (72/101, 71%). Latent class analysis revealed subgroups of experts with different perceptions of the relative importance of the concepts, which varied depending on professional specialty and geographic region. For example, 74% (14/19) of oncologists aligned with the subgroup prioritizing physical health symptoms, while 71% (12/17) of experts from Asia aligned with the subgroup considering both physical health and psychosocial aspects. Conclusions: This study identified key concepts to be considered in the development of a new measurement instrument to assess the self-reported health and functioning status of individuals using sf-TNPs. The findings contribute to the scientific evidence base for understanding and evaluating both the individual and public health impacts of sf-TNPs. UR - https://formative.jmir.org/2025/1/e58614 UR - http://dx.doi.org/10.2196/58614 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58614 ER - TY - JOUR AU - Rinehart, Marie Linda AU - Anker, Justin AU - Unruh, Amanda AU - Degeneffe, Nikki AU - Thuras, Paul AU - Norden, Amie AU - Hartnett, Lilly AU - Kushner, Matt PY - 2024/12/31 TI - Supplemental Intervention for Alcohol Use Disorder Treatment Patients With a Co-Occurring Anxiety Disorder: Technical Development and Functional Testing of an Autonomous Digital Program JO - JMIR Form Res SP - e62995 VL - 8 KW - alcohol use disorder KW - anxiety disorder KW - comorbidity KW - digital intervention KW - psychological treatments KW - addiction KW - community-based practice KW - therapy KW - stress KW - depression KW - therapist-delivered therapies N2 - Background: Anxiety disorders are common in alcohol use disorder (AUD) treatment patients. Such co-occurring conditions (?comorbidity?) have negative prognostic implications for AUD treatment outcomes, yet they commonly go unaddressed in standard AUD care. Over a decade ago, we developed and validated a cognitive behavioral therapy intervention to supplement standard AUD care that, when delivered by trained therapists, improves outcomes in comorbid patients. However, this validated intervention, like many others in addiction care, has not been taken up in community-based AUD treatment programs. This phenomenon?empirically validated treatments that fail to be widely adopted in community care?has been termed the ?research-to-practice gap.? Researchers have suggested that the availability of fully autonomous digital equivalents of validated therapist-delivered therapies could reduce some barriers underlying the research-to-practice gap, especially by eliminating the need for costly and intensive therapist training and supervision. Objective: With this in mind, we obtained a Program Development Grant (R34) to conduct formative work in the development of a fully autonomous digital version of our previously validated therapist-delivered intervention for AUD treatment patients with a comorbid anxiety disorder. Methods: In the first phase of the project, we developed the digital intervention. This process included: (1) identifying appropriate collaborators and vendors; (2) consultation with an e-learning expert to develop a storyboard and accompanying graphics and narrative; (3) video production and editing; and (4) interactive programming. The second phase of the project was functional testing of the newly developed digital intervention conducted in 52 residential AUD treatment patients with a comorbid anxiety disorder. Patients underwent the 3 one-hour segments of the newly developed intervention and completed user surveys, knowledge quizzes, and behavioral competence tests. Results: While the development of the digital intervention was successful, the timeline was approximately double that projected (1 vs 2 years) due to false starts and inefficiencies that we describe, including lessons learned. Functional testing of the newly developed digital intervention showed that, on average, patients rated the user experience in the upper (favorable) 20% of the response scales. Knowledge quizzes and behavioral demonstrations showed that over 80% of participants gained functional mastery of the key skills and information taught in the program. Conclusions: Functional testing results in this study justify a randomized controlled trial of the digital intervention?s efficacy, which is currently ongoing. In sharing the details of our challenges and solutions in developing the digital intervention, we hope to inform others developing digital tools. The extent to which the availability of empirically validated, fully autonomous digital interventions achieves their potential to reduce the research-to-practice gap remains an open but important empirical question. The present work stands as a necessary first step toward that end. UR - https://formative.jmir.org/2024/1/e62995 UR - http://dx.doi.org/10.2196/62995 ID - info:doi/10.2196/62995 ER - TY - JOUR AU - Tartaglia, Julia AU - Jaghab, Brendan AU - Ismail, Mohamed AU - Hänsel, Katrin AU - Meter, Van Anna AU - Kirschenbaum, Michael AU - Sobolev, Michael AU - Kane, M. John AU - Tang, X. Sunny PY - 2024/12/30 TI - Assessing Health Technology Literacy and Attitudes of Patients in an Urban Outpatient Psychiatry Clinic: Cross-Sectional Survey Study JO - JMIR Ment Health SP - e63034 VL - 11 KW - digital literacy KW - attitudes KW - mental health KW - digital health technology KW - cluster analysis KW - psychiatry KW - mobile phone N2 - Background: Digital health technologies are increasingly being integrated into mental health care. However, the adoption of these technologies can be influenced by patients? digital literacy and attitudes, which may vary based on sociodemographic factors. This variability necessitates a better understanding of patient digital literacy and attitudes to prevent a digital divide, which can worsen existing health care disparities. Objective: This study aimed to assess digital literacy and attitudes toward digital health technologies among a diverse psychiatric outpatient population. In addition, the study sought to identify clusters of patients based on their digital literacy and attitudes, and to compare sociodemographic characteristics among these clusters. Methods: A survey was distributed to adult psychiatric patients with various diagnoses in an urban outpatient psychiatry program. The survey included a demographic questionnaire, a digital literacy questionnaire, and a digital health attitudes questionnaire. Multiple linear regression analyses were used to identify predictors of digital literacy and attitudes. Cluster analysis was performed to categorize patients based on their responses. Pairwise comparisons and one-way ANOVA were conducted to analyze differences between clusters. Results: A total of 256 patients were included in the analysis. The mean age of participants was 32 (SD 12.6, range 16-70) years. The sample was racially and ethnically diverse: White (100/256, 38.9%), Black (39/256, 15.2%), Latinx (44/256, 17.2%), Asian (59/256, 23%), and other races and ethnicities (15/256, 5.7%). Digital literacy was high for technologies such as smartphones, videoconferencing, and social media (items with >75%, 193/256 of participants reporting at least some use) but lower for health apps, mental health apps, wearables, and virtual reality (items with <42%, 108/256 reporting at least some use). Attitudes toward using technology in clinical care were generally positive (9 out of 10 items received >75% positive score), particularly for communication with providers and health data sharing. Older age (P<.001) and lower educational attainment (P<.001) negatively predicted digital literacy scores, but no demographic variables predicted attitude scores. Cluster analysis identified 3 patient groups. Relative to the other clusters, cluster 1 (n=30) had lower digital literacy and intermediate acceptance of digital technology. Cluster 2 (n=50) had higher literacy and lower acceptance. Cluster 3 (n=176) displayed both higher literacy and acceptance. Significant between-cluster differences were observed in mean age and education level between clusters (P<.001), with cluster 1 participants being older and having lower levels of formal education. Conclusions: High digital literacy and acceptance of digital technologies were observed among our patients, indicating a generally positive outlook for digital health clinics. Our results also found that patients of older age and lower formal levels of educational attainment had lower digital literacy, highlighting the need for targeted interventions to support those who may struggle with adopting digital health tools. UR - https://mental.jmir.org/2024/1/e63034 UR - http://dx.doi.org/10.2196/63034 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63034 ER - TY - JOUR AU - Leijse, L. Merel M. AU - van Dam, Levi AU - Jambroes, Tijs AU - Timmerman, Amber AU - Popma, Arne PY - 2024/12/30 TI - Using Active and Passive Smartphone Data to Enhance Adolescents? Emotional Awareness in Forensic Outpatient Setting: A Qualitative Feasibility and Usability Study JO - JMIR Form Res SP - e53613 VL - 8 KW - emotion regulation KW - emotion awareness KW - smartphone data KW - forensic outpatient youth care KW - treatment motivation KW - treatment alliance KW - emotion KW - behavioral KW - interview KW - mHealth KW - app KW - forensic KW - usability KW - feasibility KW - delinquent KW - pediatrics KW - youth KW - adolescent KW - teenager KW - experience KW - attitude KW - opinion KW - perception KW - perspective KW - acceptance KW - emoji KW - behavioral data KW - mobile phone N2 - Background: Delinquent behavior in adolescence is a prevalent issue, often associated with difficulties across multiple life domains, which in turn perpetuates negative life outcomes. While current treatment programs show partial success in improving behavioral changes and reducing recidivism, comprehensive conclusions regarding the overall efficacy of these interventions have yet to be established. In forensic outpatient settings, the discrepancy between adolescents? limited emotional awareness and the predominant emphasis on cognitive reflection, combined with low treatment adherence, may be factors that undermine treatment efficacy. New technologies, such as smartphone apps, may offer a solution by integrating real-life data into treatment to improve emotional and behavioral patterns. The low-threshold use of smartphone data can be useful in addressing these treatment challenges. Objective: This study aimed to explore the feasibility and usability of Feelee (Garage2020), a smartphone app that integrates active emoji and passive behavioral data, as a potential addition to treatment for adolescents in a forensic outpatient setting. Methods: We conducted a prepilot study with adolescents (n=4) who used the Feelee app over a 2-week period. App usage included completing a brief emoji survey 3 times a day (active data) and allowing Feelee to track the call logs, Bluetooth devices in proximity, cell tower IDs, app usage, and phone status (passive data). During treatment sessions, both adolescents and clinicians reviewed and discussed the active and passive data. Semistructured interviews were conducted with adolescents and clinicians (n=7) to gather experiences and feedback on the feasibility and usability of incorporating smartphone data into treatment. Results: The study showed that adolescents (n=3) succeeded in using Feelee for the full 2 weeks, and data were available for discussion in at least 1 session per participant. Both adolescents and clinicians (n=7) stated that Feelee was valuable for viewing, discussing, and gaining insight into their emotions, which facilitated targeted actions based on the Feelee data. However, neither adolescents nor clinicians reported increased engagement in treatment as a result of using Feelee. Despite technical issues, overall feedback on the Feelee app, in addition to treatment, was positive (n=7). However, further improvements are needed to address the high battery consumption and the inaccuracies in the accelerometer. Conclusions: This qualitative study provides an in-depth understanding of the potential benefits of integrating active and passive smartphone data for adolescents in a forensic outpatient setting. Feelee appears to contribute to a better understanding of emotions and behaviors, suggesting its potential value in enhancing emotional awareness in treatment. Further research is needed to assess Feelee?s clinical effectiveness and explore how it enhances emotional awareness. Recommendations from adolescents and clinicians emphasize the need for prepilot studies to address user issues, guiding technical improvements and future research in forensic outpatient settings. UR - https://formative.jmir.org/2024/1/e53613 UR - http://dx.doi.org/10.2196/53613 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/53613 ER - TY - JOUR AU - Richter, Franziska AU - Kronziel, Louisa Lea AU - König, Inke AU - Langer, Thorsten AU - Gebauer, Judith PY - 2024/12/26 TI - Implementation of Regular Lifestyle Counseling During Long-Term Follow-Up Care of Childhood Cancer Survivors: Monocentric Prospective Study JO - JMIR Cancer SP - e59614 VL - 10 KW - lifestyle counseling KW - long-term follow-up KW - childhood cancer survivors KW - physical activity KW - metabolic disorders KW - cancer survivor KW - treatment-related KW - risk of obesity KW - metabolic syndrome KW - healthy lifestyle KW - morbidity KW - patient KW - hypercholesterolemia KW - diabetes mellitus KW - health care professionals N2 - Background: Many childhood cancer survivors (CCS) develop treatment-related late effects, including an increased risk of obesity and metabolic syndrome. A healthy lifestyle can reduce the risk of associated comorbidities. Therefore, at-risk CCS could benefit from lifestyle counseling during regular long-term follow-up (LTFU). Objective: We implemented a new form of care to decrease the long-term morbidity among CCS and to gain new insights into the lifestyle of those patients. Methods: Over a 1-year study period, lifestyle counseling was integrated into LTFU care. Metabolic disorders, including hypercholesterolemia, diabetes mellitus, overweight or underweight, and low activity levels, were assessed as screening parameters for various risk groups. The perspectives of CCS, physicians, and sports scientists were compared to identify those with the highest needs. Each lifestyle counseling included general recommendations for physical activity, as well as an assessment of individual preferences for and barriers to the implementation of a healthy lifestyle. A follow-up appointment after 1 month was performed. Results: Of the 155 CCS aged 18 to 63 years (n=100, 65% female and n=55, 35% male), 112 (72%) had an indication for lifestyle counseling, identified by physicians, sports scientists, or the CCS themselves. Metabolic disorders affected 45% (n=70) of these CCS, and 46% (n=72) did not meet recommended activity levels. A total of 120 (77%) CCS received lifestyle counseling, including 8 initially uninterested individuals who became open to recommendations. Those with intensive cancer treatment history showed the greatest need. A total of 65 (54%) CCS were advised to change their lifestyle in both areas (diet and exercise) while 51 (43%) CCS received recommendations for only exercise (n=43 CCS, 36%) or diet (n=8 CCS, 7%). A total of 4 (3%) CCS, although interested in counseling, received no advice, as they already met the recommendations. Follow-up revealed high adherence to recommendations and successful integration into daily lives. In total, 97% (n=150) of survivors indicated that the provision of lifestyle counseling during LTFU would be generally beneficial. Conclusions: Incorporating specialized health care professionals such as sports scientists into survivorship care enhances the multidisciplinary approach of LTFU care. Promoting a healthy lifestyle by offering guideline-based lifestyle counseling is broadly accepted among CCS and may reduce long-term morbidity. UR - https://cancer.jmir.org/2024/1/e59614 UR - http://dx.doi.org/10.2196/59614 ID - info:doi/10.2196/59614 ER - TY - JOUR AU - Foti, Kathryn AU - Hubbard, Demetria AU - Smith, A. Kimberly AU - Hearld, Larry AU - Richman, Joshua AU - Horton, Trudi AU - Parker, Sharon AU - Roughton, Dodey AU - Craft, Macie AU - Clarkson, A. Stephen AU - Jackson, A. Elizabeth AU - Cherrington, L. Andrea PY - 2024/12/20 TI - Improving Blood Pressure Control and Tobacco Use Cessation Intervention In Primary Care: Protocol for the Alabama Cardiovascular Cooperative Heart Health Improvement Project JO - JMIR Res Protoc SP - e63685 VL - 13 KW - hypertension KW - primary care KW - quality improvement KW - tobacco use KW - smoking cessation KW - healthcare quality KW - quality of care KW - risk modification KW - cardiovascular disease prevention N2 - Background: Alabama has the second highest rate of cardiovascular disease (CVD) mortality of any US state and a high prevalence of CVD risk factors such as hypertension, diabetes, obesity, and smoking. Within the state, there are disparities in CVD outcomes and risk factors by race or ethnicity and geography. Many primary care practices do not have the capacity for full-scale quality improvement (QI) initiatives. The Alabama Cardiovascular Cooperative (ALCC), which includes academic and community stakeholders, was formed to support primary care practices to implement QI initiatives to improve cardiovascular health. The ALCC is implementing a Heart Health Improvement Project (HHIP) in primary care practices with suboptimal rates of blood pressure (BP) control and tobacco use screening. Objective: The study aimed to support primary care practices to increase BP control among adults with hypertension and increase rates of tobacco use screening and cessation intervention. Methods: We are using a type 1 hybrid design to test the effects of the HHIP on BP control among adults with hypertension and tobacco use screening and cessation intervention, while collecting information on implementation. Primary care practices were recruited through existing practice networks and additional electronic and in-person outreach. To ensure participation from a broad range of clinics, we required at least 50% of practices to be Federally Qualified Health Centers or look-alikes and to include representation from practices in rural areas. At baseline, we collected information about practice characteristics and preintervention rates of BP control and tobacco use screening and cessation intervention. The QI intervention includes quarterly activities conducted over a 12-month period. The HHIP uses a multipronged approach to QI, including practice facilitation and technical assistance, on-site and e-learning, and improvement through data transparency. We will conduct a pre-post analysis to estimate the effects of the HHIP and whether there is an enduring change in outcomes after the 12 months of HHIP activities beyond what would be expected due to secular trends. Results: Practice recruitment took place between April 2021 and October 2022. After contacting 417 primary care practices, 51 were enrolled, including 28 Federally Qualified Health Centers or look-alikes; 47 practices implemented the HHIP. Among 45 practices that completed the baseline survey, 11 (24%) were solo practices, while 28 (62%) had 1-5 clinicians, and 6 (13%) had 6 or more clinicians. The median number of patient visits per year was 5819 (IQR 3707.3-8630.5). Practices had been in operation for a mean of 19.2 (SD 13.0) years. At baseline, the mean BP control rate was 49.6% and the rate of tobacco use screening and cessation intervention was 67.4%. Conclusions: If successful, the ALCC and HHIP may improve the implementation of evidence-based guidelines in primary care and, subsequently, cardiovascular health and health equity in the state of Alabama. International Registered Report Identifier (IRRID): DERR1-10.2196/63685 UR - https://www.researchprotocols.org/2024/1/e63685 UR - http://dx.doi.org/10.2196/63685 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63685 ER - TY - JOUR AU - Baee, Sonia AU - Eberle, W. Jeremy AU - Baglione, N. Anna AU - Spears, Tyler AU - Lewis, Elijah AU - Wang, Hongning AU - Funk, H. Daniel AU - Teachman, Bethany AU - E Barnes, Laura PY - 2024/12/20 TI - Early Attrition Prediction for Web-Based Interpretation Bias Modification to Reduce Anxious Thinking: A Machine Learning Study JO - JMIR Ment Health SP - e51567 VL - 11 KW - digital mental health intervention KW - attrition prediction KW - user engagement KW - cognitive bias modification KW - CBM-I KW - dropout rate KW - personalization N2 - Background: Digital mental health is a promising paradigm for individualized, patient-driven health care. For example, cognitive bias modification programs that target interpretation biases (cognitive bias modification for interpretation [CBM-I]) can provide practice thinking about ambiguous situations in less threatening ways on the web without requiring a therapist. However, digital mental health interventions, including CBM-I, are often plagued with lack of sustained engagement and high attrition rates. New attrition detection and mitigation strategies are needed to improve these interventions. Objective: This paper aims to identify participants at a high risk of dropout during the early stages of 3 web-based trials of multisession CBM-I and to investigate which self-reported and passively detected feature sets computed from the participants interacting with the intervention and assessments were most informative in making this prediction. Methods: The participants analyzed in this paper were community adults with traits such as anxiety or negative thinking about the future (Study 1: n=252, Study 2: n=326, Study 3: n=699) who had been assigned to CBM-I conditions in 3 efficacy-effectiveness trials on our team?s public research website. To identify participants at a high risk of dropout, we created 4 unique feature sets: self-reported baseline user characteristics (eg, demographics), self-reported user context and reactions to the program (eg, state affect), self-reported user clinical functioning (eg, mental health symptoms), and passively detected user behavior on the website (eg, time spent on a web page of CBM-I training exercises, time of day during which the exercises were completed, latency of completing the assessments, and type of device used). Then, we investigated the feature sets as potential predictors of which participants were at high risk of not starting the second training session of a given program using well-known machine learning algorithms. Results: The extreme gradient boosting algorithm performed the best and identified participants at high risk with macro?F1-scores of .832 (Study 1 with 146 features), .770 (Study 2 with 87 features), and .917 (Study 3 with 127 features). Features involving passive detection of user behavior contributed the most to the prediction relative to other features. The mean Gini importance scores for the passive features were as follows: .033 (95% CI .019-.047) in Study 1; .029 (95% CI .023-.035) in Study 2; and .045 (95% CI .039-.051) in Study 3. However, using all features extracted from a given study led to the best predictive performance. Conclusions: These results suggest that using passive indicators of user behavior, alongside self-reported measures, can improve the accuracy of prediction of participants at a high risk of dropout early during multisession CBM-I programs. Furthermore, our analyses highlight the challenge of generalizability in digital health intervention studies and the need for more personalized attrition prevention strategies. UR - https://mental.jmir.org/2024/1/e51567 UR - http://dx.doi.org/10.2196/51567 UR - http://www.ncbi.nlm.nih.gov/pubmed/39705068 ID - info:doi/10.2196/51567 ER - TY - JOUR AU - Kidman, G. Patrick AU - Curtis, G. Rachel AU - Watson, Amanda AU - Maher, A. Carol PY - 2024/12/18 TI - When and Why Adults Abandon Lifestyle Behavior and Mental Health Mobile Apps: Scoping Review JO - J Med Internet Res SP - e56897 VL - 26 KW - mobile health apps KW - smartphone applications KW - app abandonment KW - app attrition KW - user engagement KW - health behavior KW - user retention KW - lifestyle management KW - quantitative analysis KW - qualitative analysis KW - mobile phone N2 - Background: With 1 in 3 adults globally living with chronic conditions and the rise in smartphone ownership, mobile health apps have become a prominent tool for managing lifestyle-related health behaviors and mental health. However, high rates of app abandonment pose challenges to their effectiveness. Objective: We explored the abandonment of apps used for managing physical activity, diet, alcohol, smoking, and mental health in free-living conditions, examining the duration of app use before abandonment and the underlying reasons. Methods: A scoping review was conducted based on the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) guidelines and eligibility criteria were designed according to the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework. In total, 4 databases were searched (MEDLINE, Scopus, Embase, and PsycINFO) to identify quantitative and qualitative studies with outcome measures related to app abandonment in adults with free-living conditions, including reasons for abandonment and duration of use, for mobile apps related to WHO (World Health Organization) modifiable health behaviors and mental health. The included studies? risk of bias was appraised based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and COREQ (Consolidated Criteria for Reporting Qualitative Research) checklists. To enable data synthesis across different methodologies, app domains, demographic data, and outcome measures were categorized. Results are presented in 2 sections: quantitatively in a scatterplot to understand when users abandon apps and qualitatively through basic qualitative content analysis to identify the underlying reasons. Results: Eighteen eligible studies (525,824 participants) published between 2014 and 2022, predominantly from the United States, Canada, the United Kingdom, and Germany, were identified. Findings revealed a curvilinear pattern of app abandonment, with sharper abandonment soon after acquisition, followed by a slowing rate of abandonment over time. Taken together, a median of 70% of users discontinued use within the first 100 days. The abandonment rate appeared to vary by app domain, with apps focusing on alcohol and smoking exhibiting faster abandonment, and physical activity and mental health exhibiting longer usage durations. In total, 22 unique reasons for abandonment were organized into six categories: (1) technical and functional issues, (2) privacy concerns, (3) poor user experience, (4) content and features, (5) time and financial costs, and (6) evolving user needs and goals. Conclusions: This study highlights the complex nature of health app abandonment and the need for an improved understanding of user engagement over time, underscoring the importance of addressing various factors contributing to abandonment, from technical issues to evolving user needs. Our findings also emphasize the need for longitudinal studies and a consistent definition of app abandonment to better understand and mitigate this phenomenon, thereby enhancing the effectiveness of health apps in supporting public health initiatives. UR - https://www.jmir.org/2024/1/e56897 UR - http://dx.doi.org/10.2196/56897 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56897 ER - TY - JOUR AU - Al-Jayyousi, Fakhri Ghadir AU - Alsayed Hassan, Diana AU - Abdul Rahim, Hanan AU - E Abdel-Rahman, Manar AU - Ferreira, Isabel AU - Mukhalalati, Banan AU - O'Hara, Lily AU - Khalil, Hanan AU - Tayyem, Reema AU - S Abu Alhaija, Elham AU - Abidia, Randa AU - Zolezzi, Monica AU - El-Awaisi, Alla AU - Al-Wattary, Noor AU - Mahmood Al Saady, Rafif AU - Saffouh El Hajj, Maguy AU - Shraim, Mujahed AU - K Abouhanian, Arpi AU - Saeb, Hatoun AU - Mohammed, Mustapha AU - PY - 2024/12/18 TI - Health and Well-Being in the Context of Health-Promoting University Initiatives: Protocol for a Mixed Methods Needs Assessment Study at Qatar University JO - JMIR Res Protoc SP - e58860 VL - 13 KW - college students KW - needs assessment KW - qualitative KW - lifestyle behaviors KW - environmental scan N2 - Background: Health-promoting universities are dedicated to fostering learning environments and organizational cultures that support the physical and mental well-being of students, faculty, and staff. As students constitute the largest group within the university community, any policy intervention targeting them is likely to have a significant impact on the university as a whole. Objective: This study aims to assess the health status and needs of Qatar University (QU) students using a comprehensive and holistic definition of health, informed by the perspectives of students, faculty members, and key informants. The ultimate goal is to inform evidence-based policies and services designed to improve students? physical and mental well-being. Methods: An explanatory sequential mixed-methods research design will be used to conduct a comprehensive assessment of students? health status and needs. This assessment will consist of a quantitative component (a web-based health survey) administered to a convenience sample of students, and a qualitative component, including focus groups with students and faculty members, as well as interviews with key informants. Priority health issues and their determinants, identified through the quantitative assessment, will inform and guide the qualitative assessment to provide a deeper understanding of the various contexts and factors shaping them. Descriptive analyses (eg, proportions or means with SDs), comparative analyses (eg, t tests or chi-square tests), and association analyses (eg, linear, logistic, or Poisson regression models) will be used to analyze the quantitative data. Thematic analysis will be used in the qualitative assessments. Additionally, an environmental scan will be conducted to assess relevant facilities, services, and programs at the QU campus and the QU Primary Healthcare Corporation Center, as well as to review university policies and regulations that may affect students? health and well-being. Together, the needs assessment and environmental scan will inform the design of multilevel interventions, including health education and promotion programs, health services orientation, and proposed policy changes. Results: Between March and December 2022, 812 students completed the web-based health survey. Data have been extracted, cleaned, and harmonized. Analyses to assess the extent of selection bias and the calculation of weights to account for this in all subsequent analyses have been completed (by December 2023). Following the completion of all quantitative data analyses (expected by the end of 2024), focus groups, interviews, and the environmental scan will begin in January-December 2025. Conclusions: This project will help identify and prioritize the health needs of QU students and their determinants, and inform relevant services and policies targeting these needs. By using comprehensive and context-appropriate methods, this project will contribute to QU?s strategic efforts to become a Health-Promoting University. International Registered Report Identifier (IRRID): DERR1-10.2196/58860 UR - https://www.researchprotocols.org/2024/1/e58860 UR - http://dx.doi.org/10.2196/58860 UR - http://www.ncbi.nlm.nih.gov/pubmed/39693145 ID - info:doi/10.2196/58860 ER - TY - JOUR AU - Sourander, Saana AU - Westerlund, Minja AU - Baumel, Amit AU - Hinkka-Yli-Salomäki, Susanna AU - Ristkari, Terja AU - Kurki, Marjo AU - Sourander, Andre PY - 2024/12/16 TI - Web-Based Parent Training With Telephone Coaching Aimed at Treating Child Disruptive Behaviors in a Clinical Setting During the COVID-19 Pandemic: Single-Group Study With 2-Year Follow-Up JO - JMIR Pediatr Parent SP - e63416 VL - 7 KW - parent training KW - disruptive behavior KW - child psychopathology KW - child functioning KW - behaviors KW - behavioral KW - coaching KW - web-based KW - family counseling KW - child KW - disruptive KW - counseling KW - training KW - parents KW - parenting KW - telephone KW - telehealth KW - telemedicine KW - pediatrics KW - COVID-19 N2 - Background: There is a lack of studies examining the long-term outcomes of web-based parent training programs implemented in clinical settings during the COVID-19 pandemic. Objective: The aim is to study 2-year outcomes of families with 3? to 8-year-old children referred from family counseling centers to the Finnish Strongest Families Smart Website (SFSW), which provides digital parent training with telephone coaching aimed at treating child disruptive behaviors. Methods: Counseling centers in Helsinki identified fifty 3? to 8-year-old children with high levels of disruptive behavioral problems. Child psychopathology and functioning as well as parenting styles and parental mental health were collected from parents at baseline; posttreatment; and at 6-, 12-, and 24-month follow-ups. Results: The SFSW program had positive long-term changes in child psychopathology and parenting skills. Improvements in child psychopathology, including Strengths and Difficulties Questionnaire total score (Cohen d=0.47; P<.001), Strengths and Difficulties Questionnaire conduct scores (Cohen d=0.65; P<.001), and Affective Reactivity Index irritability scores (Cohen d=0.52; P<.001), were maintained until the 24-month follow-up. Similarly, changes in parenting skills measured with the Parenting Scale, including overreactivity (Cohen d=0.41; P=.001) and laxness (Cohen d=0.26; P=.02), were maintained until the 24-month follow-up. However, parental hostility changes were not maintained at long-term follow-up (Cohen d=?0.04; P=.70). Conclusions: The study shows that the SFSW parent training program can yield significant long-term benefits. Findings indicate that the benefits of the treatment may vary between different parenting styles, which is important to consider when developing more personalized parenting interventions. UR - https://pediatrics.jmir.org/2024/1/e63416 UR - http://dx.doi.org/10.2196/63416 ID - info:doi/10.2196/63416 ER - TY - JOUR AU - Bryne, Emilie AU - Bergum, Høyvik Kathrine AU - Gjedrem, Gilje William PY - 2024/12/11 TI - Improving Oral Health in Prisons (PriOH): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e60817 VL - 13 KW - intervention KW - motivational interviewing KW - oral care KW - marginalized groups KW - correctional services KW - implementation KW - oral hygiene KW - oral health KW - randomized controlled trial KW - RCT KW - prison KW - dental care KW - pilot study KW - people living in prison N2 - Background: People living in prisons often experience poor oral health, which could be attributed to their limited access to (dental) care, financial constraints, and a general lack of awareness and prioritization toward their oral hygiene. A pilot study involving motivational interviewing (MI) has shown promising results for improving the oral health outcomes of people living in prisons. Objective: The protocol for this study aims to assess the efficacy of integrated MI and oral hygiene packages in improving oral health among people living in prisons, compared to controls without added MI. Methods: This oral health in prisons study is a multicenter, randomized, double-blinded controlled trial that recruited inmates from 4 prisons in Rogaland County. The trial aimed to recruit 320 participants before randomly allocating them to either a control or intervention group. The intervention group received MI, consisting of a 30-minute session encouraging inmates to discuss their current and desired oral health behaviors and attitudes, highlighting discrepancies to motivate change. Assessments were conducted at 4 and 12 weeks after initiation. The primary outcome measurement is the mucosal-plaque scores to assess oral health behaviors, attitudes, and oral hygiene. Secondary outcome measurements are oral hygiene routines, sugary food and drink intake, oral health perception, and oral health-related questions. Results: Data collection started in November 2021 and ended in June 2023. A total of 327 participants were recruited, of which 126 received the intervention. Conclusions: Integrating MI in oral health programs at prisons can significantly improve the oral health of incarcerated individuals. Should the results from this study demonstrate efficacy, it could be valuable insight for policy makers, oral health practitioners, and correctional services in addressing the needs of a traditionally underserved group before being scaled up to enhance dental care practices in prisons. Trial Registration: ClinicalTrials.gov NCT05695443; https://clinicaltrials.gov/study/NCT05695443 International Registered Report Identifier (IRRID): DERR1-10.2196/60817 UR - https://www.researchprotocols.org/2024/1/e60817 UR - http://dx.doi.org/10.2196/60817 UR - http://www.ncbi.nlm.nih.gov/pubmed/39661440 ID - info:doi/10.2196/60817 ER - TY - JOUR AU - Melamed, C. Osnat AU - Mehra, Kamna AU - Panda, Roshni AU - Minian, Nadia AU - Veldhuizen, Scott AU - Zawertailo, Laurie AU - Buckley, Leslie AU - Maslej, Marta AU - Greaves, Lorraine AU - Brabete, C. Andreea AU - Rose, Jonathan AU - Ratto, Matt AU - Selby, Peter PY - 2024/12/10 TI - A Gender-Informed Smoking Cessation App for Women: Protocol for an Acceptability and Feasibility Study JO - JMIR Res Protoc SP - e60677 VL - 13 KW - smoking cessation KW - mHealth KW - co-development KW - feasibility KW - smoking KW - mobile app KW - cigarette smoking KW - tobacco cessation KW - gender-informed design KW - app design KW - women's health KW - behavior change KW - health behavior change KW - mobile phone N2 - Background: Tobacco smoking remains the leading preventable cause of death and disease among women. Quitting smoking offers numerous health benefits; however, women tend to have less success than men when attempting to quit. This discrepancy is partly due to sex- and gender-related factors, including the lower effectiveness of smoking cessation medication and the presence of unique motives for smoking and barriers to quitting among women. Despite the gendered nature of smoking, most smoking cessation apps are gender-neutral and fail to address women?s specific needs. Objective: This study aims to test the acceptability and feasibility of a smartphone app that delivers gender-informed content to support women in quitting smoking. Methods: We co-developed a smoking cessation app specifically tailored for women, named My Change Plan-Women (MCP-W). This app builds upon our previous gender-neutral app, MCP, by retaining its content grounded in behavioral change techniques aimed at supporting tobacco reduction and cessation. This includes goal setting for quitting, identifying triggers to smoking, creating coping strategies, tracking cigarettes and cravings, and assessing financial savings from quitting smoking. The MCP-W app contains additional gender-informed content that acknowledges barriers to quitting, such as coping with stress, having smokers in one?s social circle, and managing unpleasant emotions. This content is delivered through testimonials and animated videos. This study is a prospective, single-group, mixed methods investigation in which 30 women smokers will trial the app for a period of 28 days. Once participants provide informed consent, they will complete a baseline survey and download the app on their smartphones. After 28 days, participants will complete follow-up surveys. Acceptability will be assessed using the Theoretical Framework of Acceptability, which evaluates whether participants perceive the app as helpful in changing their smoking. The app will be deemed acceptable if the majority of participants rate it as such, and feasible if the majority of the participants use it for at least 7 days. Furthermore, after the 28-day trial period, participants will complete a semistructured interview regarding their experience with the app and suggestions for improvement. Results: Development of the MCP-W app was completed in September 2023. Participant recruitment for testing of the app commenced in February 2024 and was completed in July 2024. We will analyze the data upon completion of data collection from all 30 participants. We expect to share the results of this acceptability trial in the middle of 2025. Conclusions: Offering smoking cessation support tailored specifically to address the unique needs of women through a smartphone app represents a novel approach. This study will test whether women who smoke perceive this approach to be acceptable and feasible in their journey toward smoking cessation. International Registered Report Identifier (IRRID): DERR1-10.2196/60677 UR - https://www.researchprotocols.org/2024/1/e60677 UR - http://dx.doi.org/10.2196/60677 UR - http://www.ncbi.nlm.nih.gov/pubmed/39433391 ID - info:doi/10.2196/60677 ER - TY - JOUR AU - Li, Xinyi AU - Malli, Aikaterini Melina AU - Cosco, D. Theodore AU - Zhou, Guangyu PY - 2024/12/5 TI - The Relationship Between Self-Compassion and Resilience in the General Population: Protocol for a Systematic Review and Meta-Analysis JO - JMIR Res Protoc SP - e60154 VL - 13 KW - self-compassion KW - resilience KW - resiliency KW - adversity KW - compassion KW - coping KW - coping styles KW - health status KW - meta-analysis KW - meta-regression N2 - Background: Resilience can protect individuals from the negative impact of adversity, facilitating a swift recovery. The exploration of protective factors contributing to resilience has been a central focus of research. Self-compassion, a positive psychological construct that involves treating oneself with kindness, holds the potential to bolster resilience. Although several studies have indicated an association between self-compassion and resilience, there is a lack of systematic reviews and meta-analyses examining this relationship and the potential moderators and mechanisms. Objective: This study aimed to systematically review the literature on the relationship between self-compassion and resilience in the general population, perform a meta-analysis to quantify the effect size of their association, and explore potential moderators (eg, age, gender, culture, and health status) and mediators. Methods: We will search the Web of Science, PsycINFO, MEDLINE, Scopus, CINAHL, and CNKI databases for peer-reviewed studies (including observational and experimental studies) that examined the relationship between self-compassion and resilience, with no language restrictions. There are no restrictions regarding participants? age, gender, culture, or health status. Qualitative studies, conference abstracts, review articles, case reports, and editorials will be excluded. Two reviewers (XL and JH) will independently screen the literature, extract data, and assess the quality of the eligible studies. If possible, the pooled effect size between self-compassion and resilience will be meta-analyzed using a random-effect model. Meta-regression and subgroup analysis will be conducted to examine the moderating roles of age, gender, culture, health status, and other potential moderators. The characteristics and main findings of eligible studies will be summarized in tables and narrative descriptions. Results from the meta-analysis, meta-regression, and subgroup analysis will be presented quantitatively. Results: We registered our protocol with PROSPERO, conducted the search, and initiated the screening in April 2024. We expect to start data analysis in October 2024 and finalize the review by March 2025. Conclusions: The systematic review and meta-analysis will provide evidence on the protective role of self-compassion in resilience under adversity. Our investigation into potential moderators will highlight the contexts and groups where the benefits of self-compassion can be maximized. The findings are expected to provide valuable insights for health care professionals and stakeholders, informing the development of interventions aimed at enhancing resilience by fostering self-compassion. Trial Registration: PROSPERO CRD42024534390; https://tinyurl.com/3j3rmcja International Registered Report Identifier (IRRID): PRR1-10.2196/60154 UR - https://www.researchprotocols.org/2024/1/e60154 UR - http://dx.doi.org/10.2196/60154 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60154 ER - TY - JOUR AU - Lindsay, B. Julia A. AU - McGowan, M. Niall AU - Henning, Thomas AU - Harriss, Eli AU - Saunders, A. Kate E. PY - 2024/11/29 TI - Digital Interventions for Symptoms of Borderline Personality Disorder: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e54941 VL - 26 KW - borderline personality disorder KW - BPD KW - digital intervention KW - digital health KW - digital therapeutics KW - persuasive system design KW - systematic review KW - meta-analysis KW - suicidal ideation KW - paranoia KW - single symptom KW - mental health KW - behavior change KW - treatment KW - effectiveness KW - symptom KW - suicide KW - mobile phone N2 - Background: Borderline personality disorder (BPD) is a mental health condition with insufficient care availability worldwide. Digital mental health interventions could reduce this treatment gap. Persuasive system design (PSD) is a conceptual framework outlining elements of digital interventions that support behavior change. Objective: This systematic review aims to characterize digital interventions targeting BPD symptoms, assess treatment efficacy, and identify its association with intervention features, including PSD elements. Methods: A systematic review of automated digital interventions targeting symptoms of BPD was conducted. Eligible studies recruited participants aged ?18 years, based on a diagnosis of BPD or one of its common comorbidities, or as healthy volunteers. OVID Embase, OVID MEDLINE, OVID PsycINFO, and the Cochrane Central Register for Controlled Trials were searched on July 19, 2022, and February 28, 2023. Intervention characteristics were tabulated. A meta-analysis of randomized controlled trials (RCTs) determined treatment effects separately for each core symptom of BPD using Hedges g. Associations between the treatment effect and intervention features, including PSD elements, were assessed by subgroup analysis (Cochran Q test). Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for RCTs and the National Institutes of Health Quality Assessment Tool for pre-post studies. Results: A total of 40 (0.47%) publications out of 8520 met the inclusion criteria of this review, representing 6611 participants. Studies comprised examinations of 38 unique interventions, of which 32 (84%) were RCTs. Synthesis found that included interventions had the following transdiagnostic treatment targets: severity of BPD symptoms (4/38, 11%), suicidal ideation (17/38, 45%), paranoia (5/38, 13%), nonsuicidal self-injury (5/38, 13%), emotion regulation (4/38, 11%), and anger (3/38, 8%). Common therapeutic approaches were based on dialectical behavioral therapy (8/38, 21%), cognitive behavioral therapy (6/38, 16%), or both (5/38, 13%). Meta-analysis found significant effects of digital intervention for both symptoms of paranoia (Hedges g=?0.52, 95% CI ?0.86 to ?0.18; P=.01) and suicidal ideation (Hedges g=?0.13, 95% CI ?0.25 to ?0.01; P=.03) but not overall BPD symptom severity (Hedges g=?0.17, 95% CI ?0.42 to 0.10; P=.72). Subgroup analysis of suicidal ideation interventions found that evidence-based treatments such as cognitive behavioral therapy and dialectical behavior therapy were significantly more effective than alternative modalities (Cochran Q=4.87; P=.03). The degree of human support was not associated with the treatment effect. Interventions targeting suicidal ideation that used reminders, offered self-monitoring, and encouraged users to rehearse behaviors were associated with a greater reduction in ideation severity. Conclusions: Evidence suggests that digital interventions may reduce the symptoms of suicidal ideation and paranoia and that the design of digital interventions may impact the efficacy of treatments targeting suicidal ideation. These results support the use of transdiagnostic digital interventions for paranoia and suicidal ideation. Trial Registration: PROSPERO CRD42022358270; https://tinyurl.com/3mz7uc7k UR - https://www.jmir.org/2024/1/e54941 UR - http://dx.doi.org/10.2196/54941 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54941 ER - TY - JOUR AU - Gotti, Giulia AU - Gabelli, Chiara AU - Russotto, Sophia AU - Madeddu, Fabio AU - Courtet, Philippe AU - Lopez-Castroman, Jorge AU - Zeppegno, Patrizia AU - Gramaglia, Maria Carla AU - Calati, Raffaella PY - 2024/11/29 TI - Biomarkers of Response to Internet-Based Psychological Interventions: Systematic Review JO - J Med Internet Res SP - e55736 VL - 26 KW - biomarker KW - cognitive behavioral therapy KW - internet-based intervention KW - systematic review KW - psychological intervention KW - mental health intervention KW - meta analysis KW - psychiatric KW - blood glucose KW - mindfulness KW - stress management KW - immune response KW - smoking KW - cortisol N2 - Background: Internet-based psychological interventions provide accessible care to a wide range of users, overcoming some obstacles?such as distance, costs, and safety?that might discourage seeking help for mental issues. It is well known that psychological treatments and programs affect the body, as well as the mind, producing physiological changes that ought to be considered when assessing the efficacy of the intervention. However, the literature investigating changes in biomarkers specifically after internet-based psychological and mental health interventions has not yet extensively inquired into this topic. Objective: This systematic review aims to provide a synthesis of literature examining the effects of internet-based psychological interventions?targeting both clinical (mental and physical) and nonclinical conditions?on biomarkers. A secondary aim was to evaluate whether the biomarkers? variations were related to a complementary modification of the psychological or physical symptoms or to a general improvement of the participants? well-being. Methods: This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. A literature search was performed through 3 databases (PubMed, PsycINFO, and Scopus). Studies examining changes in biomarkers before and after internet-based psychological interventions or programs targeting both clinical and nonclinical samples were included, with no exclusion criteria concerning mental or physical conditions. Results: A total of 24 studies fulfilled the inclusion criteria. These studies involved individuals with psychiatric or psychological problems (n=6, 25%), those with organic or medical diseases (n=10, 42%), and nonclinical populations (n=8, 33%). Concerning psychiatric or psychological problems, cognitive behavioral therapy (CBT) and CBT-informed interventions showed partial effectiveness in decreasing glycated hemoglobin blood glucose level (n=1) and chemokines (n=1) and in increasing connectivity between the default-mode network and the premotor or dorsolateral prefrontal cortex (n=1). Among individuals with organic or medical diseases, studies reported a significant change in cardiac or cardiovascular (n=3), inflammatory (n=2), cortisol (n=2), glycated hemoglobin (n=2), and immune response (n=1) biomarkers after CBT and CBT-informed interventions, and mindfulness and stress management interventions. Lastly, mindfulness, CBT and CBT-informed interventions, and music therapy succeeded in modifying immune response (n=2), cortisol (n=1), ? amylase (n=1), posterior cingulate cortex reactivity to smoking cues (n=1), and carbon monoxide (n=1) levels in nonclinical populations. In some of the included studies (n=5), the psychological intervention or program also produced an improvement of the mental or physical condition of the participants or of their general well-being, alongside significant variations in biomarkers; CBT and CBT-informed interventions proved effective in reducing both psychological (n=2) and physical symptoms (n=2), while a mindfulness program successfully lowered cigarette consumption in a nonclinical sample (n=1). Conclusions: Although further evidence is required, we hope to raise awareness on the potential impact of internet-based interventions on biomarkers related to mental and physical health. UR - https://www.jmir.org/2024/1/e55736 UR - http://dx.doi.org/10.2196/55736 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55736 ER - TY - JOUR AU - Davenport, Rebekah AU - Bevens, William AU - Neate, Sandra AU - Jelinek, Pia AU - Yu, Maggie AU - Jelinek, George AU - Reece, Jeanette PY - 2024/11/29 TI - Perceptions of Illness Control, Coherence, and Self-Efficacy Following a Web-Based Lifestyle Program for Multiple Sclerosis: A Qualitative Analysis of Semistructured Interviews JO - J Med Internet Res SP - e60240 VL - 26 KW - illness perceptions KW - personal control perceptions KW - illness coherence KW - self-efficacy KW - lifestyle modification KW - disease management KW - multiple sclerosis KW - MS KW - qualitative KW - health behavior KW - thematic analysis N2 - Background: Evidence suggests that illness perceptions held by people living with multiple sclerosis (MS) impact affective distress and physical health outcomes. In a randomized controlled trial, we developed 2 MS Online Courses?the standard care course and the intervention course (IC). The IC was adapted from an evidence-based lifestyle program. Modifying lifestyle risk factors offers an opportunity to impact illness perceptions. Research on illness perceptions in people living with MS has focused predominately on quantitative methods. Objective: This study aimed to explore the experiences and health outcomes of randomized controlled trial participants, including individuals? perceived changes in attitudes toward MS and their health (ie, illness perceptions). Methods: Qualitative responses provided by 38 participants (22 in the IC and 16 in the standard care course) were derived from semistructured interviews 1 month after completing the MS Online Course. The impact of course engagement and lifestyle modification on illness perceptions was explored using inductive thematic analysis. Results: Themes of changes in illness perceptions were most prominent in the IC arm. Qualitative responses from 22 people living with MS informed the development of three themes: ?self-efficacy for disease management,? ?personal control,? and ?illness coherence.? Conclusions: Findings provide novel insights into the formation and modification of illness perceptions. Lifestyle modification may serve as a valuable adjunct to clinician-administered therapies, improving the sense of personal control over MS, illness coherence, and self-efficacy for disease management. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12621001605886; https://tinyurl.com/2vyve9p9 International Registered Report Identifier (IRRID): RR2-10.1186/s12883-023-03298-0 UR - https://www.jmir.org/2024/1/e60240 UR - http://dx.doi.org/10.2196/60240 UR - http://www.ncbi.nlm.nih.gov/pubmed/39612211 ID - info:doi/10.2196/60240 ER - TY - JOUR AU - Bi, Siyuan AU - Yuan, Junfeng AU - Wang, Yanling AU - Zhang, Wenxin AU - Zhang, Luqin AU - Zhang, Yongjuan AU - Zhu, Rui AU - Luo, Lin PY - 2024/11/20 TI - Effectiveness of Digital Health Interventions in Promoting Physical Activity Among College Students: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e51714 VL - 26 KW - digital health intervention KW - college students KW - physical activity behavior KW - steps KW - light intensity physical activity KW - moderate to vigorous physical activity KW - sedentary behavior KW - knowledge synthesis KW - systematic review KW - meta-analysis KW - physical activity KW - eHealth KW - digital health KW - mobile phone N2 - Background: Recent studies offer conflicting conclusions about the effectiveness of digital health interventions in changing physical activity behaviors. In addition, research focusing on digital health interventions for college students remains relatively scarce. Objective: This study aims to examine the impact of digital health interventions on physical activity behaviors among college students, using objective measures as outcome indicators. Methods: In accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a comprehensive literature search was conducted across several databases, including MEDLINE (PubMed), Web of Science, Cochrane Library, and EBSCO (CINAHL Plus with full text), to identify relevant intervention studies published up to June 6, 2023. The inclusion criteria specified studies that examined the quantitative relationships between digital health interventions and physical activity among adults aged 18 years to 29 years, focusing on light physical activity (LPA), moderate to vigorous physical activity (MVPA), sedentary time (ST), or steps. Non?randomized controlled trials were excluded. The quality of the studies was assessed using the Cochrane Risk of Bias tool. Results were synthesized both narratively and quantitatively, where applicable. When sufficient homogeneity was found among studies, a random-effects model was used for meta-analysis to account for variability. Results: In total, 8 studies, encompassing 569 participants, were included in the analysis. The primary outcomes measured were LPA, MVPA, ST, and steps. Among these studies, 3 reported on LPA, 5 on MVPA, 5 on ST, and 3 on steps. The meta-analysis revealed a significant increase in steps for the intervention group compared with the control group (standardized mean difference [SMD] 0.64, 95% CI 0.37-0.92; P<.001). However, no significant differences were observed between the intervention and control groups regarding LPA (SMD ?0.08, 95% CI ?0.32 to 0.16; P=.51), MVPA (SMD 0.02, 95% CI ?0.19 to 0.22; P=.88), and ST (SMD 0.03, 95% CI ?0.18 to 0.24; P=.78). Conclusions: Digital health interventions are effective in increasing steps among college students; however, their effects on LPA, MVPA, and sedentary behavior are limited. Trial Registration: PROSPERO CRD42024533180; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=533180 UR - https://www.jmir.org/2024/1/e51714 UR - http://dx.doi.org/10.2196/51714 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/51714 ER - TY - JOUR AU - Chen, Runnan AU - Fu, Xiaorong AU - Liu, Mochi AU - Liao, Ke AU - Bai, Lifei PY - 2024/11/19 TI - Online Depression Communities as a Complementary Approach to Improving the Attitudes of Patients With Depression Toward Medication Adherence: Cross-Sectional Survey Study JO - J Med Internet Res SP - e56166 VL - 26 KW - online depression communities KW - attitudes KW - institution-generated content KW - user-generated content KW - perceived social support KW - antidepressants KW - hopelessness KW - cross-sectional study KW - China KW - health care system KW - online health community KW - depression KW - medication adherence KW - social support KW - health care practitioner KW - peer support N2 - Background: Lack of adherence to prescribed medication is common among patients with depression in China, posing serious challenges to the health care system. Online health communities have been found to be effective in enhancing patient compliance. However, empirical evidence supporting this effect in the context of depression treatment is absent, and the influence of online health community content on patients? attitudes toward medication adherence is also underexplored. Objective: This study aims to explore whether online depression communities (ODCs) can help ameliorate the problem of poor medication taking among patients with depression. Drawing on the stimulus-organism-response and feelings-as-information theories, we established a research model to examine the influence of useful institution-generated content (IGC) and positive user-generated content (UGC) on attitudes toward medication adherence when combined with the mediating role of perceived social support, perceived value of antidepressants, and the moderating role of hopelessness. Methods: A cross-sectional questionnaire survey method was used in this research. Participants were recruited from various Chinese ODCs, generating data for a main study and 2 robustness checks. Hierarchical multiple regression analyses and bootstrapping analyses were adopted as the primary methods to test the hypotheses. Results: We received 1515 valid responses in total, contributing to 5 different datasets: model IGC (n=353, 23.3%), model UGC (n=358, 23.63%), model IGC+UGC (n=270, 17.82%), model IGC-B (n=266, 17.56%), and model UGC-B (n=268, 17.69%). Models IGC and UGC were used for the main study. Model IGC+UGC was used for robustness check A. Models IGC-B and UGC-B were used for robustness check B. Useful IGC and positive UGC were proven to have positive impact on the attitudes of patients with depression toward medication adherence through the mediations of perceived social support and perceived value of antidepressants. The findings corroborated the role of hopelessness in weakening or even negating the positive effects of ODC content on the attitudes of patients with depression toward medication adherence. Conclusions: This study provides the first empirical evidence demonstrating the relationship between ODC content and attitudes toward medication adherence, through which we offer a novel solution to the problem of poor medication adherence among patients with depression in China. Our findings also provide suggestions about how to optimize this new approach?health care practitioners should generate online content that precisely matches the informational needs of patients with depression, and ODC service providers should endeavor to regulate the community atmosphere. Nonetheless, we warn that ODC interventions cannot be used as the only approach to addressing the problem of poor medication taking among patients with severe depressive symptoms. UR - https://www.jmir.org/2024/1/e56166 UR - http://dx.doi.org/10.2196/56166 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56166 ER - TY - JOUR AU - Liu, Jianyi AU - Giannone, Alyssa AU - Wang, Hailing AU - Wetherall, Lucy AU - Juarascio, Adrienne PY - 2024/11/18 TI - Understanding Patients? Preferences for a Digital Intervention to Prevent Posttreatment Deterioration for Bulimia-Spectrum Eating Disorders: User-Centered Design Study JO - JMIR Form Res SP - e60865 VL - 8 KW - bulimia nervosa KW - binge eating KW - digital intervention KW - deterioration prevention KW - eating disorder KW - bulimia KW - digital health KW - deterioration KW - maintenance KW - mHealth KW - mobile health app KW - interviews KW - qualitative KW - user-centered design KW - psychotherapy KW - CBT KW - cognitive behavioral therapy KW - needs KW - preferences KW - mobile phone N2 - Background: Deterioration rates after enhanced cognitive behavioral therapy (CBT-E) for patients with bulimia-spectrum eating disorders (BN-EDs) remain high, and decreased posttreatment skill use might be a particularly relevant contributor. Digital interventions could be an ideal option to improve skill use after treatment ends but they have yet to be investigated for BN-EDs. Objective: This study used a user-centered design approach to explore patients? interest in a digital intervention to prevent deterioration after CBT-E and their desired features. Methods: A total of 12 participants who previously received CBT-E for BN-EDs and experienced at least a partial response to treatment completed a qualitative interview asking about their interests and needs for an app designed to prevent deterioration after treatment ended. Participants were also presented with features commonly used in digital interventions for EDs and were asked to provide feedback. Results: All 12 participants expressed interest in using an app to prevent deterioration after treatment ended. In total, 11 participants thought the proposed feature of setting a goal focusing on skill use weekly would help improve self-accountability for skill use, and 6 participants supported the idea of setting goals related to specific triggers because they would know what skills to use in high-risk situations. A total of 10 participants supported the self-monitoring ED behaviors feature because it could increase their awareness levels. Participants also reported wanting to track mood (n=6) and food intake (n=5) besides the proposed tracking feature. A total of 10 participants reported wanting knowledge-based content in the app, including instructions on skill practice (n=6), general mental health strategies outside of EDs (n=4), guided mindfulness exercises (n=3), and nutrition recommendations (n=3). Eight participants reported a desire for the app to send targeted push notifications, including reminders of skill use (n=7) and inspirational quotes for encouragement (n=3). Finally, 8 participants reported wanting a human connection in the app, 6 participants wishing to interact with other users to support and learn from each other, and 4 participants wanting to connect with professionals as needed. Overall, participants thought that having an app targeting skill use could provide continued support and improve self-accountability, thus lowering the risk of decreased skill use after treatment ended. Conclusions: Insights from participants highlighted the perceived importance of continued support for continued skill use after treatment ended. This study also provided valuable design implications regarding potential features focusing on facilitating posttreatment skill use to include in digital deterioration prevention programs. Future research should examine the optimal approaches to deliver the core features identified in this study that could lead to higher continued skill use and a lower risk of deterioration in the long term. UR - https://formative.jmir.org/2024/1/e60865 UR - http://dx.doi.org/10.2196/60865 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60865 ER - TY - JOUR AU - Shojaei, Fereshtehossadat AU - Shojaei, Fatemehalsadat AU - Desai, P. Archita AU - Long, Emily AU - Mehta, Jade AU - Fowler, R. Nicole AU - Holden, J. Richard AU - Orman, S. Eric AU - Boustani, Malaz PY - 2024/11/13 TI - The Feasibility of AgileNudge+ Software to Facilitate Positive Behavioral Change: Mixed Methods Design JO - JMIR Form Res SP - e57390 VL - 8 KW - AgileNudge+ KW - agile KW - nudge strategy KW - nudging interventions KW - agile implementation KW - human behavior KW - software design KW - human-computer interaction KW - user experience design KW - usability testing N2 - Background: In today?s digital age, web-based apps have become integral to daily life, driving transformative shifts in human behavior. ?AgileNudge+? (Indiana University Center for Health Innovation and Implementation Science) is a web-based solution to simplify the process of positive behavior change using nudging as an intervention. By integrating knowledge from behavioral economics with technology, AgileNudge+ organizes multiple steps, simplifies complex tasks, minimizes errors by enhancing user engagement, and provides resources for creating and testing nudge interventions. Objective: This paper aimed to outline the design process, methodologies, and usefulness of ?AgileNudge+? for the development of evidence-based nudges. It used a mixed methods approach to evaluate the software?s interface usability and usefulness for creating and testing nudge interventions. Methods: AgileNudge+ was developed through iterative processes integrating principles from behavioral economics and user-centered design. The content of AgileNudge+ operationalizes an Agile science?based process to efficiently design, embed, and disseminate evidence-based nudges that encourage positive behavior change without limiting choice. Using a mixed methods approach, we tested AgileNudge+ software?s ability to organize and simplify the nudge intervention process, allowing a diverse range of scholars with limited knowledge of Agile science to use nudges. Usability testing assessed the tool?s usefulness and interface with a sample of 18 health care professionals, each asked to interact with the software and create a nudge intervention to solve a problem within their professional project?s sphere. Results: The study was funded in August 2022, with data collection occurring from June 2023 to July 2024. As of July 2024, we have enrolled 18 participants. Quantitative results found a mean usefulness rating of AgileNudge+ of 3.83 (95% CI 3.00-4.66). Qualitative results highlighted ways to modify the language used in AgileNudge+ to be more comprehensible to a diverse user base and promoted modifications to the software that facilitate real-time assistance and prioritize time efficiency in user interactions. Feedback further supported the positive impact of gamification on participant motivation when using the software. Conclusions: AgileNudge+ is an effective assistive tool for simplifying the positive behavior change process using nudge interventions, with tailored content and interactions to meet users? needs and demands. Building onto the current design, future iterations of AgileNudge+ will use artificial intelligence to process large volumes of data while reducing the time and mental energy required to scan for existing cognitive biases and nudge prototypes. The software is also being upgraded to build on current gamification efforts, encouraging more sustained motivation by increasing the temporal resolution of the digital interface. These modifications stay true to the agility and user-centered aspects of AgileNudge+, emphasizing the novelty of the constantly evolving software design process. UR - https://formative.jmir.org/2024/1/e57390 UR - http://dx.doi.org/10.2196/57390 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57390 ER - TY - JOUR AU - Naicker, Sundresan AU - Tariq, Amina AU - Donovan, Raelene AU - Magon, Honor AU - White, Nicole AU - Simmons, Joshua AU - McPhail, M. Steven PY - 2024/11/8 TI - Patterns and Perceptions of Standard Order Set Use Among Physicians Working Within a Multihospital System: Mixed Methods Study JO - JMIR Form Res SP - e54022 VL - 8 KW - medical informatics KW - adoption and implementation KW - behavior KW - health systems KW - testing KW - electronic medical records KW - behavioral model KW - quantitative data KW - semistructured interview KW - clinical practice KW - user preference KW - user KW - user experience N2 - Background: Electronic standard order sets automate the ordering of specific treatment, testing, and investigative protocols by physicians. These tools may help reduce unwarranted clinical variation and improve health care efficiency. Despite their routine implementation within electronic medical records (EMRs), little is understood about how they are used and what factors influence their adoption in practice. Objective: This study aims to (1) describe the patterns of use of standard order sets implemented in a widely used EMR (PowerPlans and Cerner Millennium) within a multihospital digital health care system; (2) explore the experiences and perceptions of implementers and users regarding the factors contributing to the use of these standard order sets; and (3) map these findings to the Capability, Opportunity, and Motivation Behavior (COM-B) model of behavior change to assist those planning to develop, improve, implement, and iterate the use of standard order sets in hospital settings. Methods: Quantitative data on standard order set usage were captured from 5 hospitals over 5-month intervals for 3 years (2019, 2020, and 2021). Qualitative data, comprising unstructured and semistructured interviews (n=15), were collected and analyzed using a reflexive thematic approach. Interview themes were then mapped to a theory-informed model of behavior change (COM-B) to identify determinants of standard order set usage in routine clinical practice. The COM-B model is an evidence-based, multicomponent framework that posits that human actions result from multiple contextual influences, which can be categorized across 3 dimensions: capability, opportunity, and motivation, all of which intersect. Results: The total count of standard order set usage across the health system during the 2019 observation period was 267,253, increasing to 293,950 in 2020 and 335,066 in 2021. There was a notable shift toward using specialty order sets that received upgrades during the study period. Four emergent themes related to order set use were derived from clinician interviews: (1) Knowledge and Skills; (2) Perceptions; (3) Technical Dependencies; and (4) Unintended Consequences, all of which were mapped to the COM-B model. Findings indicate a user preference for customized order sets that respond to local context and user experience. Conclusions: The study findings suggest that ongoing investment in the development and functionality of specialty order sets has the potential to enhance usage as these sets continue to be customized in response to local context and user experience. Sustained and continuous uptake of appropriate Computerized Provider Order Entry use may require implementation strategies that address the capability, opportunity, and motivational influencers of behavior. UR - https://formative.jmir.org/2024/1/e54022 UR - http://dx.doi.org/10.2196/54022 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54022 ER - TY - JOUR AU - Yatziv, Shai-Lee AU - Pedrelli, Paola AU - Baror, Shira AU - DeCaro, Ann Sydney AU - Shachar, Noam AU - Sofer, Bar AU - Hull, Sunday AU - Curtiss, Joshua AU - Bar, Moshe PY - 2024/11/7 TI - Facilitating Thought Progression to Reduce Depressive Symptoms: Randomized Controlled Trial JO - J Med Internet Res SP - e56201 VL - 26 KW - depression KW - cognitive neuroscience KW - facilitating thought progression KW - FTP KW - mobile phone KW - digital health KW - gamification KW - depression symptoms KW - randomized controlled trial KW - RCT KW - app KW - depressive disorder KW - web-based platforms KW - effectiveness N2 - Background: The constant rise in the prevalence of major depressive disorder calls for new, effective, and accessible interventions that can rapidly and effectively reach a wide range of audiences. Recent developments in the digital health domain suggest that dedicated online platforms may potentially address this gap. Focusing on targeting ruminative thought, a major symptomatic hallmark of depression, in this study we hypothesized that delivering a digital health?based intervention designed to systematically facilitate thought progression would substantially alleviate depression. Objective: The study aims to investigate the efficacy of a novel digital intervention on the reduction of depressive symptoms. This intervention was designed as an easy-to-use gamified app specifically aimed to facilitate thought progression through intense practicing of associative, semantically broad, fast, and creative thought patterns. Methods: A randomized clinical trial was conducted, comparing changes in depression symptoms between participants who used the app in the intervention group (n=74) and waitlist control group (n=27) over the course of 8 weeks. All participants filled out a battery of clinical questionnaires to assess the severity of depression at baseline and 4 and 8 weeks after starting the study. These primarily included the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Patient Health Questionnaire-9 as well as the Positive Affect Negative Affect Scale-Negative Affect Score, Ruminative Response Scale, and Symptoms of Depression Questionnaire. Additional questionnaires were implemented to assess anxiety, positive affect, anhedonia, and quality of life. Results: The results indicate that across multiple clinical measurements, participants in the intervention group who played the gamified app showed greater and faster improvement in depressive symptoms compared with their waitlist control counterparts. The difference between the groups in MADRS improvement was ?7.01 points (95% CI ?10.72 to ?3.29; P<.001; Cohen d=0.67). Furthermore, the difference in improvement between groups persisted up to 4 weeks posttrial (MADRS differences at week 12: F49,2=6.62; P=.003; ?p2=0.21). At the end of the trial, participants who played the app showed high interest in continuing using the app. Conclusions: The results demonstrate that a gamified app designed to facilitate thought progression is associated with improvement in depressive symptoms. Given its innovative and accessibility features, this gamified method aiming to facilitate thought progression may successfully complement traditional treatments for depression in the future, providing a safe and impactful way to enhance the lives of individuals experiencing depression and anxiety. Trial Registration: ClinicalTrials.gov NCT05685758; https://clinicaltrials.gov/study/NCT05685758 UR - https://www.jmir.org/2024/1/e56201 UR - http://dx.doi.org/10.2196/56201 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56201 ER - TY - JOUR AU - Khalil, Georges AU - Ramirez, Erica AU - Khan, Meerah AU - Zhao, Bairu AU - Ribeiro, Nuno AU - Balian, Patrick PY - 2024/11/5 TI - Risk Perception and Knowledge Following a Social Game?Based Tobacco Prevention Program for Adolescents: Pilot Randomized Comparative Trial JO - JMIR Serious Games SP - e63296 VL - 12 KW - tobacco prevention KW - vaping KW - combustible tobacco KW - risk perception KW - adolescent KW - games KW - social interaction N2 - Background: Adolescence is a critical developmental stage that is particularly vulnerable to the initiation of tobacco use. Despite the well-documented health risks associated with tobacco use, it remains prevalent among adolescents. Games for health are a promising strategy for tobacco prevention, using experiential and social learning theories to enhance engagement and improve behavior change. Objective: This pilot study aims to (1) compare the social game?based program Storm-Heroes to a nonsocial program regarding adolescents? personal and social experiences and (2) examine how these experiences predict higher tobacco knowledge and perceived risks of vaping and conventional tobacco use. Methods: In a cluster-randomized comparative design, 4 after-school sites (N=79 adolescents) were recruited in person and randomized in a single-blinded format to 1 of 2 interventions: the social game Storm-Heroes (44/79, 56%) or the nonsocial program A Smoking Prevention Interactive Experience (ASPIRE; 35/79, 44%). A study team member supervised both interventions. Data were collected at baseline, immediate follow-up, and a 1.5-month follow-up (45/74, 61% retained). Repeated measures mixed effects models were conducted. Results: A total of 45 participants continued until the 1.5-month follow-up. Participants in the Strom-Heroes group were more likely to increase their perceived risk of vaping (B=0.40; P<.001), perceived risk of conventional tobacco use (B=0.35; P=.046), and tobacco knowledge (B=1.63; P<.001) than those in the control condition. The usability level of the program was related to a higher perceived risk of vaping (B=0.16; P=.003) and conventional tobacco use (B=0.16; P=.02) by follow-up. Attention to the program was also related to higher perceived risk of vaping (B=0.12; P=.002) and conventional tobacco use (B=0.14; P<.001). Distraction was not related to either perceived risk of vaping (P=.15) or perceived risk of conventional tobacco use (P=.71). In contrast, both more attention (B=0.60; P<.001) and less distraction (B=?0.37; P<.001) were related to higher tobacco knowledge. Conclusions: The increased perceived risk of vaping and conventional tobacco among Storm-Heroes participants aligns with the program?s goals of improving participants? awareness of the risks associated with tobacco use and their tobacco knowledge. However, distraction weakened the effect of the program on tobacco knowledge, indicating that emphasis needs to be placed on minimizing distraction for better outcomes. With the results of this study, researchers can work to advance the current version of Storm-Heroes and amplify engagement in the program to improve its potential for preventing adolescents? initiation of tobacco use. Trial Registration: ClinicalTrials.gov NCT02703597; https://clinicaltrials.gov/study/NCT02703597 UR - https://games.jmir.org/2024/1/e63296 UR - http://dx.doi.org/10.2196/63296 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63296 ER - TY - JOUR AU - Davis, Kevin AU - Curry, Laurel AU - Bradfield, Brian AU - Stupplebeen, A. David AU - Williams, J. Rebecca AU - Soria, Sandra AU - Lautsch, Julie PY - 2024/11/5 TI - The Validity of Impressions as a Media Dose Metric in a Tobacco Public Education Campaign Evaluation: Observational Study JO - J Med Internet Res SP - e55311 VL - 26 KW - communication KW - public education KW - tobacco KW - media KW - public health N2 - Background: Evaluation research increasingly needs alternatives to target or gross rating points to comprehensively measure total exposure to modern multichannel public education campaigns that use multiple channels, including TV, radio, digital video, and paid social media, among others. Ratings data typically only capture delivery of broadcast media (TV and radio) and excludes other channels. Studies are needed to validate objective cross-channel metrics such as impressions against self-reported exposure to campaign messages. Objective: This study aimed to examine whether higher a volume of total media campaign impressions is predictive of individual-level self-reported campaign exposure in California. Methods: We analyzed over 3 years of advertisement impressions from the California Tobacco Prevention Program?s statewide tobacco education campaigns from August 2019 through December 2022. Impressions data varied across designated market areas (DMAs) and across time. These data were merged to individual respondents from 45 waves of panel survey data of Californians aged 18-55 years (N=151,649). Impressions were merged to respondents based on respondents? DMAs and time of survey completion. We used logistic regression to estimate the odds of respondents? campaign recall as a function of cumulative and past 3-month impressions delivered to each respondent?s DMA. Results: Cumulative impressions were positively and significantly associated with recall of each of the Flavors Hook Kids (odds ratio [OR] 1.15, P<.001), Dark Balloons and Apartment (OR 1.20, P<.001), We Are Not Profit (OR 1.36, P<.001), Tell Your Story (E-cigarette, or Vaping, product use Associated Lung Injury; OR 1.06, P<.05), and Thrown Away and Little Big Lies (OR 1.05, P<.01) campaigns. Impressions delivered in the past 3 months were associated with recall of the Flavors Hook Kids (OR 1.13, P<.001), Dark Balloons and Apartment (OR 1.08, P<.001), We Are Not Profit (OR 1.14, P<.001), and Thrown Away and Little Big Lies (OR 1.04, P<.001) campaigns. Past 3-month impressions were not significantly associated with Tell Your Story campaign recall. Overall, magnitudes of these associations were greater for cumulative impressions. We visualize recall based on postestimation predicted values from our multivariate logistic regression models. Conclusions: Variation in cumulative impressions for California Tobacco Prevention Program?s long-term multichannel tobacco education campaign is predictive of increased self-reported campaign recall, suggesting that impressions may be a valid proxy for potential campaign exposure. The use of impressions for purposes of evaluating public education campaigns may help address current methodological limitations arising from the fragmented nature of modern multichannel media campaigns. UR - https://www.jmir.org/2024/1/e55311 UR - http://dx.doi.org/10.2196/55311 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55311 ER - TY - JOUR AU - Jiang, Shan AU - Ng, Y. Johan Y. AU - Choi, Ming Siu AU - Ha, S. Amy PY - 2024/11/4 TI - Relationships Among eHealth Literacy, Physical Literacy, and Physical Activity in Chinese University Students: Cross-Sectional Study JO - J Med Internet Res SP - e56386 VL - 26 KW - eHealth literacy KW - physical literacy KW - physical activity KW - university students KW - health behavior N2 - Background: eHealth literacy is critical for evaluating abilities in locating, accessing, and applying digital health information to enhance one?s understanding, skills, and attitudes toward a healthy lifestyle. Prior research indicates that enhancing eHealth literacy can improve health behaviors such as physical activity (PA). Physical literacy (PL) refers to the ability to develop sustainable PA habits, taking into account various aspects of an individual. Notably, university students have shown a decline in PA and possess low PL levels. However, the connection between eHealth literacy and PL in this demographic has not been extensively studied, and it remains uncertain whether PA acts as a mediator between eHealth literacy and PL. Objective: This study examines the extent to which PA mediates the link between eHealth literacy and PL in Chinese university students and explores gender differences in these variables. Methods: In February 2022, a cross-sectional survey was administered to 1210 students across 3 universities in China. The instruments used were the Perceived PL Instrument, the International Physical Activity Questionnaire, and the Chinese version of the eHealth Literacy Scale. Correlations between eHealth literacy, PA, and PL were analyzed using Pearson product-moment correlation and multiple linear regression, while mediation models helped elucidate the interactions among the 3 variables. Results: The response rate for the study was 92.9% (1124/1210). In the mediation analysis, eHealth literacy showed a significant direct effect on PL, with a coefficient of 0.78 (? .75, SE 0.02; P<.001). Moderate to vigorous physical activity (MVPA) accounted for 2.16% of the total effect, suggesting that MVPA partially mediates the relationship between eHealth literacy and PL. Additionally, male students outperformed female students in terms of MVPA (t636=4.94; P<.001) and PL (t636=3.18; P<.001), but no significant differences were found in eHealth literacy (t636=1.23; P=.22). Conclusions: The findings indicate that MVPA serves as a mediator in the link between eHealth literacy and PL among university students. Students with low eHealth literacy or limited PA are less likely to be physically literate. Thus, eHealth literacy plays a crucial role in enhancing PL and PA, especially when interventions targeting PL are implemented. Our results also suggest a need for targeted health education interventions aimed at improving MVPA and PL among female students, while also recognizing that eHealth literacy is comparable across genders at universities. UR - https://www.jmir.org/2024/1/e56386 UR - http://dx.doi.org/10.2196/56386 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56386 ER - TY - JOUR AU - Gentile, Alessandra AU - Kristian, Yan Yosua AU - Cini, Erica PY - 2024/11/4 TI - Effectiveness of Computer-Based Psychoeducational Self-Help Platforms for Eating Disorders (With or Without an Associated App): Protocol for a Systematic Review JO - JMIR Res Protoc SP - e60165 VL - 13 KW - self-help KW - online self-help KW - eating disorders KW - anorexia nervosa KW - psychoeducational intervention KW - psychoeducation KW - binge eating KW - anorexia KW - bulimia KW - access to care KW - patient education KW - patient self-help N2 - Background: Access to psychological health care is extremely difficult, especially for individuals with severely stigmatized disorders such as eating disorders (EDs). There has been an increase in children, adolescents, and adults with ED symptoms and ED, especially following the COVID-19 pandemic. Computer-based self-help platforms (± associated apps) allow people to bridge the treatment gap and receive support when in-person treatment is unavailable or not preferred. Objective: The aim of this systematic review is to evaluate the effectiveness of computer-based self-help platforms for EDs, some of which may have associated apps. Methods: The proposed systematic review will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. This review will report and evaluate the literature concerning the efficacy of self-help platforms for EDs. Articles were obtained from the Ovid MEDLINE, Embase, Global Health, and APA PsycInfo. The inclusion criteria included research with original data and gray literature; research evaluating the efficacy of web-based psychoeducational self-help platforms for EDs; people with an ED diagnosis, ED symptoms, at risk of developing EDs, or from the general population without ED-related behaviors; pre? and post?computer-based ± associated apps intervention clinical outcome of ED symptoms; pre? and post?computer-based ± associated apps intervention associated mental health difficulties; and literature in English. The exclusion criteria were solely guided self-help platforms, only in-person interventions with no computer-based ± associated apps comparison group, only in-person?delivered CBT, self-help platforms for conditions other than eating disorders, systematic reviews, meta-analyses, posters, leaflets, books, reviews, and research that only reported physical outcomes. Two independent authors used the search terms to conduct the initial search. The collated articles then were screened by their titles and abstracts, and finally, full-text screenings were conducted. The Cochrane Risk of Bias 2 tool will be used to assess the risks of bias in the included studies. Data extraction will be conducted, included studies will undergo narrative synthesis, and results will be presented in tables. The systematic review will be submitted to a peer-reviewed journal. Results: The authors conducted a database search for articles published by May 31, 2024. In total, 14 studies were included in the systematic review. Data charting, synthesis, and analysis were completed in Microsoft Excel by the end of July 2024. Results will be grouped based on the intervention stages. The results are expected to be published by the end of 2024. Overall, the systematic review found that computer-based self-help platforms are effective in reducing global ED psychopathology and ED-related behaviors. Conclusions: Self-help platforms are helpful first-stage resource in a tiered health care system. Trial Registration: PROSPERO CRD42024520866; https://tinyurl.com/5ys2unsw International Registered Report Identifier (IRRID): DERR1-10.2196/60165 UR - https://www.researchprotocols.org/2024/1/e60165 UR - http://dx.doi.org/10.2196/60165 UR - http://www.ncbi.nlm.nih.gov/pubmed/39495557 ID - info:doi/10.2196/60165 ER - TY - JOUR AU - Helms, Bernd Yannick AU - van der Meer, Akke AU - Crutzen, Rik AU - Ferreira, António José AU - Kretzschmar, E. Mirjam E. AU - Timen, Aura AU - Hamdiui, Nora AU - Stein, L. Mart PY - 2024/10/30 TI - Determinants of Citizens? Intention to Participate in Self-Led Contact Tracing: Cross-Sectional Online Questionnaire Study JO - JMIR Public Health Surveill SP - e56943 VL - 10 KW - contact tracing KW - telemedicine KW - health services research KW - intention KW - public health surveillance KW - machine learning KW - cross-sectional study KW - online questionnaire KW - disease outbreaks KW - task shifting N2 - Background: Contact tracing (CT) is a key intervention to contain outbreaks of communicable diseases. During large-scale outbreaks, public health services may lack the resources required to perform CT effectively. One way of mitigating this issue is to shift some of the tasks in CT normally performed by public health services to cases and their contacts, supported by digital tools. We refer to this as ?self-led CT.? However, while the effectiveness of the self-led CT inherently depends on the willingness and skills of citizens to participate, the determinants of citizens? intention to participate in self-led CT are not yet fully understood. Objective: We aimed to identify determinants of Dutch citizens? intention to participate in self-led CT and assess their potential for behavioral change, so as to identify ?behavior change targets,? which may be used in the development and implementation of self-led CT to increase citizens? intention to participate. Methods: In March 2022, we performed an online cross-sectional questionnaire study. The questionnaire was developed based on findings from a previous exploratory semistructured interview study and distributed among a Dutch consumer panel. Using all questionnaire items as potential predictors, we performed a random forest analysis to identify determinants of citizens? intention to participate in self-led CT. We then performed an Agglomerative Hierarchical Cluster Analysis to identify groups of related determinants that may be considered overarching behavior change targets. Finally, we used Confidence Interval-Based Estimation of Relevance and calculated the Potential for Change Indices to compare the potential for behavioral change of the selected individual determinants and determinant clusters. Results: The questionnaire was completed by 3019 respondents. Our sample is representative of the Dutch population in terms of age, gender, educational level, and area of residence. Out of 3019 respondents, 2295 (76%) had a positive intention to participate in self-led CT. We identified 20 determinants of citizens? intention that we grouped into 9 clusters. In general, increasing citizens? trust in the digital tools developed for self-led CT has the highest potential to increase citizens? intention, followed by increasing the belief that using digital tools makes participating in self-led CT easier, reducing privacy-related concerns, and increasing citizens? willingness?and sense of responsibility?to cooperate in CT in general. Conclusions: Overall, Dutch citizens are positive toward participating in self-led CT. Our results provide directions for the development and implementation of self-led CT, which may be particularly useful in preparing for future, large-scale outbreaks. UR - https://publichealth.jmir.org/2024/1/e56943 UR - http://dx.doi.org/10.2196/56943 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56943 ER - TY - JOUR AU - Howard-Wilson, Sakeina AU - Ching, Jack AU - Gentile, Sherri AU - Ho, Martin AU - Garcia, Alex AU - Ayturk, Didem AU - Lazar, Peter AU - Hammerquist, Nova AU - McManus, David AU - Barton, Bruce AU - Bird, Steven AU - Moore, John AU - Soni, Apurv PY - 2024/10/30 TI - Efficacy of a Multimodal Digital Behavior Change Intervention on Lifestyle Behavior, Cardiometabolic Biomarkers, and Medical Expenditure: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e50378 VL - 13 KW - health behavior KW - fitness KW - digital devices KW - lifestyle change KW - cardiovascular disease KW - chronic disease KW - physical activity KW - nutrition KW - sleep KW - mindfulness N2 - Background: The US Preventive Services Task Force recommends providers offer individualized healthy behavior interventions for all adults, independent of their risk of cardiovascular disease. While strong evidence exists to support disease-specific programs designed to improve multiple lifestyle behaviors, approaches to adapting these interventions for a broader population are not well established. Digital behavior change interventions (DBCIs) hold promise as a more generalizable and scalable approach to overcome the resource and time limitations that traditional behavioral intervention programs face, especially within an occupational setting. Objective: We aimed to evaluate the efficacy of a multimodal DBCI on (1) self-reported behaviors of physical activity, nutrition, sleep, and mindfulness; (2) cardiometabolic biomarkers; and (3) chronic disease?related medical expenditure. Methods: We conducted a 2-arm randomized controlled trial for 12 months among employees of an academic health care facility in the United States. The intervention arm received a scale, a smartphone app, an activity tracker, a video library for healthy behavior recommendations, and an on-demand health coach. The control arm received standard employer-provided health and wellness benefits. The primary outcomes of the study included changes in self-reported lifestyle behaviors, cardiometabolic biomarkers, and chronic disease?related medical expenditure. We collected health behavior data via baseline and quarterly web-based surveys, biometric measures via clinic visits at baseline and 12 months, and identified relevant costs through claims datasets. Results: A total of 603 participants were enrolled and randomized to the intervention (n=300, 49.8%) and control arms (n=303, 50.2%). The average age was 46.7 (SD 11.2) years, and the majority of participants were female (80.3%, n=484), White (85.4%, n=504), and non-Hispanic (90.7%, n=547), with no systematic differences in baseline characteristics observed between the study arms. We observed retention rates of 86.1% (n=519) for completing the final survey and 77.9% (n=490) for attending the exit visit. Conclusions: This study represents the largest and most comprehensive evaluation of DBCIs among participants who were not selected based on their underlying condition to assess its impact on behavior, cardiometabolic biomarkers, and medical expenditure. Trial Registration: ClinicalTrials.gov NCT04712383; https://clinicaltrials.gov/study/NCT04712383 International Registered Report Identifier (IRRID): RR1-10.2196/50378 UR - https://www.researchprotocols.org/2024/1/e50378 UR - http://dx.doi.org/10.2196/50378 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50378 ER - TY - JOUR AU - Zhou, Shuo AU - Brunetta, Paul AU - Silvasstar, Joshva AU - Feldman, Greg AU - Oromi, Nicolas AU - Bull, Sheana PY - 2024/10/29 TI - Initial Evaluation of Acceptability, Engagement, and Effectiveness of the MO App to Provide Tailored and Comprehensive Support for Smoking Cessation: Development and Usability Study JO - JMIR Mhealth Uhealth SP - e55239 VL - 12 KW - smoking cessation KW - tobacco KW - mobile phone app KW - mHealth KW - mobile health KW - iterative design KW - feasibility KW - acceptability KW - engagement KW - efficacy KW - mobile phone N2 - Background: Despite the growing availability of smoking cessation apps, low engagement and cessation rates have remained a significant challenge. To address this issue, we used a user-centered design to iteratively develop a mobile app (MO) to provide comprehensive, tailored, and evidence-based content to support smokers in their quitting journey. Objective: This study examined the acceptability, use, and preliminary efficacy of the MO app for smoking cessation. Specifically, we sought to understand smokers? preferred features, engagement, and satisfaction with MO; identify concerns in using the app and ways to improve the app; and evaluate its smoking cessation outcomes. Methods: Through 3 cohorts, we recruited 10, 12, and 85 adult smokers who attempted to quit smoking to pilot-test the MO app between December 2019 and July 2022. Participants were instructed to complete a baseline survey, interact with the app for 6 weeks, and fill in a postsurvey at week 6. Participants in cohort 3 completed an additional postsurvey at week 12. Participants? app use was tracked and analyzed. The primary outcome measures were participants? 7-day point prevalence abstinence at 6 and 12 weeks. Results: Participants reported high levels of satisfaction with the MO app across all 3 cohorts, rating it between 4.40 and 4.76 on a scale of 5 for acceptability. Users engaged with app activities for an average of 89 to 159 times over 35 days. The most liked features of the app included ?quit plan,? ?tracking,? ?reminders and notifications,? ?MOtalks,? and ?motivational quotes.? The 7-day point prevalence abstinence rate of the modified intention to treat population in cohort 3 was 58% at 6 weeks and 52% at 12 weeks. Those who interacted more frequently with app features and engaged with more diverse activities were more likely to maintain abstinence at weeks 6 and 12. For each additional time logged into the app, the odds of staying abstinent at week 12 increased by 5% (odds ratio [OR] 1.05, 95% CI 1.01-1.08). Participants who earned >5000 points during app use also had higher odds of quitting at both 6 weeks (OR 3.12, 95% CI 1.25-7.75) and 12 weeks (OR 4.65, 95% CI 1.83-11.76), compared with those who earned <5000 points. Conclusions: Our study demonstrated that MO is a feasible mobile phone app with high acceptability and usability and can effectively deliver smoking cessation support to individuals who want to quit. Implications for developing and evaluating mobile phone apps for smoking cessation are discussed. UR - https://mhealth.jmir.org/2024/1/e55239 UR - http://dx.doi.org/10.2196/55239 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55239 ER - TY - JOUR AU - Hayashi, Kosuke AU - Imai, Hiromitsu AU - Oikawa, Ichiro AU - Ishihara, Yugo AU - Wakuda, Hirokazu AU - Miura, Iori AU - Uenohara, Shingo AU - Kuwae, Asuka AU - Kai, Megumi AU - Furuya, Ken'ichi AU - Uemura, Naoto PY - 2024/10/24 TI - Cadence-Based Pedometer App With Financial Incentives to Enhance Moderate-to-Vigorous Physical Activity: Development and Single-Arm Feasibility Study JO - JMIR Form Res SP - e56376 VL - 8 KW - physical activity KW - behavioral economics KW - pedometer KW - arm KW - cadence KW - app KW - public health KW - walk KW - Google Fit KW - heart points KW - exercise KW - mobile phone N2 - Background: High levels of physical activity are key to improving health outcomes, yet many people fail to take action. Using pedometers to target steps per day and providing financial incentives is a simple and scalable approach to promoting public health. However, conventional pedometers do not account for ?intensity? and ?duration,? making it challenging to efficiently increase people?s moderate-to-vigorous physical activity (MVPA), which is expected to improve health outcomes. Based on these rationales, we developed a smartphone app that sets step cadence as a goal (defined as a daily challenge of walking more than 1500 steps in 15 minutes twice a day, which is a heuristic threshold for moderate physical activity) and provides financial incentive when the challenge is met. Objective: This study aimed to evaluate the feasibility of our novel app and explore whether its use can increase users? daily MVPA. Methods: A single-arm pre-post study evaluated the feasibility and efficacy of the app. A total of 15 participants used app 1 (an app without financial incentives) for the first period (4 weeks) and then switched to app 2 (an app with financial incentives) for the second period (4 weeks). The primary outcome was the difference between the first and second periods in the number of successful challenge attempts per week. Secondary outcomes were differences between the first and second periods in daily steps and distance walked. Exploratory outcomes included the difference between the first and second periods in daily ?heart points? as measured by Google Fit, a publicly available app that measures users? daily MVPA. Results: The number of successful challenge attempts per week increased significantly compared to the first period (5.6 times per week vs 0.7 times per week; P<.001). Although not statistically significant, there was a trend toward an increase in the mean steps per day and distance walked per day (6586 steps per day vs 5950 steps per day; P=.19; and 4.69 km per day vs 3.85 km per day; P=.09, respectively). An exploratory end point examining daily MVPA by ?heart points? collected from Google Fit also showed a significant increase compared to the first period (22.7 points per day vs 12.8 points per day; P=.02). Conclusions: Our app using step cadence as a goal and providing financial incentives seemed feasible and could be an effective app to increase users? daily MVPA. Based on the results of this study, we are motivated to conduct a confirmatory study with a broader and larger number of participants. Trial Registration: UMIN 000050518; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000057420 UR - https://formative.jmir.org/2024/1/e56376 UR - http://dx.doi.org/10.2196/56376 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56376 ER - TY - JOUR AU - Tarp, Kristine AU - Christiansen, Regina AU - Bilberg, Randi AU - Borkner, Simone AU - Dalsgaard, Caroline AU - Paldam Folker, Marie AU - Søgaard Nielsen, Anette PY - 2024/10/23 TI - Patient Perspectives on Blended Internet-Based and Face-to-Face Cognitive Behavioral Therapy for Alcohol Use Disorder: Qualitative Study JO - J Med Internet Res SP - e47083 VL - 26 KW - internet-based KW - alcohol use disorder treatment KW - user perspective KW - qualitative KW - blended treatment KW - blended learning KW - cognitive behavioral therapy KW - alcoholism KW - alcohol use disorder KW - treatment KW - barriers KW - patient perspectives KW - rehabilitation N2 - Background: Harmful alcohol consumption has been identified as a major contributor to disease, mortality, and social harm, accounting for 5.3% of worldwide deaths annually. In Denmark, an estimated 150,000 people suffer from alcohol use disorder (AUD), but a low proportion seek treatment due to person- and treatment-related barriers. Internet-based cognitive behavioral therapy (iCBT) has shown positive effects on the treatment gap, with patients reporting benefits such as increased knowledge and flexibility. However, there is a lack of research on blended cognitive behavioral therapy (bCBT), which combines face-to-face CBT (FtF CBT) and iCBT for AUD. Objective: This study aims to investigate user experiences of bCBT. More specifically, it seeks to explore the advantages and disadvantages that users have experienced with bCBT for AUD, as well as their motivations for choosing this treatment format. Methods: A total of 30 patients who had participated in the Blend-A (Blending Internet Treatment into Conventional Face-to-Face Treatment for AUD) study and received the intervention were contacted and offered the opportunity to participate in semistructured individual telephone interviews. Of these, 12 patients consented to participate. Furthermore, an additional participant was approached at a municipal clinic and agreed to engage in an individual FtF interview. Thus, the final sample consisted of 13 patients. The interviews explored their background, experiences with digital technology, motivations for choosing internet-based treatment, and experiences with the program during AUD treatment. The interviews were audio-recorded and transcribed in full length and analyzed using thematic analysis. All data were anonymized and securely stored. Results: We found that users experienced several advantages of iCBT over a larger part of the treatment course, including increased anonymity and privacy. Most importantly, it offered flexibility, allowing patients to focus on their rehabilitation process at their own pace. Patients appreciated the availability of written text in the online program, finding it helpful for gaining knowledge and understanding of AUD and its impact on the individual with the condition. They emphasized how the assignments helped them fully engage in treatment by first acknowledging their problem with alcohol and then dedicating time to self-reflection before FtF sessions, allowing for more in-depth discussions with the therapist. They also appreciated the reminders, which motivated them to complete their assignments. Conclusions: Overall, patients perceived more benefits than disadvantages in using bCBT. Essentially, bCBT offers a form of assisted autonomy that cannot be fully achieved through iCBT or FtF CBT alone. It is only through their combination that patients can fully appreciate the benefits of the treatment, as they have time for self-reflection, with guidance from the therapist between FtF CBT sessions. Trial Registration: ClinicalTrials.gov NCT04535258; https://clinicaltrials.gov/ct2/show/NCT04535258 UR - https://www.jmir.org/2024/1/e47083 UR - http://dx.doi.org/10.2196/47083 UR - http://www.ncbi.nlm.nih.gov/pubmed/39441642 ID - info:doi/10.2196/47083 ER - TY - JOUR AU - Gee, Brioney AU - Teague, Bonnie AU - Laphan, Andrew AU - Clarke, Tim AU - Coote, Georgianna AU - Garner, Jessica AU - Wilson, Jon PY - 2024/10/22 TI - Outcomes of Providing Children Aged 7-12 Years With Access to Evidence-Based Anxiety Treatment Via a Standalone Digital Intervention Using Immersive Gaming Technology: Real-World Evaluation JO - JMIR Ment Health SP - e52866 VL - 11 KW - anxiety KW - children KW - young people KW - exposure therapy KW - graded exposures KW - cognitive behavioural therapy KW - digital intervention KW - mobile app KW - gaming KW - real-world evaluation KW - gaming technology KW - real-world implementation N2 - Background: Anxiety disorders are among the most common mental health conditions in childhood, but most children with anxiety disorders do not access evidence-based interventions. The delivery of therapeutic interventions via digital technologies has been proposed to significantly increase timely access to evidence-based treatment. Lumi Nova (BfB Labs Limited) is a digital therapeutic intervention designed to deliver evidence-based anxiety treatment for those aged 7?12 years through a mobile app incorporating immersive gaming technology. Objective: We aimed to evaluate the real-world impact of providing access to Lumi Nova through UK National Health Service?funded mental health services. Methods: We analyzed precollected anonymized data routinely captured through the implementation of Lumi Nova from children aged 7?12 years, who lived in the United Kingdom and had the opportunity to use the intervention for at least 1 week over an 18-month period. Engagement indices included whether the game key was activated, number of unique sessions, time spent engaging, and number of ?challenges? completed. Clinical outcomes were assessed using the Goal-Based Outcomes measure and Child Outcome Rating Scale. Demographic data were analyzed to assess the health equality implications of Lumi Nova. Results: Of 1029 eligible families invited to use Lumi Nova, 644 (62.5%) activated their game key, of whom 374 (58.1%) completed at least one in-game graded exposure challenge. The median number of unique sessions was 6 (IQR 3?12) and the median time spent engaging with the intervention was 42 (IQR 15?79) minutes. For the subset of young people with paired outcomes, there were statistically significant small to medium improvements in goal-based outcome scores (n=224; t223=5.78, P<.001; d=0.37, 95% CI 0.25?0.52) and Child Outcome Rating Scale scores (n=123; t122=5.10, P<.001; d=0.46, 95% CI 0.27?0.65) between the first and last data points. Two in 5 young people?s scores reflected a change that would be considered reliable. Analysis of demographic characteristics tentatively suggested that children from ethnic minority backgrounds and those living in the most deprived neighbourhoods may be less likely to access Lumi Nova, but children from socioeconomically deprived areas were more likely to successfully complete a challenge once they accessed the intervention (P=.02). However, the level of missing data and small number of children in some demographic groups limited meaningful statistical comparisons. Conclusions: This study provides initial evidence that Lumi Nova may be associated with improved outcomes for those aged 7?12 years seeking anxiety treatment in real-world settings. However, the lack of a control comparator group and information about concurrent treatments accessed by the young people, in addition to substantial attrition, limited the analysis that could be conducted and confidence in the conclusions drawn. UR - https://mental.jmir.org/2024/1/e52866 UR - http://dx.doi.org/10.2196/52866 ID - info:doi/10.2196/52866 ER - TY - JOUR AU - Nguyen, Nhung AU - Koester, A. Kimberly AU - Tran, Christine AU - Ling, M. Pamela PY - 2024/10/22 TI - Desires and Needs for Quitting Both e-Cigarettes and Cigarettes Among Young Adults: Formative Qualitative Study Informing the Development of a Smartphone Intervention for Dual Tobacco Cessation JO - JMIR Form Res SP - e63156 VL - 8 KW - smoking cessation KW - vaping cessation KW - mHealth intervention KW - mobile health KW - e-cigarettes KW - cigarettes KW - smartphone intervention KW - nicotine dependence KW - additive adverse health effects KW - tobacco cessation N2 - Background: Dual use of both e-cigarettes and cigarettes is popular among young adults and may lead to greater nicotine dependence and additive adverse health effects than single-product use. However, existing cessation programs target quitting either e-cigarettes or cigarettes, highlighting a need for interventions to help young adults quit both products (ie, dual tobacco cessation). Objective: This formative study is part of a larger project to develop a smartphone intervention for dual tobacco cessation among young adults. This study aimed to (1) explore desires for and experiences with quitting both e-cigarettes and cigarettes and (2) identify needs and preferences for dual tobacco cessation intervention programming. Methods: Semistructured interviews were conducted to elicit the need for and experience with dual tobacco cessation among 14 young adults (18-29 years old) recruited through Instagram (Meta) advertisements in 2023. We conducted a thematic analysis to identify common themes related to quitting experiences and cessation needs. Results: Participants expressed a strong desire for dual tobacco cessation and had attempted to quit both tobacco products, mostly ?cold turkey.? The priority product for quitting first varied by the individual?s perceived harm or level of consumption. Targets for dual tobacco cessation interventions included (1) highlighting the health effects of dual tobacco use compared with single product use, (2) providing cessation support to quit one prioritized product while cutting down the other product with the explicit goal to quit both, (3) emphasizing unique facilitators and barriers to quitting each product (eg, unpleasant smell of cigarettes facilitating smoking cessation and accessibility and flavors of e-cigarettes hindering vaping cessation), and (4) addressing co-use of tobacco with alcohol or cannabis. Participants wanted personalized interventions through smartphone apps that would tailor support to their tobacco use patterns and unique quitting goals and needs. They also suggested presenting intervention content in multimedia (eg, videos, graphic pictures, quizzes, and games) to increase engagement. Conclusions: This study provides important insights into young adults? experiences, needs, and preferences for dual tobacco product cessation. We highlight important targets for future smartphone apps to deliver personalized and tailored support to meet the heterogeneous needs and preferences of young people who want to quit using both e-cigarettes and cigarettes. UR - https://formative.jmir.org/2024/1/e63156 UR - http://dx.doi.org/10.2196/63156 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63156 ER - TY - JOUR AU - Korthauer, E. Laura AU - Rosen, K. Rochelle AU - Tremont, Geoffrey AU - Davis, D. Jennifer PY - 2024/10/16 TI - Intervention Development for Tailored Education for Aging and Cognitive Health (TEACH) for Dementia Prevention in Midlife Adults: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e60395 VL - 13 KW - health behavior change KW - dementia prevention KW - Alzheimer disease KW - multidomain health intervention KW - intervention development KW - dementia N2 - Background: A total of 12 modifiable risk factors account for 40% of dementia cases globally, yet population adherence to health behaviors associated with these factors is low. Midlife is a critical window for dementia prevention, as brain pathology often begins to accumulate years or decades before the onset of symptoms. Although multidomain behavioral interventions have been efficacious in reducing the risk of cognitive decline, adherence is low. Intrapersonal factors, such as health beliefs, are known mediators of the relationship between knowledge and health behavior. Objective: In keeping with stage I of the National Institutes of Health (NIH) Stage Model for Behavioral Intervention Development, this study will use mixed methods to (1) develop an enhanced health education intervention, including an explanatory method for communicating information about dementia risk and personal health beliefs, and (2) conduct a pilot randomized controlled trial (n=20 per intervention arm) over 8 weeks to assess the feasibility of delivering the enhanced intervention versus basic health education alone. Methods: Phase 1 will involve focus groups and individual qualitative interviews. Focus groups will be analyzed using (1) a descriptive framework matrix analysis and (2) interpretive data review by the research team. Individual qualitative interviews will be coded using applied thematic analysis using a phenomenographic approach. Phase 2 will involve a pilot randomized controlled trial. Proximal outcomes (measured at baseline, 4 weeks, and 8 weeks) include the perceived threat of Alzheimer disease, dementia awareness, and self-efficacy. Results: This project was funded in August 2022. Data collection began in 2023 and is projected to be completed in 2025. Conclusions: Study findings will reveal the feasibility of delivering an 8-week multidomain health education intervention for primary prevention of dementia in midlife and will provide preliminary evidence of mechanisms of change. Trial Registration: ClinicalTrials.gov NCT05599425; https://clinicaltrials.gov/study/NCT05599425 International Registered Report Identifier (IRRID): DERR1-10.2196/60395 UR - https://www.researchprotocols.org/2024/1/e60395 UR - http://dx.doi.org/10.2196/60395 UR - http://www.ncbi.nlm.nih.gov/pubmed/39412840 ID - info:doi/10.2196/60395 ER - TY - JOUR AU - Frischholz, Katja AU - Tanaka, Hiroki AU - Shidara, Kazuhiro AU - Onishi, Kazuyo AU - Nakamura, Satoshi PY - 2024/10/15 TI - Examining the Effects of Cognitive Behavioral Therapy With a Virtual Agent on User Motivation and Improvement in Psychological Distress and Anxiety: Two-Session Experimental Study JO - JMIR Form Res SP - e55234 VL - 8 KW - cognitive behavioral therapy KW - cognitive restructuring KW - motivation KW - virtual agent KW - automatic negative thoughts N2 - Background: Cognitive behavioral therapy (CBT) is a valuable treatment for mood disorders and anxiety. CBT methods, such as cognitive restructuring, are employed to change automatic negative thoughts to more realistic ones. Objective: This study extends on previous research conducted by the authors, focused on the process of correcting automatic negative thoughts to realistic ones and reducing distress and anxiety via CBT with a virtual agent. It was aimed to investigate whether the previously applied virtual agent would achieve changes in automatic negative thoughts when modifications to the previous experimental paradigm are applied and when user motivation is taken into consideration. Furthermore, the potential effects of existing participant knowledge concerning CBT or automatic thoughts were explored. Methods: A single-group, 2-session experiment was conducted using a within-group design. The study recruited 35 participants from May 15, 2023, to June 2, 2023, via Inter Group Corporation, with data collection following from June 5 to June 20, 2023, at Nara Institute of Science and Technology, Japan. There were 19 male and 16 female participants (age range: 18-50 years; mean 33.66, SD 10.77 years). Participants answered multiple questionnaires covering depressive symptomatology and other cognitive variables before and after a CBT session. CBT was carried out using a virtual agent, who participants conversed with using a CBT dialogue scenario on the topic of automatic negative thoughts. Session 2 of the experiment took place 1 week after session 1. Changes in distress and state anxiety were analyzed using a Wilcoxon signed-rank test and t-test for paired samples. The relationships of motivation with cognitive changes and distress or anxiety changes were investigated via correlation analysis. Multiple linear regression was used to analyze the potential predictive qualities of previous knowledge of CBT and automatic negative thoughts regarding outcome measures. Results: Significant reductions in distress (all P<.001) and state anxiety (all P<.003) emerged throughout the first and second experimental sessions. The CBT intervention increased participants? recognition of their negative thinking and their intention to change it, namely their motivation to change it. However, no clear correlations of motivation with changes in distress or anxiety were found (all P>.04). Participants reported moderate subjective changes in their cognition, which were in part positively correlated with their motivation (all P<.007). Lastly, existing knowledge of CBT did not predict reductions in distress during the first session of the experiment (P=.02). Conclusions: CBT using a virtual agent and a CBT dialogue scenario was successful in reducing distress and anxiety when talking about automatic negative thoughts. The promotion of client motivation needs to be critically considered when designing interventions using CBT with a virtual agent, and further experimental investigations on the causal influences between motivation and outcome measures need to be conducted. UR - https://formative.jmir.org/2024/1/e55234 UR - http://dx.doi.org/10.2196/55234 UR - http://www.ncbi.nlm.nih.gov/pubmed/39405101 ID - info:doi/10.2196/55234 ER - TY - JOUR AU - Aubert, Morghane AU - Clavel, Céline AU - Le Scanff, Christine AU - Martin, Jean-Claude PY - 2024/10/15 TI - Intervention to Improve Well-Being, Nutrition, and Physical Activity in Adults: Experimental Study JO - JMIR Form Res SP - e47251 VL - 8 KW - mindfulness KW - well-being KW - affects KW - nutrition KW - physical activity KW - intervention KW - lifestyle habits KW - mindfulness exercises N2 - Background: Mindfulness improves well-being, improves emotional regulation, reduces impulses to eat, and is linked to increased physical activity. Mindfulness interventions usually focus on 1 aspect but do not offer an approach to holistically improving lifestyle. Objective: This study aims to address this gap by designing and evaluating a holistic mindfulness intervention. Methods: Committing to a 12-week intervention with 2-hour sessions without knowing whether you will enjoy it can be a hindrance for someone completely unfamiliar with mindfulness. For this reason, we decided to design a mindfulness intervention with short sessions over a reduced number of weeks. The aim is to enable novices to discover different aspects of mindfulness while at the same time offering a satisfactory practice for people who are already practicing mindfulness. We designed and evaluated a web-based mindfulness intervention in 5 sessions of 5 to 10 minutes each on well-being, diet, and physical activity to support a healthier lifestyle. The first 2 sessions focus on formal mindfulness meditation to enable novices to discover mindfulness and its main principles. Then there are 2 sessions about food. The first session about food aims to develop a sense of satisfaction with the food we eat and to focus our attention on new sensations. The second session about food aims to develop the ability to resist the lure of unhealthy foods. Finally, there is a session on physical activity. The aim is to develop a particular awareness of the body during movement, to increase satisfaction with physical activity, and to develop regular exercise. Results: In total, 32 participants completed the intervention. After the intervention, we observed decreases in negative affect, anxiety, and emotional distress, and an increase in dispositional mindfulness. There was no effect on reported healthy eating habits and physical activity habits. Few participants repeated the exercises as recommended. The majority of our participants were new to mindfulness. The majority of our participants reported being satisfied with the different sessions. A few minor difficulties were mentioned, mainly related to the environment in which the participants carried out the sessions. Only 1 session was less satisfactory for one-third of the participants. The session on resistance to unhealthy foods was formulated too strictly and the idea of banning certain foods was a hindrance for one-third of the participants. A reformulation is needed. Conclusions: The mindfulness exercises were well accepted and promoted a state of mindfulness. It would be interesting to provide easier technical access to the exercises via a mobile app so that they can be repeated easily. UR - https://formative.jmir.org/2024/1/e47251 UR - http://dx.doi.org/10.2196/47251 UR - http://www.ncbi.nlm.nih.gov/pubmed/39405102 ID - info:doi/10.2196/47251 ER - TY - JOUR AU - Wakeman, Michael AU - Tesfaye, Lydia AU - Gregory, Tim AU - Leahy, Erin AU - Kendrick, Brandon AU - El-Toukhy, Sherine PY - 2024/10/11 TI - Perceptions of the Use of Mobile Technologies for Smoking Cessation: Focus Group Study With Individuals of Low Socioeconomic Status Who Smoke JO - JMIR Form Res SP - e58221 VL - 8 KW - smoking cessation KW - social determinants of health KW - mhealth KW - apps KW - qualitative research KW - young adults N2 - Background: The use of mobile technologies to deliver behavioral health interventions, including smoking cessation support, has grown. Users? perceptions are important determinants of the adoption and use of new technologies. However, little is known about users? perceptions of mobile technologies as smoking cessation aids, particularly among disadvantaged individuals who smoke. Objective: This study aimed to examine the acceptance of mobile technologies for smoking cessation among young adults with low socioeconomic status who smoke. Methods: In total, 38 current cigarette smokers, 18 to 29 years old, who wanted to quit and did not have a 4-year college degree nor were enrolled in a 4-year college, participated in 12 semistructured digital focus groups. The moderation guide was guided by the Unified Theory of Acceptance and Use of Technology. Discussions were audio recorded, transcribed verbatim, and coded for the Unified Theory of Acceptance and Use of Technology constructs (ie, effort expectancy, facilitating conditions, performance expectancy, and social influence), sentiment (ie, negative, neutral, and positive), and purpose of using mobile technologies (ie, lifestyle and health management and smoking cessation) following a deductive thematic analysis approach. Results: Participants had positive experiences using mobile technologies for lifestyle and health management, primarily for fitness and dietary purposes. Salient themes were facilitating conditions of use (44/80, 55%), with prior experiences and costs subthemes, followed by perceived usefulness of mobile technologies in helping users attain health goals (22/80, 27.50%), which were generally positive. Ease of use (11/80, 13.75%) and social influences (3/80, 3.75%) were minimally discussed. Conversely, participants had limited awareness of smoking cessation uses of mobile technologies, which was the primary barrier under facilitating conditions discussed (33/51, 64.70%). Participants expressed skepticism about the usefulness of mobile technologies in helping them quit smoking (14/51, 27.45%). Effort expectancy was not discussed, given participants? limited prior use. Social influences on mobile technology use for smoking cessation were minimally discussed (4/51, 7.84%). Conclusions: The use of mobile technologies for smoking cessation was unknown to young adults with low socioeconomic status who smoke. To reduce cigarette smoking and associated health disparities, increasing awareness and use of evidence-based mobile-based smoking cessation interventions are needed. Smoking cessation interventions should incorporate features perceived as useful and easy to use to capitalize on positive user experiences and the acceptability of mobile technologies for lifestyle and health management. UR - https://formative.jmir.org/2024/1/e58221 UR - http://dx.doi.org/10.2196/58221 UR - http://www.ncbi.nlm.nih.gov/pubmed/39392684 ID - info:doi/10.2196/58221 ER - TY - JOUR AU - Hichborn, Emily AU - Turner, Avery AU - Moore, Sarah AU - Gauthier, Phoebe AU - Bell, Kathleen AU - Montgomery, LaTrice AU - Boggis, Jesse AU - Lambert-Harris, Chantal AU - Saunders, Elizabeth AU - Dallery, Jesse AU - McLeman, Bethany AU - Marsch, Lisa PY - 2024/10/10 TI - Technology-Based Interventions in Tobacco Use Treatment Among People Who Identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native: Scoping Review JO - J Med Internet Res SP - e50748 VL - 26 KW - health disparities KW - underrepresented KW - social determinants of health KW - tobacco use KW - technology-based interventions KW - scoping review KW - mobile phone N2 - Background: Although tobacco use has significantly declined in the general population, traditional tobacco use treatment uptake and success rates remain disproportionately low among people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native. Technology-based interventions (TBIs) for tobacco use are promising alternatives to traditional tobacco use treatments. Objective: This scoping review aims to investigate the extent to which the use of digital TBIs in tobacco use treatment research promotes health equity among people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native. Methods: This scoping review identifies US-based studies (between January 2000 and March 2021) that enlist TBIs for tobacco use treatment and include people who identify as African American/Black, Hispanic/Latina/o, and American Indian/Alaska Native at ?50% of the sample when combined; features studies that are also race and ethnicity conscious; and highlights health equity?promoting insights from included studies. Results: In 85% (22/26) of the studies, the largest proportion of the sample was African American/Black, most participants had low socioeconomic status, and recruitment was most commonly from medical settings. In total, 58% (15/26) of the studies were race and ethnicity conscious, and 67% (10/15) of these studies sought to partner with potential end users. An array of TBIs were represented; however, SMS text messaging was most prevalent. Most TBIs were combined with other evidence-based intervention components (eg, nicotine replacement therapy). Approximately one-third of the studies (8/26, 31%) required participants to have their own device or internet access. The majority were underpowered to detect substantial differences. Conclusions: The modest number of studies, particularly for persons who identify as Hispanic/Latina/o and American Indian/Alaska Native, demonstrates the limited application of TBIs for tobacco use and that additional research is needed to determine the extent to which TBIs for tobacco use promote health equity among these populations. International Registered Report Identifier (IRRID): RR2-10.2196/34508 UR - https://www.jmir.org/2024/1/e50748 UR - http://dx.doi.org/10.2196/50748 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50748 ER - TY - JOUR AU - Mozafari, Sogol AU - Yang, Alan AU - Talaei-Khoei, Jason PY - 2024/10/10 TI - Health Locus of Control and Medical Behavioral Interventions: Systematic Review and Recommendations JO - Interact J Med Res SP - e52287 VL - 13 KW - medical behavioral interventions KW - health locus of control KW - internal control KW - external control KW - patient behavior KW - synthesis KW - review methods KW - literature review KW - narrative review KW - behavior change N2 - Background: Health locus of control (HLOC) is a theory that describes how individuals perceive different forces that influence their lives. The concept of a locus of control can affect an individual?s likelihood to commit to behaviors related to their health. This study explores the literature on the relationships between HLOC and medical behavioral interventions. Objective: This study aims to better understand how HLOC constructs can potentially affect patient responses to health behavioral interventions and to propose a series of guidelines for individuals interested in designing medical behavioral interventions related to HLOC. Methods: We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology and performed an analysis of 50 papers related to the topic of HLOC and medical behavioral interventions. Inclusion criteria were studies that had a behavioral intervention involving patients and contained a metric of at least 1 of the constructs related to HLOC. The initial screening and search were conducted by 2 researchers (AY and SM) separately. The results were then combined and compared. Results: Our findings explore the influence of different levels of HLOC along with the importance of both patient- and health-related context when assessing the relationships between HLOC constructs and the likelihood of health behavior change. The findings show that different constructs related to HLOC can act as reliable predictors for patient responses to medical behavioral interventions. Patients who score higher on internal HLOC measures are more likely to exhibit behaviors that are consistent with positive health outcomes. Patients who score higher on chance HLOC are more likely to exhibit behaviors that may lead to adverse health outcomes. These conclusions are supported by most of the 50 studies surveyed. Conclusions: We propose guidelines for individuals designing medical behavioral interventions so that they can make use of these relationships linked to HLOC. The three guidelines suggested are as follows: (1) in most situations, improving internal HLOC will improve health outcomes for patients; (2) patients with high external HLOC should be further studied to determine the source of the external HLOC; and (3) patients with a high chance HLOC are less likely to follow preventative behaviors or be responsive to interventions. Limitations of the study are that the primary search and analysis were conducted by 2 principal researchers (AY and SM). Interpretation and development of the guidelines are subject to individual interpretation of results and may not be applicable to all contexts. UR - https://www.i-jmr.org/2024/1/e52287 UR - http://dx.doi.org/10.2196/52287 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/52287 ER - TY - JOUR AU - Mitchell, W. Jason AU - Bursac, Zoran AU - Diaz, David AU - Reyes Diaz, Michael Edward AU - Silva-Santisteban, Alfonso AU - Konda, A. Kelika PY - 2024/10/10 TI - Assessing a Couples-Based, Digital HIV Serostatus-Neutral Intervention (Para Ti, Para Mí, Para Nosotros) for Adult Cisgender Sexual Minority Male Couples in Lima, Peru: Protocol for a 6-Month Pilot Randomized Controlled Trial JO - JMIR Res Protoc SP - e63106 VL - 13 KW - digital health intervention KW - HIV prevention care KW - sexually transmitted infection KW - cisgender, sexual minority male couples KW - randomized controlled trial KW - Peru KW - mobile phone N2 - Background: HIV disproportionately affects sexual minority men (SMM; eg, gay, bisexual, and other men who have sex with men) in Lima, Peru; epidemiological data estimate that 32% to 39% of new HIV infections occur among adult cisgender SMM within primary partnerships (ie, male couples). Most HIV prevention-care research in Lima, Peru, has focused on SMM as individuals and not couples. To help address this critical gap in prevention care, we developed Para Ti, Para Mí, Para Nosotros (P3): a couples-based, digital HIV serostatus-neutral intervention (DHI) for adult cisgender SMM couples in Lima, Peru. The P3 DHI is designed to facilitate couples with skill-building, communication, decision-making, and working together to form and adhere to a detailed prevention care plan that aligns with their explicit sexual agreement. The P3 DHI is theoretically informed, self-guided, directed, sequential, and fully automated. Objective: This pilot randomized controlled trial (RCT) aims to examine the preliminary effects of P3 on couples? formation and adherence to a detailed prevention care plan containing evidence-based strategies that also aligns with their explicit sexual agreement over time. In addition, the feasibility of enrollment and retention and couples? acceptability of P3 will be assessed. Methods: The research implements a prospective, 6-month pilot RCT with a 3-month delayed control condition. After baseline, 60 enrolled SMM couples will be randomized to 1 of 2 conditions. Couples randomized to the unmatched, delayed control condition will receive access to the P3 DHI to use during the last 3 months of the trial after the 3-month assessment. Couples randomized to the immediate intervention condition will immediately receive access to the P3 DHI for 6 months. Study assessments will occur at baseline and months 3 and 6. Descriptive, comparative, qualitative, and longitudinal analyses using generalized linear mixed-effect, multilevel, and actor-partner interdependence models will be conducted to address the specific aims. Results: The 6-month pilot RCT is ongoing. Recruitment, enrollment, and data collection began in January 2023 and ended in April 2024. A total of 74 adult cisgender SMM couples met all inclusion criteria, provided consent, and were enrolled in the pilot RCT. Retention was 92% (68/74) at month 6. Data are currently being analyzed to address the 3 specific aims regarding feasibility, acceptability, and preliminary efficacy. Conclusions: Findings from this research will reveal whether couples deemed the P3 DHI to be acceptable. Findings will also highlight the preliminary efficacy of the P3 DHI on couples managing their vulnerability to HIV and other sexually transmitted infections (STIs) over time via alignment of their prevention-care plan and sexual agreement. Trial findings will help shape the future direction of the P3 DHI while addressing the existing gap in prevention and care services for couples in the local context. Trial Registration: ClinicalTrials.gov NCT05873855; https://clinicaltrials.gov/study/NCT05873855 International Registered Report Identifier (IRRID): DERR1-10.2196/63106 UR - https://www.researchprotocols.org/2024/1/e63106 UR - http://dx.doi.org/10.2196/63106 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63106 ER - TY - JOUR AU - Liang, Zilu AU - Melcer, Edward AU - Khotchasing, Kingkarn AU - Chen, Samantha AU - Hwang, Daeun AU - Hoang, Huyen Nhung PY - 2024/10/8 TI - The Role of Relevance in Shaping Perceptions of Sleep Hygiene Games Among University Students: Mixed Methods Study JO - JMIR Serious Games SP - e64063 VL - 12 KW - serious games KW - sleep hygiene KW - sleep technologies KW - co-design KW - relevance KW - self-determination theory KW - digital health KW - persuasive technology KW - behavior change N2 - Background: Sleep games are an emerging topic in the realm of serious health game research. However, designing features that are both enjoyable and effective at engaging users, particularly university students, to develop healthy sleep habits remains a challenge. Objective: This study aims to investigate user preferences for 3 sleep game prototypes, that is, Hero?s Sleep Journey, Sleep Tamagotchi, and Sleepland, and to explore their popularity and perceived utility in promoting sleep health. Methods: A mixed methods approach was used in this study. Quantitative and qualitative data were collected through a co-design workshop involving 47 university students. Participants were presented with storyboard cards of game features and were asked to provide an overall rating on each game, as well as ratings for individual features. They were also encouraged to provide free-form comments on the features and suggest improvements. In addition, participants were asked to express their preferences among the 3 games regarding which game they would most like to play and which one they found most useful for promoting sleep health. Results: Surprisingly, while Hero?s Sleep Journey was the most popular choice among participants, Sleep Tamagotchi was perceived as the most beneficial for improving sleep health. Relevance emerged as an overarching theme in the qualitative data analysis, with 3 interconnected dimensions: psychological relevance to users? personal lives, logical relevance to sleep health, and situational relevance to users? circumstantial context. We discussed how the 3 dimensions of relevance address the autonomy and relatedness constructs outlined in the self-determination theory and proposed 3 design recommendations. Conclusions: Our serious sleep game prototypes demonstrated the potential to engage university students to develop healthy sleep hygiene. Future sleep game designs should aim to create a sense of relevance to users? personal lives, sleep health goals, and situational contexts. Rather than a one-size-fits-all approach, it is essential to develop a wide range of game genres and features to cater to diverse users. Aligning game features with sleep health goals and educating users on the design rationale through sleep knowledge are also important aspects. Furthermore, allowing users to customize their game experience and manage technology boundaries is necessary to nurture a sense of control and autonomy in the process of forming good sleep hygiene. UR - https://games.jmir.org/2024/1/e64063 UR - http://dx.doi.org/10.2196/64063 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/64063 ER - TY - JOUR AU - Klapow, C. Max AU - Rosenblatt, Andrew AU - Lachman, Jamie AU - Gardner, Frances PY - 2024/10/7 TI - The Feasibility and Acceptability of Using a Digital Conversational Agent (Chatbot) for Delivering Parenting Interventions: Systematic Review JO - JMIR Pediatr Parent SP - e55726 VL - 7 KW - chatbot KW - parenting intervention KW - feasibility KW - acceptability KW - systematic review KW - implementation N2 - Background: Parenting interventions are crucial for promoting family well-being, reducing violence against children, and improving child development outcomes; however, scaling these programs remains a challenge. Prior reviews have characterized the feasibility, acceptability, and effectiveness of other more robust forms of digital parenting interventions (eg, via the web, mobile apps, and videoconferencing). Recently, chatbot technology has emerged as a possible mode for adapting and delivering parenting programs to larger populations (eg, Parenting for Lifelong Health, Incredible Years, and Triple P Parenting). Objective: This study aims to review the evidence of using chatbots to deliver parenting interventions and assess the feasibility of implementation, acceptability of these interventions, and preliminary outcomes. Methods: This review conducted a comprehensive search of databases, including Web of Science, MEDLINE, Scopus, ProQuest, and Cochrane Central Register of Controlled Trials. Cochrane Handbook for Systematic Review of Interventions and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to conduct the search. Eligible studies targeted parents of children aged 0 to 18 years; used chatbots via digital platforms, such as the internet, mobile apps, or SMS text messaging; and targeted improving family well-being through parenting. Implementation measures, acceptability, and any reported preliminary measures of effectiveness were included. Results: Of the 1766 initial results, 10 studies met the inclusion criteria. The included studies, primarily conducted in high-income countries (8/10, 80%), demonstrated a high mean retention rate (72.8%) and reported high acceptability (10/10, 100%). However, significant heterogeneity in interventions, measurement methods, and study quality necessitate cautious interpretation. Reporting bias, lack of clarity in the operationalization of engagement measures, and platform limitations were identified as limiting factors in interpreting findings. Conclusions: This is the first study to review the implementation feasibility and acceptability of chatbots for delivering parenting programs. While preliminary evidence suggests that chatbots can be used to deliver parenting programs, further research, standardization of reporting, and scaling up of effectiveness testing are critical to harness the full benefits of chatbots for promoting family well-being. UR - https://pediatrics.jmir.org/2024/1/e55726 UR - http://dx.doi.org/10.2196/55726 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55726 ER - TY - JOUR AU - Bustamante Perez, Adriana Luz AU - Romo, Lucia AU - Zerhouni, Oulmann PY - 2024/10/2 TI - Feasibility and Engagement of a Mobile App Preparation Program (Kwit) for Smoking Cessation in an Ecological Context: Quantitative Study JO - JMIR Mhealth Uhealth SP - e51025 VL - 12 KW - smoking cessation KW - digital intervention KW - behavior change techniques KW - attrition rate KW - mobile app KW - preparation program KW - motivation KW - quit smoking KW - ecological settings KW - mobile phone N2 - Background: Mobile health apps can facilitate access to effective treatment and therapeutic information services. However, the real-world effectiveness of mobile apps for smoking cessation and their potential impact in everyday settings remain unclear. Objective: In an ecological context, this study aimed to estimate the engagement rate of a mobile app?based smoking cessation preparation program and its potential impact on users? willingness, ability, and readiness to quit smoking. Methods: A total of 2331 ?organic users? (ie, users who discover and install a mobile app on their own, without any prompts) chose 1 of 2 program versions of the mobile app (Kwit): the basic version or the premium version. Both versions were identical in design, with 4 more evidence-based content items and strategies in the premium version. Outcomes were analyzed based on automated data registered in the app (engagement rate, motivation to quit, motivation type, motivation levels, and satisfaction level). Mann-Whitney and ?2 tests were used to compare the results of both groups. Results: As expected, in the ecological context, a high dropout rate was observed at different moments. A significant difference was observed between the 2 versions (n=2331; ?21=5.4; P=.02), with a proportionally higher engagement rate in the premium version (premium=4.7% vs basic=2%). Likewise, differences were also observed between the 2 groups in terms of reasons to quit (n=2331; ?24=19; P?.001; V=0.08), motivation type (n=2331; ?27=14.7; P=.04), and motivation level. Users of the app?s premium version more frequently reported ?well-being? (23.3% vs 17.9%) and ?planning a pregnancy? (7.4% vs 4.4%) as their primary reasons for quitting smoking compared to those with the basic version. Moreover, they reported being more likely to be driven in the smoking cessation process by intrinsic motivation (premium=28% vs basic=20.4%), as well as feeling significantly more willing (z score=156,055; P?.001; Cohen d=0.15), able (z score=172,905; P=.04; Cohen d=0.09), and ready (z score=166,390; P=.005; Cohen d=0.12) to stop smoking than users who had the basic version before completion of the preparation program. Among participants who finished each version of the program (premium: 9/189, 4.8%; basic: 47/2142, 2.19%), significant improvements in motivation levels were observed in both groups, although in different areas for each group (willingness levels for the premium group and ability for the basic group). Conclusions: These results suggest that even in ecological contexts where engagement rates are meager, the Kwit preparation program can address ambivalence by increasing willingness to change, self-confidence, and readiness to quit among its users, especially those who feel less able to do so. Further development and evaluations are needed to better understand determinants for regular mobile health apps. UR - https://mhealth.jmir.org/2024/1/e51025 UR - http://dx.doi.org/10.2196/51025 UR - http://www.ncbi.nlm.nih.gov/pubmed/39357053 ID - info:doi/10.2196/51025 ER - TY - JOUR AU - Bello, Oneyi Medina AU - Mammino, Michael Kevin AU - Vernon, Anthony Mark AU - Wakeman, G. Daniel AU - Denmon, Aerius Chanse AU - Krishnamurthy, Crystal Lisa AU - Krishnamurthy, Venkatagiri AU - McGregor, Matthew Keith AU - Novak, Samuel Thomas AU - Nocera, Robert Joe PY - 2024/9/26 TI - Graded Intensity Aerobic Exercise to Improve Cerebrovascular Function and Performance in Older Veterans: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e58316 VL - 13 KW - aerobic exercise KW - exercise KW - functional magnetic resonance imaging KW - fMRI KW - veterans KW - quality of life KW - sedentary lifestyle KW - elderly KW - geriatrics KW - geriatric KW - older adults KW - cardiovascular disease KW - health promotion KW - aging KW - cognitive KW - cognitive health KW - physical health N2 - Background: Growing health care challenges resulting from a rapidly expanding aging population necessitate examining effective rehabilitation techniques that mitigate age-related comorbidity and improve quality of life. To date, exercise is one of a few proven interventions known to attenuate age-related declines in cognitive and sensorimotor functions critical to sustained independence. Objective: This work aims to implement a multimodal imaging approach to better understand the mechanistic underpinnings of the beneficial exercise-induced adaptations to sedentary older adults? brains and behaviors. Due to the complex cerebral and vascular dynamics that encompass neuroplastic change with aging and exercise, we propose an imaging protocol that will model exercise-induced changes to cerebral perfusion, cerebral vascular reactivity (CVR), and cognitive and sensorimotor task-dependent functional magnetic resonance imaging (fMRI) after prescribed exercise. Methods: Sedentary older adults (aged 65-80 years) were randomly assigned to either a 12-week aerobic-based interval-based cycling intervention or a 12-week balance and stretching intervention. Assessments of cardiovascular fitness used the YMCA submaximal VO2 test, basal cerebral perfusion using arterial spin labeling (ASL), CVR using hypercapnic fMRI, and cortical activation using fMRI during verbal fluency and motor tapping tasks. A battery of cognitive-executive and motor function tasks outside the scanning environment will be performed before and after the interventions. Results: Our studies and others show that improved cardiovascular fitness in older adults results in improved outcomes related to physical and cognitive health as well as quality of life. A consistent but unexplained finding in many of these studies is a change in cortical activation patterns during task-based fMRI, which corresponds with improved task performance (cognitive-executive and motor). We hypothesize that the 12-week aerobic exercise intervention will increase basal perfusion and improve CVR through a greater magnitude of reactivity in brain areas susceptible to neural and vascular decline (inferior frontal and motor cortices) in previously sedentary older adults. To differentiate between neural and vascular adaptations in these regions, we will map changes in basal perfusion and CVR over the inferior frontal and the motor cortices?regions we have previously shown to be beneficially altered during fMRI BOLD (blood oxygen level dependent), such as verbal fluency and motor tapping, through improved cardiovascular fitness. Conclusions: Exercise is one of the most impactful interventions for improving physical and cognitive health in aging. This study aims to better understand the mechanistic underpinnings of improved health and function of the cerebrovascular system. If our hypothesis of improved perfusion and cerebrovascular reactivity following a 12-week aerobic exercise intervention is supported, it would add critically important insights into the potential of exercise to improve brain health in aging and could inform exercise prescription for older adults at risk for neurodegenerative disease brought on by cerebrovascular dysfunction. Trial Registration: ClinicalTrials.gov NCT05932069; https://clinicaltrials.gov/study/NCT05932069 International Registered Report Identifier (IRRID): DERR1-10.2196/58316 UR - https://www.researchprotocols.org/2024/1/e58316 UR - http://dx.doi.org/10.2196/58316 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58316 ER - TY - JOUR AU - Gunn, L. Rachel AU - Metrik, Jane AU - Barnett, P. Nancy AU - Jackson, M. Kristina AU - Lipperman-Kreda, Sharon AU - Miranda Jr, Robert AU - Trull, J. Timothy AU - Fernandez, Ellen Mary PY - 2024/9/25 TI - Examining the Impact of Simultaneous Alcohol and Cannabis Use on Alcohol Consumption and Consequences: Protocol for an Observational Ambulatory Assessment Study in Young Adults JO - JMIR Res Protoc SP - e58685 VL - 13 KW - ecological momentary assessment KW - alcohol KW - cannabis KW - consequences KW - transdermal alcohol biosensors KW - ambulatory assessment KW - mobile phone N2 - Background: There is significant conflicting evidence as to how using cannabis while drinking alcohol (ie, simultaneous alcohol and cannabis use) impacts alcohol volume consumed, patterns of drinking, and alcohol-related consequences. The impact of simultaneous use on drinking outcomes may be influenced by several within-person (eg, contextual) and between-person (individual) factors. Objective: This study was designed to examine naturalistic patterns of alcohol and cannabis use to understand how simultaneous use may impact drinking outcomes. The primary aims were to understand the following: (1) if simultaneous use is associated with increased alcohol consumption and riskier patterns of drinking, (2) if simultaneous use leads to increased alcohol consequences, and (3) how contextual circumstances moderate the impact of simultaneous use on consumption and consequences. Methods: Data collection involves a 28-day ambulatory assessment protocol in which a sample of non?treatment-seeking young adults who report simultaneous use of alcohol and cannabis complete ecological momentary assessments (random, event-contingent, and time-contingent surveys) of alcohol and cannabis use, contexts, motives, and consequences on their personal smartphones while continuously wearing an alcohol biosensor bracelet. Participants also complete a baseline assessment, brief internet-based check-in on day 14, and a final session on day 28. Community-based recruitment strategies (eg, social media and flyers) were used to enroll 95 participants to obtain a target sample of 80, accounting for attrition. Results: Recruitment and data collection began in May 2021 and continued through June 2024. Initial results for primary aims are expected in October 2024. As of March 2024, the project had recruited 118 eligible participants, of whom 94 (79.7%) completed the study, exceeding initial projections for the study time frame. Remaining recruitment will provide the capacity to probe cross-level interactions that were not initially statistically powered. Strengths of the project include rigorous data collection, good retention and compliance rates, faster-than-expected enrollment procedures, use of a novel alcohol biosensor, and successful adaptation of recruitment and data collection procedures during the COVID-19 pandemic. Conclusions: This is the first investigation to assess the key momentary predictors and outcomes of simultaneous use as well as self-reported and objective (via alcohol biosensor) measures of alcohol consumption and patterns. The results of this study will inform prevention efforts and studies of individuals who use cannabis who are engaged in alcohol treatment. International Registered Report Identifier (IRRID): DERR1-10.2196/58685 UR - https://www.researchprotocols.org/2024/1/e58685 UR - http://dx.doi.org/10.2196/58685 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58685 ER - TY - JOUR AU - Nakagami, Yukako AU - Uwatoko, Teruhisa AU - Shimamoto, Tomonari AU - Sakata, Masatsugu AU - Toyomoto, Rie AU - Yoshida, Kazufumi AU - Luo, Yan AU - Shiraishi, Nao AU - Tajika, Aran AU - Sahker, Ethan AU - Horikoshi, Masaru AU - Noma, Hisashi AU - Iwami, Taku AU - Furukawa, A. Toshi PY - 2024/9/24 TI - Long-Term Effects of Internet-Based Cognitive Behavioral Therapy on Depression Prevention Among University Students: Randomized Controlled Factorial Trial JO - JMIR Ment Health SP - e56691 VL - 11 KW - iCBT KW - depression prevention KW - student mental health KW - factorial randomized controlled trial KW - mobile phone N2 - Background: Internet-based cognitive behavioral therapy (iCBT) shows promise in the prevention of depression. However, the specific iCBT components that contribute to its effectiveness remain unclear. Objective: We aim to evaluate the effects of iCBT components in preventing depression among university students. Methods: Using a smartphone cognitive behavioral therapy (CBT) app, we randomly allocated university students to the presence or absence of 5 different iCBT components: self-monitoring, behavioral activation, cognitive restructuring, assertiveness training, and problem-solving. The active intervention lasted 8 weeks but the app remained accessible through the follow-up. The primary outcome was the onset of a major depressive episode (MDE) between baseline and the follow-up after 52 weeks, as assessed with the computerized World Health Organization Composite International Diagnostic Interview. Secondary outcomes included changes in the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, and CBT Skills Scale. Results: During the 12-month follow-up, 133 of 1301 (10.22%) participants reported the onset of an MDE. There were no significant differences in the incidence of MDEs between the groups with or without each component (hazard ratios ranged from 0.85, 95% CI 0.60?1.20, for assertiveness training to 1.26, 95% CI 0.88?1.79, for self-monitoring). Furthermore, there were no significant differences in the changes on the 9-item Patient Health Questionnaire, 7-item General Anxiety Disorder, or for CBT Skills Scale between component allocation groups. However, significant reductions in depression and anxiety symptoms were observed among all participants at the 52-week follow-up. Conclusions: In this study, we could not identify any specific iCBT components that were effective in preventing depression or the acquisition of CBT skills over the 12-month follow-up period, but all participants with and without intervention of each iCBT component demonstrated significant improvements in depressive and anxiety symptoms. Further research is needed to explore the potential impact of frequency of psychological assessments, nonspecific intervention effects, natural change in the mental state, and the baseline depression level. Trial Registration: UMINCTR UMIN000031307; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035735 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-2719-z UR - https://mental.jmir.org/2024/1/e56691 UR - http://dx.doi.org/10.2196/56691 ID - info:doi/10.2196/56691 ER - TY - JOUR AU - Taj, Umar AU - Grimani, Aikaterini AU - Read, Daniel AU - Vlaev, Ivo PY - 2024/9/24 TI - Using Games to Simulate Medication Adherence and Nonadherence: Laboratory Experiment in Gamified Behavioral Simulation JO - JMIR Serious Games SP - e47141 VL - 12 KW - behavior change KW - experimental modeling KW - gamification KW - medication adherence KW - antibiotics KW - games KW - medication KW - testing behavior KW - clinical outcome KW - simulate KW - diagnosis KW - devices KW - symptoms KW - tool N2 - Background: Medical nonadherence is a significant problem associated with worse clinical outcomes, higher downstream rehospitalization rates, and a higher use of resources. To improve medication adherence, it is vital for researchers and practitioners to have a solid theoretical understanding of what interventions are likely to work. To achieve this understanding, we propose that researchers should focus on creating small-scale laboratory analogs to the larger real-world setting and determine what interventions, such as nudges or incentives, work to change behavior in the laboratory. To do this, we took inspiration from the literature on serious games and gamification and experimental economics. We call our approach ?gamified behavioral simulation.? In this paper, we modeled everyday life as the state of being engaged in a simple but addictive game, illness as being interruptions to the functionality of that game, treatment as being a series of actions that can be taken to prevent or mitigate those interruptions, and adherence as sticking to a prescribed rule for the application of those actions. Objective: This study carries out a behavioral diagnosis of the medication adherence problem through a theoretically informed framework and then develops the gamified behavioral modeling approach to simulate medication nonadherence. Methods: A laboratory experiment was conducted using a modified popular and addictive open-source video game called ?2048,? which created an abstract model for the medication adherence behavior observed in real life. In total, 509 participants were assigned to the control and 4 intervention groups (?incentive? group, ?reminder? group, ?commitment device? group, and ?elongated duration for symptoms? group). Results: The results of the modeling experiment showed that having theoretically informed interventions can increase the likelihood for them to be successful. In particular, there is evidence that the use of reminders improves the medication adherence rates for patients, and the same result was found in the modeling experiment, as they improved adherence significantly by 23% (95% CI ?33.97% to ?11.72%; P<.001). However, providing an incentive did not improve the adherence rate. We also tested the use of commitment devices, which, in line with real-world evidence, did not improve adherence rates. The fourth treatment tested elongated duration for symptoms, which attempted to show the power of modeling experiments where we test a what-if scenario that is extremely difficult to test in a real setting. The results indicated that if symptoms last longer, people did not adhere more to their medication regimen. Conclusions: Gamified behavioral simulation is a useful tool to explain real health behaviors and help in identifying which interventions are most likely to work in a randomized trial. UR - https://games.jmir.org/2024/1/e47141 UR - http://dx.doi.org/10.2196/47141 ID - info:doi/10.2196/47141 ER - TY - JOUR AU - Okamoto, Masumi AU - Saito, Yoshinobu AU - Nakamura, Sho AU - Nagasawa, Makoto AU - Shibuya, Megumi AU - Nagasaka, Go AU - Narimatsu, Hiroto PY - 2024/9/24 TI - Smartphone-Based Digital Peer Support for a Walking Intervention Among Public Officers in Kanagawa Prefecture: Single-Arm Pre- and Postintervention Evaluation JO - JMIR Form Res SP - e53759 VL - 8 KW - digital health KW - mhealth KW - ehealth KW - smartphone app KW - smartphone application KW - peer support KW - digital peer support KW - social support KW - group intervention KW - physical activity KW - health promotion KW - behavior change KW - apps KW - step counting KW - workplace health N2 - Background: Digital peer support, defined as peer support delivered through technology such as smartphone apps, may be promising to promote activity in the form of step counts. Interactions among users have a positive impact on retention rates, and apps with social elements show significant improvements in daily step count. However, the feasibility of digital peer support in promoting physical activity (PA) is unknown; therefore, its effectiveness on step count and the clinical implications remain unconfirmed. Objective: This study aimed to assess the feasibility of digital peer support over a 3-month intervention period using the retention rate as the outcome. Moreover, changes in daily step count and physical measurements were compared between pre- and postintervention. Methods: The study design was a 3-month 1-arm intervention with participants from local government offices in Kanagawa, Japan. We used an available smartphone app, Minchalle, as the tool for the group intervention. Participants were required to report their daily step count to a maximum of 5 members composed exclusively of study participants. The primary outcome was the retention rate. Secondary outcomes included daily step count, the rate of achieving daily step goals, physical measurements, and lifestyle characteristics. Descriptive statistics and the Pearson coefficient were used to examine the relationship between goal achievement and step count, as well as changes in step count and various variables including physical measurements. Results: Of the 63 participants, 62 completed the intervention. The retention rate was 98% (62/63). The average daily step count during the intervention was 6993 (SD 2328) steps, an 1182-step increase compared with the count observed 1 week before the intervention began. The rate of achieving the daily step count during the intervention was 53.5% (SD 26.2%). There was a significant correlation (r=0.27, P=.05) between achieving daily step goals and increasing daily step count. Comparative analyses showed that changes in weight (68.56, SD 16.97 kg vs 67.30, SD 16.86 kg; P<.001), BMI (24.82, SD 4.80 kg/m2 vs 24.35, SD 4.73 kg/m2; P<.001), somatic fat rate (28.50%, SD 7.44% vs 26.58%, SD 7.90%; P=.005), systolic blood pressure (130.42, SD 17.92 mm Hg vs 122.00, SD 15.06 mm Hg; P<.001), and diastolic blood pressure (83.24, SD 13.27 mm Hg vs 77.92, SD 11.71 mm Hg; P=.002) were significantly different before and after the intervention. Similarly, the daily amount of PA significantly improved from 5.77 (SD 3.81) metabolic equivalent (MET)?hours per day to 9.85 (SD 7.84) MET-hours per day (P<.001). Conclusions: This study demonstrated that digital peer support is feasible for maintaining a high retention rate and can, therefore, effectively promote PA. It can be a promising tool to improve daily step count, subjective PA, and clinical outcomes, such as weight and somatic fat rate. Trial Registration: UMIN Clinical Trials Registry UMIN000042520; https://tinyurl.com/46c4nm8z UR - https://formative.jmir.org/2024/1/e53759 UR - http://dx.doi.org/10.2196/53759 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/53759 ER - TY - JOUR AU - Kotov, Alexander AU - Idalski Carcone, April AU - Towner, Elizabeth PY - 2024/9/20 TI - Neural Conversational Agent for Weight Loss Counseling: Protocol for an Implementation and Feasibility Study JO - JMIR Res Protoc SP - e60361 VL - 13 KW - conversational agents KW - artificial intelligence KW - behavior change KW - weight loss KW - obesity KW - motivational interviewing KW - web-based application KW - deep learning KW - transformers KW - large language models KW - feasibility study N2 - Background: Obesity is a common, serious and costly chronic disease. Current clinical practice guidelines recommend that providers augment the longitudinal care of people living with obesity with consistent support for the development of self-efficacy and motivation to modify their lifestyle behaviors. Lifestyle behavior change aligns with the goals of motivational interviewing (MI), a client-centered yet directive counseling modality. However, training health care providers to be proficient in MI is expensive and time-consuming, resulting in a lack of trained counselors and limiting the widespread adoption of MI in clinical practice. Artificial intelligence (AI) counselors accessible via the internet can help circumvent these barriers. Objective: The primary objective is to explore the feasibility of conducting unscripted MI-consistent counseling using Neural Agent for Obesity Motivational Interviewing (NAOMI), a large language model (LLM)?based web app for weight loss counseling. The secondary objectives are to test the acceptability and usability of NAOMI?s counseling and examine its ability to shift motivational precursors in a sample of patients with overweight and obesity recruited from primary care clinics. Methods: NAOMI will be developed based on recent advances in deep learning in four stages. In stages 1 and 2, NAOMI will be implemented using an open-source foundation LLM and (1) few-shot learning based on a prompt with task-specific instructions and (2) domain adaptation strategy based on fine-tuning LLM using a large corpus of general psychotherapy and MI treatment transcripts. In stages 3 and 4, we will refine the best of these 2 approaches. Each NAOMI version will be evaluated using a mixed methods approach in which 10 adults (18-65 years) meeting the criteria for overweight or obesity (25.0?BMI?39.9) interact with NAOMI and provide feedback. NAOMI?s fidelity to the MI framework will be assessed using the Motivational Interviewing Treatment Integrity scale. Participants? general perceptions of AI conversational agents and NAOMI specifically will be assessed via Pre- and Post-Interaction Questionnaires. Motivational precursors, such as participants? confidence, importance, and readiness for changing lifestyle behaviors (eg, diet and activity), will be measured before and after the interaction, and 1 week later. A qualitative analysis of changes in the measures of perceptions of AI agents and counselors and motivational precursors will be performed. Participants will rate NAOMI?s usability and empathic skills post interaction via questionnaire-based assessments along with providing feedback about their experience with NAOMI via a qualitative interview. Results: NAOMI (version 1.0) has been developed. Participant recruitment will commence in September 2024. Data collection activities are expected to conclude in May 2025. Conclusions: If proven effective, LLM-based counseling agents can become a cost-effective approach for addressing the obesity epidemic at a public health level. They can also have a broad, transformative impact on the delivery of MI and other psychotherapeutic treatment modalities extending their reach and broadening access. International Registered Report Identifier (IRRID): PRR1-10.2196/60361 UR - https://www.researchprotocols.org/2024/1/e60361 UR - http://dx.doi.org/10.2196/60361 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/60361 ER - TY - JOUR AU - Molander, Olof AU - Berman, H. Anne AU - Jakobson, Miriam AU - Gajecki, Mikael AU - Hällström, Hanna AU - Ramnerö, Jonas AU - Bjureberg, Johan AU - Carlbring, Per AU - Lindner, Philip PY - 2024/9/18 TI - Introducing and Evaluating the Effectiveness of Online Cognitive Behavior Therapy for Gambling Disorder in Routine Addiction Care: Comparative Cohort Study JO - J Med Internet Res SP - e54754 VL - 26 KW - gambling disorder KW - internet-delivered cognitive behavioral therapy KW - routine addiction care KW - registry study KW - gambling KW - addiction KW - health care setting KW - iCBT KW - Sweden KW - feasibility KW - clinic KW - hospital KW - psychological treatment KW - digital intervention KW - addictive disorder KW - eHealth KW - digital care KW - survival analysis KW - comorbidity N2 - Background: Several treatment-related challenges exist for gambling disorder, in particular at-scale dissemination in health care settings. Objective: This study describes the introduction of a newly developed internet-delivered cognitive behavioral therapy (iCBT) program for gambling disorder (GD), provided with therapist support in routine addiction care, in a nationally recruited sample in Sweden. The study details the introduction of the iCBT program, evaluates its effectiveness and acceptability, and compares registry outcomes among iCBT patients with other patients with GD at the clinic who received face-to-face psychological treatment as usual. Methods: The study site was the Stockholm Addiction eClinic, which offers digital interventions for addictive disorders in routine care. The iCBT program was introduced nationally for treatment-seeking patients through the Swedish eHealth platform. After approximately 2 years of routine treatment provision, we conducted a registry study, including ordinary patients in routine digital care (n=218), and a reference sample receiving face-to-face psychological treatment for GD (n=216). Results: A statistically significant reduction in the Gambling Symptom Assessment Scale scores during the treatment was observed (B=?1.33, SE=0.17, P<.001), corresponding to a large within-group Cohen d effect size of d=1.39. The iCBT program was rated high for satisfaction. A registry-based survival analysis, controlling for psychiatric comorbidity, showed that patients receiving iCBT exhibited posttreatment outcomes (re-engagement in outpatient addiction care, receiving new psychiatric prescriptions, enrollment in psychiatric inpatient care, and care events indicative of contact with social services) similar to comparable patients who underwent face-to-face treatment-as-usual. Conclusions: A lack of randomized allocation notwithstanding, the iCBT program for GD evaluated in this study was well-received by patients in routine addiction care, was associated with the expected symptom decrease during treatment, and appears to result in posttreatment registry outcomes similar to face-to-face treatment. Future studies on treatment mechanisms and moderators are warranted. International Registered Report Identifier (IRRID): RR2-10.1186/s40814-020-00647-5 UR - https://www.jmir.org/2024/1/e54754 UR - http://dx.doi.org/10.2196/54754 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54754 ER - TY - JOUR AU - Lyzwinski, Lynnette AU - Dong, Meichen AU - Wolfinger, D. Russell AU - Filion, B. Kristian AU - Eisenberg, J. Mark PY - 2024/9/16 TI - e-Cigarettes, Smoking Cessation, and Weight Change: Retrospective Secondary Analysis of the Evaluating the Efficacy of e-Cigarette Use for Smoking Cessation Trial JO - JMIR Public Health Surveill SP - e58260 VL - 10 KW - nicotine KW - smoking cessation KW - e-cigarettes KW - vaping KW - weight change KW - weight gain N2 - Background: While smoking cessation has been linked to substantial weight gain, the potential influence of e-cigarettes on weight changes among individuals who use these devices to quit smoking is not fully understood. Objective: This study aims to reanalyze data from the Evaluating the Efficacy of e-Cigarette Use for Smoking Cessation (E3) trial to assess the causal effects of e-cigarette use on change in body weight. Methods: This is a secondary analysis of the E3 trial in which participants were randomized into 3 groups: nicotine e-cigarettes plus counseling, nonnicotine e-cigarettes plus counseling, and counseling alone. With adjustment for baseline variables and the follow-up smoking abstinence status, weight changes were compared between the groups from baseline to 12 weeks? follow-up. Intention-to-treat and as-treated analyses were conducted using doubly robust estimation. Further causal analysis used 2 different propensity scoring methods to estimate causal regression curves for 4 smoking-related continuous variables. We evaluated 5 different subsets of data for each method. Selection bias was addressed, and missing data were imputed by the machine learning method extreme gradient boosting (XGBoost). Results: A total of 257 individuals with measured weight at week 12 (mean age: 52, SD 12 y; women: n=122, 47.5%) were included. Across the 3 treatment groups, of the 257 participants, 204 (79.4%) who continued to smoke had, on average, largely unchanged weight at 12 weeks, with comparable mean weight gain ranging from ?0.24 kg to 0.33 kg, while 53 (20.6%) smoking-abstinent participants gained weight, with a mean weight gain ranging from 2.05 kg to 2.70 kg. After adjustment, our analyses showed that the 2 e-cigarette arms exhibited a mean gain of 0.56 kg versus the counseling alone arm. The causal regression curves analysis also showed no strong evidence supporting a causal relationship between weight gain and the 3 e-cigarette?related variables. e-Cigarettes have small and variable causal effects on weight gain associated with smoking cessation. Conclusions: In the E3 trial, e-cigarettes seemed to have minimal effects on mitigating the weight gain observed in individuals who smoke and subsequently quit at 3 months. However, given the modest sample size and the potential underuse of e-cigarettes among those randomized to the e-cigarette treatment arms, these results need to be replicated in large, adequately powered trials. Trial Registration: ClinicalTrials.gov NCT02417467; https://www.clinicaltrials.gov/study/NCT02417467 UR - https://publichealth.jmir.org/2024/1/e58260 UR - http://dx.doi.org/10.2196/58260 UR - http://www.ncbi.nlm.nih.gov/pubmed/39283667 ID - info:doi/10.2196/58260 ER - TY - JOUR AU - Suh, Jina AU - Howe, Esther AU - Lewis, Robert AU - Hernandez, Javier AU - Saha, Koustuv AU - Althoff, Tim AU - Czerwinski, Mary PY - 2024/9/12 TI - Toward Tailoring Just-in-Time Adaptive Intervention Systems for Workplace Stress Reduction: Exploratory Analysis of Intervention Implementation JO - JMIR Ment Health SP - e48974 VL - 11 KW - workplace stress KW - just-in-time KW - just-in-time adaptive intervention KW - JITAI KW - engagement KW - microintervention KW - stress reduction KW - psychotherapy N2 - Background: Integrating stress-reduction interventions into the workplace may improve the health and well-being of employees, and there is an opportunity to leverage ubiquitous everyday work technologies to understand dynamic work contexts and facilitate stress reduction wherever work happens. Sensing-powered just-in-time adaptive intervention (JITAI) systems have the potential to adapt and deliver tailored interventions, but such adaptation requires a comprehensive analysis of contextual and individual-level variables that may influence intervention outcomes and be leveraged to drive the system?s decision-making. Objective: This study aims to identify key tailoring variables that influence momentary engagement in digital stress reduction microinterventions to inform the design of similar JITAI systems. Methods: To inform the design of such dynamic adaptation, we analyzed data from the implementation and deployment of a system that incorporates passively sensed data across everyday work devices to send just-in-time stress reduction microinterventions in the workplace to 43 participants during a 4-week deployment. We evaluated 27 trait-based factors (ie, individual characteristics), state-based factors (ie, workplace contextual and behavioral signals and momentary stress), and intervention-related factors (ie, location and function) across 1585 system-initiated interventions. We built logistical regression models to identify the factors contributing to momentary engagement, the choice of interventions, the engagement given an intervention choice, the user rating of interventions engaged, and the stress reduction from the engagement. Results: We found that women (odds ratio [OR] 0.41, 95% CI 0.21-0.77; P=.03), those with higher neuroticism (OR 0.57, 95% CI 0.39-0.81; P=.01), those with higher cognitive reappraisal skills (OR 0.69, 95% CI 0.52-0.91; P=.04), and those that chose calm interventions (OR 0.43, 95% CI 0.23-0.78; P=.03) were significantly less likely to experience stress reduction, while those with higher agreeableness (OR 1.73, 95% CI 1.10-2.76; P=.06) and those that chose prompt-based (OR 6.65, 95% CI 1.53-36.45; P=.06) or video-based (OR 5.62, 95% CI 1.12-34.10; P=.12) interventions were substantially more likely to experience stress reduction. We also found that work-related contextual signals such as higher meeting counts (OR 0.62, 95% CI 0.49-0.78; P<.001) and higher engagement skewness (OR 0.64, 95% CI 0.51-0.79; P<.001) were associated with a lower likelihood of engagement, indicating that state-based contextual factors such as being in a meeting or the time of the day may matter more for engagement than efficacy. In addition, a just-in-time intervention that was explicitly rescheduled to a later time was more likely to be engaged with (OR 1.77, 95% CI 1.32-2.38; P<.001). Conclusions: JITAI systems have the potential to integrate timely support into the workplace. On the basis of our findings, we recommend that individual, contextual, and content-based factors be incorporated into the system for tailoring as well as for monitoring ineffective engagements across subgroups and contexts. UR - https://mental.jmir.org/2024/1/e48974 UR - http://dx.doi.org/10.2196/48974 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/48974 ER - TY - JOUR AU - Braddock, Amy AU - Ghosh, Parijat AU - Montgomery, Emma AU - Lim, Crystal AU - Ghosh, Jaya AU - Henry, Nicole AU - Popescu, Mihail AU - Kimchi, Kimberly AU - Guo, Congyu AU - Bosworth, Taylor K. AU - Koopman, J. Richelle PY - 2024/9/10 TI - Effectiveness of an mHealth App That Uses Financial Incentives and Gamification to Promote Health Behavior Change in Adolescents and Caregivers: Protocol for a Clinic-Based Randomized Controlled Trial JO - JMIR Res Protoc SP - e63505 VL - 13 KW - mHealth KW - adolescents KW - apps KW - caregivers KW - obesity KW - healthy lifestyle KW - CommitFit KW - mobile health N2 - Background: Adolescent and adult obesity continues to be a public health epidemic in the United States. Despite the popularity of mHealth apps with gamification among adolescents, there are insufficient studies to evaluate the efficacy of gamified mHealth apps and financial incentives to motivate sustained health behavior change in adolescents or their adult caregivers. Objective: This study aims to evaluate the effectiveness of gamification techniques and financial incentives used in the novel ?CommitFit? mHealth app to motivate health behavior change and improve various mental and physical health metrics in adolescents and their caregivers. Methods: This study is a 3-month randomized controlled trial (RCT) with 30 adolescents (aged 13-15 years) and their adult caregivers (N=60). It evaluates ?CommitFit,? which uses gamification including points and leaderboards to motivate logging and achievement of self-selected health behavior goals (eg, more water, sleep, physical activity, fruits, or vegetables or fewer sugary beverages). The RCT had three arms, each with 10 dyads: (1) CommitFit-only users; (2) CommitFit$, where adolescents were paid US $0.05 for each point they earned; and (3) waitlist control. Intervention dyads used the app for 3 months and had the option to use it for the fourth month without prompts or extra financial incentives. User analytic software was used to evaluate the frequency of user logs and goal achievement. Monthly surveys evaluated self-reported change in the 5 CommitFit health behaviors. Changes in BMI and blood pressure were evaluated for all participants at 3 clinical visits. Mental health, gamification, and behavior economics surveys were completed during the clinical visits. Results: Recruitment began in August 2023 and was completed in 10 weeks. The research team successfully recruited and enrolled 30 dyads. Researchers emailed and called 89 caregivers on a physician-approved adolescent patient list, a 33% recruitment rate. Data collection and analysis will be conducted in the spring and summer of 2024. The results of this study are anticipated to be published between late 2024 and early 2025. Conclusions: This RCT will expand knowledge of the effectiveness of gamification techniques, financial incentives, and mHealth apps to motivate sustained health behavior change among adolescents and caregivers. These results may offer new opportunities to caregivers, health insurers, health care systems, and clinicians to motivate health behavior change in adolescents and caregivers, with the ultimate goal of preventing or reducing obesity and obesity-related diseases. Additional gamification, mental health surveys, and app user analytics included in the study may provide further insight into the characteristics of adolescents or caregivers who would benefit the most from using a gamified mHealth app like CommitFit. International Registered Report Identifier (IRRID): DERR1-10.2196/63505 UR - https://www.researchprotocols.org/2024/1/e63505 UR - http://dx.doi.org/10.2196/63505 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/63505 ER - TY - JOUR AU - Wähnke, Laura AU - Dose, Christina AU - Klemp, Marie-Theres AU - Mühlenmeister, Judith AU - Plück, Julia AU - Döpfner, Manfred PY - 2024/9/4 TI - The Relationship Between Symptom Change and Use of a Web-Based Self-Help Intervention for Parents of Children With Externalizing Behavior Disorders: Exploratory Study JO - JMIR Pediatr Parent SP - e54051 VL - 7 KW - web-based self-help KW - eHealth KW - parent management training KW - externalizing symptom KW - ADHD KW - attention-deficit hyperactivity disorder KW - self-help KW - use KW - child KW - children KW - parent KW - parents KW - management KW - management training KW - symptom KW - symptoms KW - caregiver KW - ODD KW - oppositional defiant disorder KW - treatment KW - web-based KW - caregivers KW - longitudinal data N2 - Background: Web-based self-help (WASH) has been found to be effective in the treatment of child externalizing behavior disorders. However, research on the associations of caregivers? use of WASH and symptom changes of child externalizing behaviors is lacking. Objective: This study examined the longitudinal and reciprocal associations between the use of WASH by caregivers of children with externalizing behavior disorders and their children?s externalizing behavior symptoms. Methods: Longitudinal data of 276 families from 2 intervention conditions of a randomized controlled trial (either unguided or supported by a therapist over the phone) were analyzed. Caregiver- and clinician-rated child externalizing behavior symptoms were assessed before (T1), in the middle (T2), and after the 6-month WASH intervention (T3). Additionally, 2 indicators of the caregivers? use of the WASH intervention were considered: number of log-ins (frequency) and the percentage of completed material (intensity). Associations of caregivers? use during early (T1-T2) and late (T2-T3) treatment with child externalizing behavior symptoms were analyzed using path analyses (structural equation modeling). Results: Frequency and intensity of use were higher during the first 3 months than during the next 3 months of the intervention period. The number of log-ins at early treatment was significantly but weakly associated with caregiver-reported child externalizing behavior symptoms in the long term (T3). Moreover, caregiver-reported child externalizing severity at T2 predicted the number of log-ins in the late treatment. The results were not replicated when considering the percentage of completed material as a measure of use or when considering clinician ratings of child externalizing behavior symptoms. Conclusions: The findings provide the first, albeit weak, evidence for longitudinal associations between caregivers? use of WASH and improvements in caregiver-rated child externalizing behavior symptoms. However, as the associations were rather weak and could not be replicated across different rater perspectives and operationalizations of use, further research is needed to better understand these relations and their interplay with other putative influence factors (eg, quality of the implementation of the interventions, changes in parenting behaviors). Trial Registration: German Clinical Trials Register DRKS00013456; https://www.drks.de/DRKS00013456 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-020-2481-0 UR - https://pediatrics.jmir.org/2024/1/e54051 UR - http://dx.doi.org/10.2196/54051 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54051 ER - TY - JOUR AU - Mahtani, L. Sitara AU - Viswanath, Kasisomayajula AU - Gupte, A. Himanshu AU - Mandal, Gauri AU - Jagiasi, Dinesh AU - Chawla, Ratandeep AU - D'Costa, Marina AU - Xuan, Ziming AU - Minsky, Sara AU - Ramanadhan, Shoba PY - 2024/9/3 TI - Adapting and Evaluating a Brief Advice Tobacco Cessation Intervention in High-reach, Low-resource Settings in India: Protocol for a Cluster Randomized Controlled Trial JO - JMIR Res Protoc SP - e57236 VL - 13 KW - tobacco use Cessation KW - India KW - resource-limited settings KW - task-shifting KW - counseling KW - nonprofit organizations KW - dental health services KW - tuberculosis KW - social media KW - mobile app N2 - Background: About 1.35 million deaths annually are attributed to tobacco use in India. The main challenge, given the magnitude of tobacco use and limited resources, is delivering cessation support at scale, low cost, and through a coordinated cross-system effort; one such example being brief advice interventions. However, highly credentialed staff to identify and counsel tobacco users are scarce. Task-shifting is an important opportunity for scaling these interventions. Objective: The LifeFirst SWASTH (Supporting Wellbeing among Adults by Stopping Tobacco Habit) program?adapted from the LifeFirst program (developed by the Narotam Sekhsaria Foundation, Mumbai, India)?is a tobacco cessation program focusing on lower-socioeconomic status patients in Mumbai receiving private health care. This parallel-arm, cluster randomized controlled trial investigates whether the LifeFirst SWASTH program increases tobacco cessation rates in low-resource, high-reach health care settings in Mumbai. Methods: This study will target tuberculosis-specific nongovernmental organizations (NGOs), dental clinics, and NGOs implementing general health programs serving lower-socioeconomic status patients. Intervention arm patients will receive a pamphlet explaining tobacco?s harmful effects. Practitioners will be trained to deliver brief cessation advice, and interested patients will be referred to a Narotam Sekhsaria Foundation counselor for free telephone counseling for 6 months. Control arm patients will receive the same pamphlet but not brief advice or counseling. Practitioners will have a customized mobile app to facilitate intervention delivery. Practitioners will also have access to a peer network through WhatsApp. The primary outcome is a 30-day point prevalence abstinence from tobacco. Secondary outcomes for patients and practitioners relate to intervention implementation. Results: The study was funded in June 2020. Due to the COVID-19 pandemic, the study experienced some delays, and practitioner recruitment commenced in November 2023. As of July 2024, all practitioners have been recruited, and practitioner recruitment and training are complete. Furthermore, 36% (1687/4688) of patients have been recruited. Conclusions: It is hypothesized that those patients who participated in the LifeFirst SWASTH program will be more likely to have been abstinent from tobacco for 30 consecutive days by the end of 6 months or at least decreased their tobacco use. LifeFirst SWASTH, if found to be effective in terms of cessation outcomes and implementation, has the potential to be scaled to other settings in India and other low- and middle-income countries. The study will be conducted in low-resource settings and will reach many patients, which will increase the impact if scaled. It will use task-shifting and an app that can be tailored to different settings, also enabling scalability. Findings will build the literature for translating evidence-based interventions from high-income countries to low- and middle-income countries and from high- to low-resource settings. Trial Registration: ClinicalTrials.gov NCT05234983; https://clinicaltrials.gov/study/NCT05234983 International Registered Report Identifier (IRRID): DERR1-10.2196/57236 UR - https://www.researchprotocols.org/2024/1/e57236 UR - http://dx.doi.org/10.2196/57236 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57236 ER - TY - JOUR AU - Banire, Bilikis AU - Orr, Matt AU - Burns, Hailey AU - McGowan, Youna AU - Orji, Rita AU - Meier, Sandra PY - 2024/9/2 TI - Smartphone-Delivered Attentional Bias Modification Training for Mental Health: Systematic Review and Meta-Analysis JO - JMIR Ment Health SP - e56326 VL - 11 KW - attentional bias KW - mental health problem KW - anxiety KW - depression KW - systematic review KW - meta-analysis KW - smartphone KW - mobile phone N2 - Background: Smartphone-delivered attentional bias modification training (ABMT) intervention has gained popularity as a remote solution for alleviating symptoms of mental health problems. However, the existing literature presents mixed results indicating both significant and insignificant effects of smartphone-delivered interventions. Objective: This systematic review and meta-analysis aims to assess the impact of smartphone-delivered ABMT on attentional bias and symptoms of mental health problems. Specifically, we examined different design approaches and methods of administration, focusing on common mental health issues, such as anxiety and depression, and design elements, including gamification and stimulus types. Methods: Our search spanned from 2014 to 2023 and encompassed 4 major databases: MEDLINE, PsycINFO, PubMed, and Scopus. Study selection, data extraction, and critical appraisal were performed independently by 3 authors using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. When necessary, we pooled the standardized mean difference with a 95% CI. In addition, we conducted sensitivity, subgroup, and meta-regression analyses to explore moderator variables of active and placebo ABMT interventions on reducing symptoms of mental health problems and attentional bias. Results: Our review included 12 papers, involving a total of 24,503 participants, and we were able to conduct a meta-analysis on 20 different study samples from 11 papers. Active ABMT exhibited an effect size (Hedges g) of ?0.18 (P=.03) in reducing symptoms of mental health problems, while the overall effect remained significant. Similarly, placebo ABMT showed an effect size of ?0.38 (P=.008) in reducing symptoms of mental health problems. In addition, active ABMT (Hedges g ?0.17; P=.004) had significant effects on reducing attentional bias, while placebo ABMT did not significantly alter attentional bias (Hedges g ?0.04; P=.66). Conclusions: Our understanding of smartphone-delivered ABMT?s potential highlights the value of both active and placebo interventions in mental health care. The insights from the moderator analysis also showed that tailoring smartphone-delivered ABMT interventions to specific threat stimuli and considering exposure duration are crucial for optimizing their efficacy. This research underscores the need for personalized approaches in ABMT to effectively reduce attentional bias and symptoms of mental health problems. Trial Registration: PROSPERO CRD42023460749; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=460749 UR - https://mental.jmir.org/2024/1/e56326 UR - http://dx.doi.org/10.2196/56326 UR - http://www.ncbi.nlm.nih.gov/pubmed/39222349 ID - info:doi/10.2196/56326 ER - TY - JOUR AU - Santopetro, Nicholas AU - Jones, Danielle AU - Garron, Andrew AU - Meyer, Alexandria AU - Joyner, Keanan AU - Hajcak, Greg PY - 2024/8/30 TI - Examining a Fully Automated Mobile-Based Behavioral Activation Intervention in Depression: Randomized Controlled Trial JO - JMIR Ment Health SP - e54252 VL - 11 KW - digital intervention KW - digital health KW - digital application KW - digital applications KW - mobile health KW - mHealth KW - automation KW - automate KW - automated KW - behavioral activation KW - BA KW - BA intervention KW - depression KW - depressed KW - depressive KW - depressive symptoms KW - anhedonia KW - anhedonia symptoms KW - anxiety KW - anxious KW - anxiety symptoms KW - adults KW - adult KW - psychiatry KW - psych KW - psychology KW - major depressive disorder KW - MDD N2 - Background: Despite significant progress in our understanding of depression, prevalence rates have substantially increased in recent years. Thus, there is an imperative need for more cost-effective and scalable mental health treatment options, including digital interventions that minimize therapist burden. Objective: This study focuses on a fully automated digital implementation of behavioral activation (BA)?a core behavioral component of cognitive behavioral therapy for depression. We examine the efficacy of a 1-month fully automated SMS text message?based BA intervention for reducing depressive symptoms and anhedonia. Methods: To this end, adults reporting at least moderate current depressive symptoms (8-item Patient Health Questionnaire score ?10) were recruited online across the United States and randomized to one of three conditions: enjoyable activities (ie, BA), healthy activities (ie, an active control condition), and passive control (ie, no contact). Participants randomized to enjoyable and healthy activities received daily SMS text messages prompting them to complete 2 activities per day; participants also provided a daily report on the number and enjoyment of activities completed the prior day. Results: A total of 126 adults (mean age 32.46, SD 7.41 years) with current moderate depressive symptoms (mean score 16.53, SD 3.90) were recruited. Participants in the enjoyable activities condition (BA; n=39) experienced significantly greater reductions in depressive symptoms compared to participants in the passive condition (n=46). Participants in both active conditions?enjoyable activities and healthy activities (n=41)?reported reduced symptoms of anxiety compared to those in the control condition. Conclusions: These findings provide preliminary evidence regarding the efficacy of a fully automated digital BA intervention for depression and anxiety symptoms. Moreover, reminders to complete healthy activities may be a promising intervention for reducing anxiety symptoms. Trial Registration: ClincalTrials.gov NCT06492824; https://clinicaltrials.gov/study/NCT06492824 UR - https://mental.jmir.org/2024/1/e54252 UR - http://dx.doi.org/10.2196/54252 ID - info:doi/10.2196/54252 ER - TY - JOUR AU - Suffoletto, Brian PY - 2024/8/27 TI - Deceptively Simple yet Profoundly Impactful: Text Messaging Interventions to Support Health JO - J Med Internet Res SP - e58726 VL - 26 KW - SMS intervention KW - behavior KW - intervention KW - review KW - text messaging KW - SMS KW - interventions KW - behaviors KW - behaviour KW - behaviours KW - effectiveness KW - development KW - impact KW - narrative review KW - physical activity KW - diet KW - weight loss KW - mental health KW - substance use KW - meta-analysis KW - chatbot KW - chatbots KW - large language model KW - LLM KW - large language models KW - mobile phone UR - https://www.jmir.org/2024/1/e58726 UR - http://dx.doi.org/10.2196/58726 UR - http://www.ncbi.nlm.nih.gov/pubmed/39190427 ID - info:doi/10.2196/58726 ER - TY - JOUR AU - Knutzen, Møgelberg Sofie AU - Christensen, Skjærlund Dinne AU - Cairns, Patrick AU - Damholdt, Flensborg Malene AU - Amidi, Ali AU - Zachariae, Robert PY - 2024/8/26 TI - Efficacy of eHealth Versus In-Person Cognitive Behavioral Therapy for Insomnia: Systematic Review and Meta-Analysis of Equivalence JO - JMIR Ment Health SP - e58217 VL - 11 KW - sleep disturbance KW - digital KW - telehealth KW - face-to-face KW - head-to-head comparison KW - CBTI KW - cognitive behavioral therapy for insomnia KW - mobile phone N2 - Background: Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive behavioral therapy for insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person?delivered CBTI (ipCBTI), electronically delivered eHealth CBTI (eCBTI), ranging from telephone- and videoconference-delivered interventions to fully automated web-based programs and mobile apps, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined. Objective: This study aims to test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized controlled trials directly comparing the 2 delivery formats. Methods: A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and nonsleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences. Supplementary Bayesian analyses were conducted to determine the strength of the available evidence. Results: The meta-analysis included 15 studies with a total of 1083 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the 2 delivery formats were statistically significantly equivalent (P<.05) for most sleep and nonsleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements (P<.05) in insomnia severity; sleep quality; and secondary outcomes such as fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and dropout rates as potential moderators of the differences in treatment efficacy. Conclusions: eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and dropout rates on efficacy. Trial Registration: PROSPERO CRD42023390811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=390811 UR - https://mental.jmir.org/2024/1/e58217 UR - http://dx.doi.org/10.2196/58217 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/58217 ER - TY - JOUR AU - Kim, Ae Seung AU - Han, Kyungdo AU - Choi, Soyoun AU - Youn, Sojung Michelle AU - Jang, Hyemin AU - Lee, Ji Mi PY - 2024/8/23 TI - Effect of Smoking on the Development of Migraine in Women: Nationwide Cohort Study in South Korea JO - JMIR Public Health Surveill SP - e58105 VL - 10 KW - smoking KW - migraine KW - premenopausal women KW - postmenopausal women KW - incidence KW - risk N2 - Background: Smoking is known to be a significant risk factor for various diseases. Migraine, a condition requiring careful lifestyle management, currently lacks specific guidelines advocating for smoking cessation as a preventive measure. Although cross-sectional studies have suggested a potential link between smoking and an increased risk of migraine, the findings have been inconsistent and conflicting. To date, there has been no longitudinal study which investigated the effect of smoking on the risk of migraine in a prospective setting. Objective: This longitudinal study aimed to investigate the impact of smoking on the incidence of migraine in women and examine the modifying effect of menopausal status. Methods: Using nationally representative National Health Insurance Service (NHIS) data, women aged ?40 years who participated in national breast cancer screening in 2009 were followed-up until the end of 2019. Baseline data on smoking status (non-, ex-, and current smoker) as well as the duration and amount of cigarette smoking were collected. A Cox proportional hazards regression model was used to examine the independent effect of smoking on the risk of incident migraine after adjusting for demographics, comorbidities, and female reproductive factors. The results were stratified by menopausal status, and an interaction analysis (smoking × menopause) was performed. Results: In total, 1,827,129 women were included in the analysis. Women with a history of smoking exhibited a higher risk of developing migraine, compared with nonsmokers. Specifically, a higher risk of migraine was observed in women with past (adjusted hazard ratio [HR] 1.044, 95% CI 1.000-1.089) and current cigarette use (adjusted HR 1.050, 95% CI, 1.023-1.079) than in nonsmokers. The effect was greater in premenopausal women (adjusted HR 1.140, 95% CI, 1.108-1.172) than in postmenopausal women (adjusted HR 1.045, 95% CI 1.018-1.073; P<.001). The risk increased with an increased amount of smoking, with a greater association in premenopausal women (P<.001). Conclusions: Smoking increases the risk of migraine in women, with a dose-dependent relationship. Menopause modifies this effect. Our findings suggest that smoking is an important modifiable risk factor of migraine, with a higher impact in premenopausal women. The interaction between smoking and estrogen may increase the vulnerability of the migraine brain. UR - https://publichealth.jmir.org/2024/1/e58105 UR - http://dx.doi.org/10.2196/58105 ID - info:doi/10.2196/58105 ER - TY - JOUR AU - Pedersen, R. Eric AU - Davis, P. Jordan AU - Hummer, F. Justin AU - Bouskill, Kathryn AU - Buch, D. Keegan AU - Shute, M. Ireland AU - Fitzke, E. Reagan AU - Tran, D. Denise AU - Neighbors, Clayton AU - Saba, Shaddy PY - 2024/8/22 TI - Reducing Alcohol Misuse and Promoting Treatment Initiation Among Veterans Through a Brief Internet-Based Intervention: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e59993 VL - 13 KW - military KW - mental health KW - substance use KW - mobile KW - PTSD KW - posttraumatic stress disorder KW - drinking KW - mobile intervention KW - digital intervention KW - alcohol KW - alcohol misuse KW - veterans KW - young adults KW - depression KW - alcohol use KW - veteran health KW - veteran N2 - Background: Young adult veterans who served after the September 11 attacks on the United States in 2001 (ie, post-9/11) are at heightened risk for experiencing behavioral health distress and disorders including hazardous drinking, posttraumatic stress disorder, and depression. These veterans often face significant barriers to behavioral health treatment, and reaching them through brief mobile phone?based interventions may help reduce drinking and promote treatment engagement. Objective: Following a successful pilot study, this randomized controlled trial (RCT) aims to further test the efficacy of a brief (ie, single session) mobile phone?delivered personalized normative feedback intervention enhanced with content to promote treatment engagement. Methods: We will conduct an RCT with 800 post-9/11 young adult veterans (aged 18 to 40 years) with potentially hazardous drinking and who have not recently received treatment for any behavioral health problems. Participants will be randomly assigned to the personalized intervention or a control condition with resources for seeking care. The personalized normative feedback module in the intervention focuses on the correction of misperceived norms of peer alcohol use and uses empirically informed approaches to increase motivation to address alcohol use and co-occurring behavioral health problems. Past 30-day drinking, alcohol-related consequences, and treatment-seeking behaviors will be assessed at baseline and 3, 6, 9, and 12 months post intervention. Sex, barriers to care, posttraumatic stress disorder, depression, and severity of alcohol use disorder symptoms will be explored as potential moderators of outcomes. Results: We expect recruitment to be completed within 6 months, with data collection taking 12 months for each enrolled participant. Analyses will begin within 3 months of the final data collection point (ie, 12 months follow-up). Conclusions: This RCT will evaluate the efficacy of a novel intervention for non?treatment-seeking veterans who struggle with hazardous drinking and possible co-occurring behavioral health problems. This intervention has the potential to improve veteran health outcomes and overcome significant barriers to treatment. Trial Registration: ClinicalTrials.gov NCT04244461; https://clinicaltrials.gov/study/NCT04244461 International Registered Report Identifier (IRRID): DERR1-10.2196/59993 UR - https://www.researchprotocols.org/2024/1/e59993 UR - http://dx.doi.org/10.2196/59993 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59993 ER - TY - JOUR AU - Jackson, Rosie AU - Gu, Chao AU - Haszard, Jillian AU - Meredith-Jones, Kim AU - Galland, Barbara AU - Camp, Justine AU - Brown, Deirdre AU - Taylor, Rachael PY - 2024/8/20 TI - The Effect of Prebedtime Behaviors on Sleep Duration and Quality in Children: Protocol for a Randomized Crossover Trial JO - JMIR Res Protoc SP - e63692 VL - 13 KW - screen time KW - digital device KW - diet KW - physical activity KW - objective measurement KW - wearable camera KW - sleep KW - mobile phone N2 - Background: It is recommended that children should avoid eating dinner, being physically active, or using screens in the hour before bed to ensure good sleep health. However, the evidence base behind these guidelines is weak and limited to cross-sectional studies using questionnaires. Objective: The aim of this randomized crossover trial was to use objective measures to experimentally determine whether recommendations to improve sleep by banning electronic media, physical activity, or food intake in the hour before bed, impact sleep quantity and quality in the youth. Methods: After a baseline week to assess usual behavior, 72 children (10-14.9 years old) will be randomized to four conditions, which are (1) avoid all 3 behaviors, (2) use screens for at least 30 minutes, (3) be physically active for at least 30 minutes, and (4) eat a large meal, during the hour before bed on days 5 to 7 of weeks 2 to 5. Families can choose which days of the week they undertake the intervention, but they must be the same days for each intervention week. Guidance on how to undertake each intervention will be provided. Interventions will only be undertaken during the school term to avoid known changes in sleep during school holidays. Intervention adherence and shuteye latency (time from getting into bed until attempting sleep) will be measured by wearable and stationary PatrolEyes video cameras (StuntCams). Sleep (total sleep time, sleep onset, and wake after sleep onset) will be measured using actigraphy (baseline, days 5 to 7 of each intervention week). Mixed effects regression models with a random effect for participants will be used to estimate mean differences (95% CI) for conditions 2 to 4 compared with condition 1. Results: Recruitment started in March 2024, and is anticipated to finish in April 2025. Following data analysis, we expect that results will be available later in 2026. Conclusions: Using objective measures, we will be able to establish if causal relationships exist between prebedtime behaviors and sleep in children. Such information is critical to ensure appropriate and achievable sleep guidelines. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12624000206527; https://tinyurl.com/3kcjmfnj International Registered Report Identifier (IRRID): DERR1-10.2196/63692 UR - https://www.researchprotocols.org/2024/1/e63692 UR - http://dx.doi.org/10.2196/63692 UR - http://www.ncbi.nlm.nih.gov/pubmed/39163119 ID - info:doi/10.2196/63692 ER - TY - JOUR AU - Bore, Per AU - Nilsson, Sara AU - Andersson, Mitchell AU - Oehm, Kajsa AU - Attvall, Joel AU - Håkansson, Anders AU - Claesdotter-Knutsson, Emma PY - 2024/8/16 TI - Effectiveness and Acceptability of Cognitive Behavioral Therapy and Family Therapy for Gaming Disorder: Protocol for a Nonrandomized Intervention Study of a Novel Psychological Treatment JO - JMIR Res Protoc SP - e56315 VL - 13 KW - gaming disorder KW - psychological treatment KW - CBT KW - cognitive behavioral therapy KW - family therapy KW - effectiveness KW - acceptability KW - gaming KW - addiction KW - mixed method design KW - video games KW - leisure activity KW - Sweden KW - young adult KW - teenager KW - internet gaming disorder N2 - Background: Gaming disorder (GD) is a new official diagnosis in the International Classification of Diseases, 11th Revision, and with its recognition, the need to offer treatment for the condition has become apparent. More knowledge is needed about the type of treatment needed for this group of patients. Objective: This study aims to evaluate the effectiveness and acceptability of a novel module-based psychological treatment for GD based on cognitive behavioral therapy and family therapy. Methods: This study is a nonrandomized intervention study, with a pretest, posttest, and 3-month follow-up design. It will assess changes in GD symptoms, psychological distress, and gaming time, alongside treatment satisfaction, working alliance, and a qualitative exploration of patients? and relatives? experiences of the treatment. Results: This study started in March 2022 and the recruitment is expected to close in August 2024. Conclusions: This study evaluates the effectiveness and acceptability of a psychological treatment for patients with problematic gaming behavior and GD. It is an effectiveness trial and will be conducted in routine care. This study will have high external validity and ensure that the results are relevant for a diverse clinical population with psychiatric comorbidity. Trial Registration: ClinicalTrials.gov NCT06018922; https://clinicaltrials.gov/study/NCT06018922 International Registered Report Identifier (IRRID): DERR1-10.2196/56315 UR - https://www.researchprotocols.org/2024/1/e56315 UR - http://dx.doi.org/10.2196/56315 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56315 ER - TY - JOUR AU - Bourne, E. Jessica AU - Kelly, Paul AU - Armstrong, G. Miranda E. PY - 2024/8/16 TI - A Theory and Evidence-Informed e-Cycling Intervention for Individuals Diagnosed With Cancer: Development Study JO - JMIR Cancer SP - e54785 VL - 10 KW - prostate cancer KW - breast cancer KW - electrically assisted cycling KW - physical activity promotion KW - behavior change techniques KW - BCTs KW - Behaviour Change Wheel KW - Medical Research Council KW - Theoretical Domains Framework KW - TDF KW - physical activity KW - e-cycling intervention KW - e-cycling KW - cancer KW - risk of disease KW - all-cause mortality KW - behavioral health KW - instructor KW - instructors KW - cancer survivor KW - patient with cancer KW - healthy lifestyle KW - intervention KW - physical fitness KW - exercise N2 - Background: Physical activity engagement following a cancer diagnosis is positively associated with survival, reduced risk of disease recurrence, and reduced cancer-specific and all-cause mortality. However, rates of physical activity engagement are low among individuals diagnosed with and being treated for breast cancer or prostate cancer. Objective: The purpose of this study was to describe the systematic process of developing an e-cycling intervention aimed at increasing physical activity among individuals living with prostate cancer or breast cancer and outline the key components to be implemented. Methods: The Medical Research Council guidance for developing complex interventions and the Behaviour Change Wheel were used to guide intervention development. Information was gathered from the literature and through discussions with end users to understand factors influencing e-cycling. These factors were mapped onto the Theoretical Domains Framework to identify potential mechanisms of action. Behavior change techniques were selected from theory and evidence to develop intervention content. Interested parties, including cycling instructors, end users, and behavior change experts, reviewed and refined the intervention. Results: Anticipated barriers and facilitators to e-cycling engagement were mapped onto 11 of the 14 domains of the Theoretical Domains Framework. A total of 23 behavior change techniques were selected to target these domains over 4 one-to-one e-cycling sessions delivered by trained cycling instructors in the community. Cycling instructors were provided a 3-hour classroom training session on delivering the intervention and a 3-hour practical session with feedback. The outcome of this work is a theory and evidence-informed intervention aimed at promoting e-cycling behavior among individuals being treated for breast cancer or prostate cancer, which is currently being implemented and evaluated. Conclusions: Transparent intervention development and reporting of content is important for comprehensively examining intervention implementation. The implementation of this intervention package is currently being evaluated in a pilot randomized controlled trial. If the intervention is found to be effective and the content and delivery are acceptable, this intervention will form a basis for the development of e-cycling interventions in other survivors of cancer. Trial Registration: ISRCTN Registry ISRCTN39112034 https://www.isrctn.com/ISRCTN39112034; and IRSCTN Registry ISRCTN42852156;https://www.isrctn.com/ISRCTN42852156 UR - https://cancer.jmir.org/2024/1/e54785 UR - http://dx.doi.org/10.2196/54785 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54785 ER - TY - JOUR AU - McCall, C. Hugh AU - Hadjistavropoulos, D. Heather PY - 2024/8/14 TI - Impact of an Online Discussion Forum on Self-Guided Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Randomized Trial JO - J Med Internet Res SP - e59699 VL - 26 KW - internet KW - cognitive behavioral therapy KW - forum KW - persuasive design KW - generalized anxiety disorder KW - major depressive disorder KW - posttraumatic stress disorder KW - public safety personnel N2 - Background: Internet-delivered cognitive behavioral therapy (ICBT) is an effective and accessible treatment for various mental health concerns. ICBT has shown promising treatment outcomes among public safety personnel (PSP), who experience high rates of mental health problems and face barriers to accessing other mental health services. Client engagement and clinical outcomes are better in ICBT with therapist guidance, but ICBT is easier to implement on a large scale when it is self-guided. Therefore, it is important to identify strategies to improve outcomes and engagement in self-guided ICBT and other self-guided digital mental health interventions. One such strategy is the use of online discussion forums to provide ICBT clients with opportunities for mutual social support. Self-guided interventions accompanied by online discussion forums have shown excellent treatment outcomes, but there is a need for research experimentally testing the impact of online discussion forums in ICBT. Objective: We aimed to evaluate a transdiagnostic, self-guided ICBT intervention tailored specifically for PSP (which had not previously been assessed), assess the impact of adding a therapist-moderated online discussion forum on outcomes, and analyze participants? feedback to inform future research and implementation efforts. Methods: In this randomized trial, we randomly assigned participating PSP (N=107) to access an 8-week transdiagnostic, self-guided ICBT course with or without a built-in online discussion forum. Enrollment and participation were entirely web-based. We assessed changes in depression, anxiety, and posttraumatic stress as well as several secondary outcome measures (eg, treatment engagement and satisfaction) using questionnaires at the pre-enrollment, 8-week postenrollment, and 20-week postenrollment time points. Mixed methods analyses included multilevel modeling and qualitative content analysis. Results: Participants engaged minimally with the forum, creating 9 posts. There were no differences in treatment outcomes between participants who were randomly assigned to access the forum (56/107, 52.3%) and those who were not (51/107, 47.7%). Across conditions, participants who reported clinically significant symptoms during enrollment showed large and statistically significant reductions in symptoms (P<.05 and d>0.97 in all cases). Participants also showed good treatment engagement and satisfaction, with 43% (46/107) of participants fully completing the intervention during the course of the study and 96% (79/82) indicating that the intervention was worth their time. Conclusions: Previous research has shown excellent clinical outcomes for self-guided ICBT accompanied by discussion forums and good engagement with those forums. Although clinical outcomes in our study were excellent across conditions, engagement with the forum was poor, in contrast to previous research. We discuss several possible interpretations of this finding (eg, related to the population under study or the design of the forum). Our findings highlight a need for more research evaluating the impact of online discussion forums and other strategies for improving outcomes and engagement in self-guided ICBT and other digital mental health interventions. Trial Registration: ClinicalTrials.gov NCT05145582; https://clinicaltrials.gov/study/NCT05145582 UR - https://www.jmir.org/2024/1/e59699 UR - http://dx.doi.org/10.2196/59699 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59699 ER - TY - JOUR AU - Edge, Daniel AU - Watkins, Edward AU - Newbold, Alexandra AU - Ehring, Thomas AU - Frost, Mads AU - Rosenkranz, Tabea PY - 2024/8/13 TI - Evaluating the Effects of a Self-Help Mobile Phone App on Worry and Rumination Experienced by Young Adults: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e51932 VL - 12 KW - worry KW - rumination KW - repetitive negative thinking KW - prevention-mechanism KW - well-being KW - depression KW - anxiety KW - mobile-based interventions KW - mobile phone KW - mobile health application KW - app KW - application N2 - Background: Delivery of preventative interventions via mobile phone apps offers an effective and accessible way to address the global priority of improving the mental health of adolescents and young adults. A proven risk factor for anxiety and depression is elevated worry and rumination, also known as repetitive negative thinking (RNT). Objective: This was a prevention mechanism trial that aimed to investigate whether an RNT-targeting self-help mobile phone app (MyMoodCoach) reduces worry and rumination in young adults residing in the United Kingdom. A secondary objective was to test whether the app reduces symptoms of anxiety and depression and improves well-being. Methods: A web-based, single-blind, 2-arm parallel-group randomized controlled trial was conducted with 236 people aged between 16 and 24 years, who self-reported high levels of worry or rumination. Eligible participants were randomized to an active intervention group (usual practice, plus up to 6 weeks of using the RNT-targeting mobile app, n=119) or a waitlist control group (usual practice with no access to the app until after 6 weeks, n=117). The primary outcome was changes in worry and rumination 6 weeks after randomization. Secondary outcomes included changes in well-being and symptoms of anxiety and depression after 6 weeks and changes in all measures after 12 weeks. Results: Participants randomly allocated to use the RNT-targeting self-help app showed significantly lower levels of rumination (mean difference ?2.92, 95% CI ?5.57 to ?0.28; P=.03; ?p2=0.02) and worry (mean difference ?3.97, 95% CI ?6.21 to ?1.73; P<.001; ?p2=0.06) at 6-week follow-up, relative to the waitlist control. Similar differences were observed for well-being (P<.001), anxiety (P=.03), and depression (P=.04). The waitlist control group also showed improvement when given access to the app after 6 weeks. Improvements observed in the intervention group after 6 weeks of using the app were maintained at the 12-week follow-up point. Conclusions: The MyMoodCoach app had a significant positive effect on worry and rumination, well-being, anxiety, and depression in young adults, relative to waitlist controls, providing proof-of-principle that an unguided self-help app can effectively reduce RNT. This app, therefore, has potential for the prevention of anxiety and depression although longer-term effects on incidence need to be directly evaluated. Trial Registration: ClinicalTrials.gov NCT04950257; https://www.clinicaltrials.gov/ct2/show/NCT04950257 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-021-03536-0 UR - https://mhealth.jmir.org/2024/1/e51932 UR - http://dx.doi.org/10.2196/51932 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/51932 ER - TY - JOUR AU - Tepencelik, Necip Onur AU - Wei, Wenchuan AU - Luo, Mirabel AU - Cosman, Pamela AU - Dey, Sujit PY - 2024/8/12 TI - Behavioral Intervention for Adults With Autism on Distribution of Attention in Triadic Conversations: A/B-Tested Pre-Post Study JO - JMIR Form Res SP - e55339 VL - 8 KW - autism spectrum condition KW - social attention KW - social orienting KW - behavioral intervention KW - attention distribution KW - triadic conversation N2 - Background: Cross-neurotype differences in social communication patterns contribute to high unemployment rates among adults with autism. Adults with autism can be unsuccessful in job searches or terminated from employment due to mismatches between their social attention behaviors and society?s expectations on workplace communication. Objective: We propose a behavioral intervention concerning distribution of attention in triadic (three-way) conversations. Specifically, the objective is to determine whether providing personalized feedback to each individual with autism based on an analysis of their attention distribution behavior during an initial conversation session would cause them to modify their orientation behavior in a subsequent conversation session. Methods: Our system uses an unobtrusive head orientation estimation model to track the focus of attention of each individual. Head orientation sequences from a conversation session are analyzed based on five statistical domains (eg, maximum exclusion duration and average contact duration) representing different types of attention distribution behavior. An intervention is provided to a participant if they exceeded the nonautistic average for that behavior by at least 2 SDs. The intervention uses data analysis and video modeling along with a constructive discussion about the targeted behaviors. Twenty-four individuals with autism with no intellectual disabilities participated in the study. The participants were divided into test and control groups of 12 participants each. Results: Based on their attention distribution behavior in the initial conversation session, 11 of the 12 participants in the test group received an intervention in at least one domain. Of the 11 participants who received the intervention, 10 showed improvement in at least one domain on which they received feedback. Independent t tests for larger test groups (df>15) confirmed that the group improvements are statistically significant compared with the corresponding controls (P<.05). Crawford-Howell t tests confirmed that 78% of the interventions resulted in significant improvements when compared individually against corresponding controls (P<.05). Additional t tests comparing the first conversation sessions of the test and control groups and comparing the first and second conversation sessions of the control group resulted in nonsignificant differences, pointing to the intervention being the main effect behind the behavioral changes displayed by the test group, as opposed to confounding effects or group differences. Conclusions: Our proposed behavioral intervention offers a useful framework for practicing social attention behavior in multiparty conversations that are common in social and professional settings. UR - https://formative.jmir.org/2024/1/e55339 UR - http://dx.doi.org/10.2196/55339 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55339 ER - TY - JOUR AU - Chan, Sze Wai AU - Cheng, Yee Wing AU - Lok, Chun Samson Hoi AU - Cheah, Mun Amanda Kah AU - Lee, Win Anna Kai AU - Ng, Ying Albe Sin AU - Kowatsch, Tobias PY - 2024/8/7 TI - Assessing the Short-Term Efficacy of Digital Cognitive Behavioral Therapy for Insomnia With Different Types of Coaching: Randomized Controlled Comparative Trial JO - JMIR Ment Health SP - e51716 VL - 11 KW - insomnia KW - cognitive behavioral therapy KW - digital intervention KW - mobile health KW - mHealth KW - chatbot-based coaching KW - human support KW - mobile phone N2 - Background: Digital cognitive behavioral therapy for insomnia (dCBTi) is an effective intervention for treating insomnia. The findings regarding its efficacy compared to face-to-face cognitive behavioral therapy for insomnia are inconclusive but suggest that dCBTi might be inferior. The lack of human support and low treatment adherence are believed to be barriers to dCBTi achieving its optimal efficacy. However, there has yet to be a direct comparative trial of dCBTi with different types of coaching support. Objective: This study examines whether adding chatbot-based and human coaching would improve the treatment efficacy of, and adherence to, dCBTi. Methods: Overall, 129 participants (n=98, 76% women; age: mean 34.09, SD 12.05 y) whose scores on the Insomnia Severity Index [ISI] were greater than 9 were recruited. A randomized controlled comparative trial with 5 arms was conducted: dCBTi with chatbot-based coaching and therapist support (dCBTi-therapist), dCBTi with chatbot-based coaching and research assistant support, dCBTi with chatbot-based coaching only, dCBTi without any coaching, and digital sleep hygiene and self-monitoring control. Participants were blinded to the condition assignment and study hypotheses, and the outcomes were self-assessed using questionnaires administered on the web. The outcomes included measures of insomnia (the ISI and the Sleep Condition Indicator), mood disturbances, fatigue, daytime sleepiness, quality of life, dysfunctional beliefs about sleep, and sleep-related safety behaviors administered at baseline, after treatment, and at 4-week follow-up. Treatment adherence was measured by the completion of video sessions and sleep diaries. An intention-to-treat analysis was conducted. Results: Significant condition-by-time interaction effects showed that dCBTi recipients, regardless of having any coaching, had greater improvements in insomnia measured by the Sleep Condition Indicator (P=.003; d=0.45) but not the ISI (P=.86; d=?0.28), depressive symptoms (P<.001; d=?0.62), anxiety (P=.01; d=?0.40), fatigue (P=.02; d=?0.35), dysfunctional beliefs about sleep (P<.001; d=?0.53), and safety behaviors related to sleep (P=.001; d=?0.50) than those who received digital sleep hygiene and self-monitoring control. The addition of chatbot-based coaching and human support did not improve treatment efficacy. However, adding human support promoted greater reductions in fatigue (P=.03; d=?0.33) and sleep-related safety behaviors (P=.05; d=?0.30) than dCBTi with chatbot-based coaching only at 4-week follow-up. dCBTi-therapist had the highest video and diary completion rates compared to other conditions (video: 16/25, 60% in dCBTi-therapist vs <3/21, <25% in dCBTi without any coaching), indicating greater treatment adherence. Conclusions: Our findings support the efficacy of dCBTi in treating insomnia, reducing thoughts and behaviors that perpetuate insomnia, reducing mood disturbances and fatigue, and improving quality of life. Adding chatbot-based coaching and human support did not significantly improve the efficacy of dCBTi after treatment. However, adding human support had incremental benefits on reducing fatigue and behaviors that could perpetuate insomnia, and hence may improve long-term efficacy. Trial Registration: ClinicalTrials.gov NCT05136638; https://www.clinicaltrials.gov/study/NCT05136638 UR - https://mental.jmir.org/2024/1/e51716 UR - http://dx.doi.org/10.2196/51716 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/51716 ER - TY - JOUR AU - He, Linwei AU - Basar, Erkan AU - Krahmer, Emiel AU - Wiers, Reinout AU - Antheunis, Marjolijn PY - 2024/8/6 TI - Effectiveness and User Experience of a Smoking Cessation Chatbot: Mixed Methods Study Comparing Motivational Interviewing and Confrontational Counseling JO - J Med Internet Res SP - e53134 VL - 26 KW - chatbot KW - smoking cessation KW - counseling KW - motivational interviewing KW - confrontational counseling KW - user experience KW - engagement N2 - Background: Cigarette smoking poses a major public health risk. Chatbots may serve as an accessible and useful tool to promote cessation due to their high accessibility and potential in facilitating long-term personalized interactions. To increase effectiveness and acceptability, there remains a need to identify and evaluate counseling strategies for these chatbots, an aspect that has not been comprehensively addressed in previous research. Objective: This study aims to identify effective counseling strategies for such chatbots to support smoking cessation. In addition, we sought to gain insights into smokers? expectations of and experiences with the chatbot. Methods: This mixed methods study incorporated a web-based experiment and semistructured interviews. Smokers (N=229) interacted with either a motivational interviewing (MI)?style (n=112, 48.9%) or a confrontational counseling?style (n=117, 51.1%) chatbot. Both cessation-related (ie, intention to quit and self-efficacy) and user experience?related outcomes (ie, engagement, therapeutic alliance, perceived empathy, and interaction satisfaction) were assessed. Semistructured interviews were conducted with 16 participants, 8 (50%) from each condition, and data were analyzed using thematic analysis. Results: Results from a multivariate ANOVA showed that participants had a significantly higher overall rating for the MI (vs confrontational counseling) chatbot. Follow-up discriminant analysis revealed that the better perception of the MI chatbot was mostly explained by the user experience?related outcomes, with cessation-related outcomes playing a lesser role. Exploratory analyses indicated that smokers in both conditions reported increased intention to quit and self-efficacy after the chatbot interaction. Interview findings illustrated several constructs (eg, affective attitude and engagement) explaining people?s previous expectations and timely and retrospective experience with the chatbot. Conclusions: The results confirmed that chatbots are a promising tool in motivating smoking cessation and the use of MI can improve user experience. We did not find extra support for MI to motivate cessation and have discussed possible reasons. Smokers expressed both relational and instrumental needs in the quitting process. Implications for future research and practice are discussed. UR - https://www.jmir.org/2024/1/e53134 UR - http://dx.doi.org/10.2196/53134 UR - http://www.ncbi.nlm.nih.gov/pubmed/39106097 ID - info:doi/10.2196/53134 ER - TY - JOUR AU - Thomas, Carien Pamela AU - Curtis, Kristina AU - Potts, W. Henry W. AU - Bark, Pippa AU - Perowne, Rachel AU - Rookes, Tasmin AU - Rowe, Sarah PY - 2024/8/1 TI - Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis JO - JMIR Ment Health SP - e57577 VL - 11 KW - digital health KW - eHealth KW - mobile health KW - mHealth KW - mobile apps KW - smartphone KW - behavior change KW - behavior change technique KW - systematic review KW - eating disorders KW - disordered eating KW - binge eating KW - bulimia nervosa KW - mobile phone N2 - Background: Previous systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design. Objective: This study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included. Methods: A literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes. Results: Digital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: ?21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results. Conclusions: There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions. Trial Registration: PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060 UR - https://mental.jmir.org/2024/1/e57577 UR - http://dx.doi.org/10.2196/57577 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57577 ER - TY - JOUR AU - Guo, Ziqiu AU - Wu, Yongda AU - Wang, Ping Man PY - 2024/8/1 TI - Mobile Phone?Based Personalized and Interactive Augmented Reality Pictorial Health Warnings for Enhancing a Brief Advice Model for Smoking Cessation: Pilot Randomized Controlled Trial JO - JMIR XR Spatial Comput SP - e52893 VL - 1 KW - augmented reality KW - mobile-based KW - smoking cessation KW - brief advice KW - pictorial health warning KW - pilot randomized controlled trial N2 - Background: Augmented reality (AR) is a novel modality for promoting smoking cessation (SC). AR-visualized adverse consequences for education and smoking prevention have only been evaluated in nonsmokers in previous studies. Objective: To assess the feasibility and preliminary effectiveness for SC of AR pictorial health warnings (PHWs) on cigarette packs. Methods: We conducted a pilot randomized controlled trial in adult daily smokers in communities in Hong Kong. All participants received AWARD (ask, warn, advise, referral, do-it-again) model?guided SC advice, a warning leaflet, and referral to SC services at baseline. Interactive, chat-based SC support comprising regular messages and real-time support was provided to all participants via instant messaging apps (eg, WhatsApp) for 3 months after randomization. Participants in the intervention group additionally received 6 links to the AR PHWs showing the worsening health status of various organs caused by smoking. The level of the AR PHWs was adjustable to smoking behaviors (ie, smoking duration or daily cigarette consumption) to increase interaction. Participants could swipe, drag, or rotate the 3D PHWs to reinforce their impression of the health consequences of smoking. The primary outcome was self-reported past 7-day point-prevalence abstinence (PPA) at 3 months. The acceptability of the AR intervention was assessed by the proportion of participants who had viewed AR PHWs during the intervention. Participants who viewed AR PHWs further evaluated the perceived effect of the AR PHWs on a scale of 0 (not helpful at all) to 10 (very helpful). Intention to treat was used, and the risk ratio (RR) of the intervention effect was estimated by Poisson regression. Results: From April to November 2021, 80 participants were recruited and randomly assigned to intervention (n=40) and control (n=40) groups. Most participants were male (66/80, 83%) and planned to quit beyond 30 days or were undecided (65/80, 81%). The intervention group had a higher but nonsignificant 7-day PPA (7/40, 18% vs 5/40, 13%; RR 1.40, 95% CI 0.48-4.07) and quit attempts (15/40, 38% vs 11/40, 28%; RR 1.36, 95% CI 0.71-2.60) at 3 months than the control group. In the intervention group, 17 of 40 (43%) participants viewed the AR PHWs. The AR PHWs had modest effects on knowledge of the adverse consequences of smoking on personal health (mean score 3.94, SD 3.52), reducing the frequency of buying cigarettes (mean score 3.29, SD 3.08), increasing the perceived importance of quitting (mean score 3.88, SD 3.50), and making the PHWs more disgusting (mean score 3.41, SD 3.08) and horrible (mean score 3.38, SD 3.05). The 3-month self-reported 7-day PPA was higher in those who ever (vs never) viewed the AR PHWs (5/17, 29% vs 2/23, 9%). Conclusions: The mobile-based interactive AR PHWs were feasible, and the effectiveness on smoking abstinence warrants further testing. Trial Registration: ClinicalTrials.gov NCT04830072; https://clinicaltrials.gov/study/NCT04830072 UR - https://xr.jmir.org/2024/1/e52893 UR - http://dx.doi.org/10.2196/52893 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/52893 ER - TY - JOUR AU - Bälter, Katarina AU - King, C. Abby AU - Fritz, Johanna AU - Tillander, Annika AU - Halling Ullberg, Oskar PY - 2024/7/31 TI - Sustainable Lifestyle Among Office Workers (the SOFIA Study): Protocol for a Cluster Randomized Controlled Trial JO - JMIR Res Protoc SP - e57777 VL - 13 KW - diet KW - physical activity KW - work life KW - health promotion KW - climate change KW - sustainable lifestyle KW - citizen science KW - Our Voice N2 - Background: Society is facing multiple challenges, including lifestyle- and age-related diseases of major public health relevance, and this is of particular importance when the general population, as well as the workforce, is getting older. In addition, we are facing global climate change due to extensive emissions of greenhouse gases and negative environmental effects. A lifestyle that promotes healthy life choices as well as climate and environmentally friendly decisions is considered a sustainable lifestyle. Objective: This study aims to evaluate if providing information about a sustainable lifestyle encourages individuals to adopt more nutritious dietary habits and increase physical activity, as compared to receiving information solely centered around health-related recommendations for dietary intake and physical activity by the Nordic Nutrition Recommendations and the World Health Organization. Novel features of this study include the use of the workplace as an arena for health promotion, particularly among office workers?a group known to be often sedentary at work and making up 60% of all employees in Sweden. Methods: The Sustainable Office Intervention (SOFIA) study is a 2-arm, participant-blinded, cluster randomized controlled trial that includes a multilevel sustainable lifestyle arm (intervention arm, n=19) and a healthy lifestyle arm (control arm, n=14). The eligibility criteria were being aged 18-65 years and doing office work ?20 hours per week. Both intervention arms are embedded in the theoretically based behavioral change wheel method. The intervention study runs for approximately 8 weeks and contains 6 workshops. The study focuses on individual behavior change as well as environmental and policy features at an organizational level to facilitate or hinder a sustainable lifestyle at work. Through implementing a citizen science methodology within the trial, the participants (citizen scientists) collect data using the Stanford Our Voice Discovery Tool app and are involved in analyzing the data, formulating a list of potential actions to bring about feasible changes in the workplace. Results: Participant recruitment and data collection began in August 2022. As of June 2024, a total of 37 participants have been recruited. The results of the pilot phase are expected to be published in 2024 or 2025. Conclusions: Given the ongoing climate change, negative environmental effects, and the global epidemic of metabolic diseases, a sustainable lifestyle among office workers holds important potential to help in counteracting this trend. Thus, there is an urgent unmet need to test the impact of a sustainable lifestyle on food intake, physical activity, and environmental and climate impacts in a worksite-based randomized controlled trial. This study protocol responds to a societal need by addressing multilevel aspects, including individual behavior changes as well as environmental and organizational changes of importance for the successful implementation of sustainable lifestyle habits in an office setting. International Registered Report Identifier (IRRID): DERR1-10.2196/57777 UR - https://www.researchprotocols.org/2024/1/e57777 UR - http://dx.doi.org/10.2196/57777 UR - http://www.ncbi.nlm.nih.gov/pubmed/39083333 ID - info:doi/10.2196/57777 ER - TY - JOUR AU - Sacher, M. Paul AU - Fulton, Emily AU - Rogers, Victoria AU - Wilson, Julia AU - Gramatica, Marco AU - Dent, E. Jennifer AU - Aarts, O. Edo AU - Eccleston, David AU - Greve, Willem Jan AU - Palm-Meinders, Inge AU - Chuttani, Ram PY - 2024/7/31 TI - Impact of a Health Coach?Led, Text-Based Digital Behavior Change Intervention on Weight Loss and Psychological Well-Being in Patients Receiving a Procedureless Intragastric Balloon Program: Prospective Single-Arm Study JO - JMIR Form Res SP - e54723 VL - 8 KW - intragastric balloon KW - obesity KW - behavior change KW - health coaching KW - digital health KW - weight management KW - well-being KW - mobile phone N2 - Background: Digital health interventions show promise for weight management. However, few text-based behavior change interventions have been designed to support patients receiving intragastric balloons, and none have simultaneously evaluated weight loss, psychological well-being, and behavior change despite the crucial interplay of these factors in weight management. Objective: This study aims to assess whether a health coach?led, asynchronous, text-based digital behavior change coaching intervention (DBCCI) delivered to participants receiving an intragastric balloon and its aftercare program was feasible and acceptable to participants and supported improved outcomes, including weight loss, psychological well-being, and lifestyle behavior change conducive to weight loss maintenance. Methods: This 12-month, single-arm prospective study enrolled adults aged 21 to 65 years with BMI ?27 kg/m2 receiving a procedureless intragastric balloon (PIGB) at 5 bariatric clinics in the United Kingdom and the Netherlands. Participants received the DBCCI and the clinic-led PIGB aftercare program (remotely delivered) for 6 months after PIGB placement and then no intervention for an additional 6 months. The DBCCI was an evidence-based, personalized intervention wherein health coaches supported participants via exchanged asynchronous in-app text-based messages. Over the 12-month study, we assessed percentage of total body weight loss and psychological well-being via self-administered validated questionnaires (Warwick-Edinburgh Mental Wellbeing Scale, Generalized Anxiety Disorder Scale, Impact of Weight on Quality of Life?Lite?Clinical Trials Version, Loss of Control Over Eating Scale?Brief, Weight Efficacy Lifestyle Questionnaire?Short Form, and Barriers to Being Active Quiz). Participant engagement with and acceptability of the intervention were assessed via self-reported surveys. Results: Overall, 107 participants (n=96, 89.7% female; mean baseline BMI 35.4, SD 5.4 kg/m2) were included in the analysis. Mean total body weight loss was 13.5% (SEM 2.3%) at the end of the DBCCI and 11.22% (SEM 2.3%) at the 12-month follow-up (P<.001). Improvements were observed for all psychological well-being measures throughout the 12 months except for the Generalized Anxiety Disorder Scale (improvement at month 1) and Barriers to Being Active Quiz (improvements at months 3 and 6). Surveys showed high levels of engagement with and acceptability of the DBCCI. Conclusions: This study provides evidence that the health coach?led, asynchronous, text-based DBCCI was engaging and acceptable to participants with overweight and obesity. The DBCCI, delivered alongside the PIGB and its aftercare program, supported improved weight loss outcomes and psychological well-being versus baseline and was associated with lifestyle behavior changes known to help achieve and maintain long-term weight loss and improved health outcomes. Follow-up findings suggest a potential need for longer-term, more intense coaching to focus on weight loss maintenance and support ongoing self-coaching. This could be achieved by leveraging generative artificial intelligence to provide ongoing automated behavior change coaching support to augment human-led care. Trial Registration: ClinicalTrials.gov NCT05884606; https://clinicaltrials.gov/study/NCT05884606 UR - https://formative.jmir.org/2024/1/e54723 UR - http://dx.doi.org/10.2196/54723 UR - http://www.ncbi.nlm.nih.gov/pubmed/39083340 ID - info:doi/10.2196/54723 ER - TY - JOUR AU - Shin, Jiyoon AU - Kim, Sujin AU - Lee, Jooyoung AU - Gu, Hyerin AU - Ahn, Jihye AU - Park, Chowon AU - Seo, Mincheol AU - Jeon, Eun Jeong AU - Lee, Young Ha AU - Yeom, Won Ji AU - Kim, Sojeong AU - Yoon, Yeaseul AU - Lee, Heon-Jeong AU - Kim, Ju Seog AU - Lee, Jin Yu PY - 2024/7/26 TI - Efficacy of Mobile App?Based Cognitive Behavioral Therapy for Insomnia: Multicenter, Single-Blind Randomized Clinical Trial JO - J Med Internet Res SP - e50555 VL - 26 KW - digital therapeutics KW - mobile app?based cognitive behavioral therapy for insomnia KW - cognitive behavioral therapy KW - insomnia KW - mental health KW - mobile phone N2 - Background: Cognitive behavioral therapy for insomnia (CBTi) is the first-line therapy for chronic insomnia. Mobile app?based CBTi (MCBTi) can enhance the accessibility of CBTi treatment; however, few studies have evaluated the effectiveness of MCBTi using a multicenter, randomized controlled trial design. Objective: We aimed to assess the efficacy of Somzz, an MCBTi that provides real-time and tailored feedback to users, through comparison with an active comparator app. Methods: In our multicenter, single-blind randomized controlled trial study, participants were recruited from 3 university hospitals and randomized into a Somzz group and a sleep hygiene education (SHE) group at a 1:1 ratio. The intervention included 6 sessions for 6 weeks, with follow-up visits over a 4-month period. The Somzz group received audiovisual sleep education, guidance on relaxation therapy, and real-time feedback on sleep behavior. The primary outcome was the Insomnia Severity Index score, and secondary outcomes included sleep diary measures and mental health self-reports. We analyzed the outcomes based on the intention-to-treat principle. Results: A total of 98 participants were randomized into the Somzz (n=49, 50%) and SHE (n=49, 50%) groups. Insomnia Severity Index scores for the Somzz group were significantly lower at the postintervention time point (9.0 vs 12.8; t95=3.85; F2,95=22.76; ?p2=0.13; P<.001) and at the 3-month follow-up visit (11.3 vs 14.7; t68=2.61; F2,68=5.85; ?p2=0.03; P=.01) compared to those of the SHE group. The Somzz group maintained their treatment effect at the postintervention time point and follow-ups, with a moderate to large effect size (Cohen d=?0.62 to ?1.35; P<.01 in all cases). Furthermore, the Somzz group showed better sleep efficiency (t95=?3.32; F2,91=69.87; ?p2=0.41; P=.001), wake after sleep onset (t95=2.55; F2,91=51.81; ?p2=0.36; P=.01), satisfaction (t95=?2.05; F2,91=26.63; ?p2=0.20; P=.04) related to sleep, and mental health outcomes, including depression (t95=2.11; F2,94=29.64; ?p2=0.21; P=.04) and quality of life (t95=?3.13; F2,94=54.20; ?p2=0.33; P=.002), compared to the SHE group after the intervention. The attrition rate in the Somzz group was 12% (6/49). Conclusions: Somzz outperformed SHE in improving insomnia, mental health, and quality of life. The MCBTi can be a highly accessible, time-efficient, and effective treatment option for chronic insomnia, with high compliance. Trial Registration: Clinical Research Information Service (CRiS) KCT0007292; https://cris.nih.go.kr/cris/search/detailSearch.do?seq=22214&search_page=L UR - https://www.jmir.org/2024/1/e50555 UR - http://dx.doi.org/10.2196/50555 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/50555 ER - TY - JOUR AU - Bisby, Madelyne AU - Staples, Lauren AU - Dear, Blake AU - Titov, Nickolai PY - 2024/7/25 TI - Changes in the Frequency of Actions Associated With Mental Health During Online Treatment: Analysis of Demographic and Clinical Factors JO - JMIR Form Res SP - e57938 VL - 8 KW - anxiety KW - depression KW - daily actions KW - treatments KW - personalization KW - mental health KW - digital treatment KW - analysis KW - clinical factors KW - questionnaire KW - depression symptoms KW - anxiety symptoms KW - patients KW - Australian KW - Australia KW - digital psychology service KW - psychology KW - symptom severity KW - severity N2 - Background: Specific daily actions (eg, goal setting, meaningful activities) are associated with mental health. Performing specific daily actions at a higher frequency is associated with significantly lower baseline symptoms of depression and anxiety, as well as better psychological treatment outcomes for depression and anxiety. Objective: This study explored how the frequency of specific daily actions associated with mental health may differ prior to, during, and following treatment according to demographic and clinical characteristics. Methods: Using a sample of 448 patients from an Australian national digital psychology service, we examined baseline differences in daily action frequency and changes in daily action frequency during a digital psychological treatment according to demographic and clinical subgroups. A total of 5 specific types of daily actions were measured using the Things You Do Questionnaire: healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections. Results: The frequency of daily actions differed according to employment status (largest P=.005) and educational level (largest P=.004). Daily action frequency was lower in those participants with more severe or chronic depression or anxiety symptoms (largest P=.004). Participants reported larger increases in how often they did these daily actions from baseline to midtreatment compared to mid- to posttreatment. Depression duration (P=.01) and severity (P<.001) were associated with differences in how daily action frequency changed during treatment. Conclusions: The findings of this study support continued research exploring the relationship between daily actions and mental health, how this relationship might differ between individuals, and the clinical potential of supporting individuals to increase the frequency of daily actions to improve mental health. UR - https://formative.jmir.org/2024/1/e57938 UR - http://dx.doi.org/10.2196/57938 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57938 ER - TY - JOUR AU - Hanano, Maria AU - Rith-Najarian, Leslie AU - Gong-Guy, Elizabeth AU - Chavira, Denise PY - 2024/7/3 TI - Motivational Variables as Moderating Effects of a Web-Based Mental Health Program for University Students: Secondary Analysis of a Randomized Controlled Trial JO - JMIR Form Res SP - e56118 VL - 8 KW - web-based intervention KW - internal motivation KW - depression KW - anxiety KW - self-determination theory KW - mental health KW - university students KW - university KW - students KW - web-based KW - analysis KW - randomized controlled trial KW - self-guided N2 - Background: Self-guided web-based interventions have the potential of addressing help-seeking barriers and symptoms common among university students, such as depression and anxiety. Unfortunately, self-guided interventions are also associated with less adherence, implicating motivation as a potential moderator for adherence and improvement for such interventions. Previous studies examining motivation as a moderator or predictor of improvement on web-based interventions have defined and measured motivation variably, producing conflicting results. Objective: This secondary analysis of data from a randomized controlled trial aimed to examine constructs of motivation as moderators of improvement for a self-guided 8-week web-based intervention in university students (N=1607). Methods: Tested moderators included internal motivation, external motivation, and confidence in treatment derived from the Treatment Motivation Questionnaire. The primary outcome was an improvement in depression and anxiety measured by the Depression Anxiety Stress Scale-21. Results: Piecewise linear mixed effects models showed that internal motivation significantly moderated symptom change for the intervention group (t1504=?2.94; P=.003) at average and high (+1 SD) motivation levels (t1507=?2.28; P=.02 and t1507=?4.05; P<.001, respectively). Significant results remained even after controlling for baseline severity. The results showed that confidence in treatment did not significantly moderate symptom change for the intervention group (t1504=1.44; P=.15). In this sample, only internal motivation was positively correlated with service initiation, intervention adherence, and intervention satisfaction. Conclusions: The combination of a web-based intervention and high or moderate internal motivation resulted in greater improvement in the total Depression Anxiety Stress Scale-21 score. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. The results suggest that the combination of a web-based intervention and high or moderate internal motivation results in greater improvement. These findings highlight the importance of conceptually differentiating motivation-related constructs when examining moderators of improvement. To better understand the moderating role of internal motivation, future research is encouraged to replicate these findings in diverse samples as well as to examine related constructs such as baseline severity and adherence. Understanding these characteristics informs treatment strategies to maximize adherence and improvement when developing web-based interventions as well as allows services to be targeted to individuals likely to benefit from such interventions. Trial Registration: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/study/NCT04361045 UR - https://formative.jmir.org/2024/1/e56118 UR - http://dx.doi.org/10.2196/56118 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/56118 ER - TY - JOUR AU - Wen, Xu AU - Gou, Mengke AU - Chen, Huijing AU - Kishimoto, Tomoko AU - Qian, Mingyi AU - Margraf, Jürgen AU - Berger, Thomas PY - 2024/6/27 TI - The Efficacy of Web-Based Cognitive Behavioral Therapy With a Shame-Specific Intervention for Social Anxiety Disorder: Randomized Controlled Trial JO - JMIR Ment Health SP - e50535 VL - 11 KW - social anxiety disorder KW - web-based cognitive behavioral therapy KW - shame intervention KW - mediating effects KW - shame experience N2 - Background: Social anxiety disorder (SAD) is one of the most prevalent psychological disorders and generally co-occurs with elevated shame levels. Previous shame-specific interventions could significantly improve outcomes in social anxiety treatments. Recent review suggests that integrating a more direct shame intervention could potentially increase the effectiveness of cognitive behavioral therapy. Web-based cognitive behavioral therapy (WCBT) has proven efficacy, sustaining benefits for 6 months to 4 years. Previous evidence indicated that shame predicted the reduction of social anxiety and mediated between engagements in exposure and changes in social anxiety during WCBT. Objective: This study aimed to design a shame intervention component through a longitudinal study and conduct a randomized controlled trial to investigate the effectiveness of a shame intervention component in reducing social anxiety symptoms and shame experience in a clinical sample of people with SAD. Methods: The development of a shame intervention component was informed by cognitive behavioral principles and insights from longitudinal data that measured the Experience of Shame Scale (ESS), the Coping Styles Questionnaire, and the Social Interaction Anxiety Scale (SIAS) in 153 participants. The psychoeducation, cognitive construct, and exposure sections were tailored to focus more on shame-related problem-solving and self-blame. A total of 1220 participants were recruited to complete questionnaires, including the ESS, the SIAS, the Social Phobia Scale (SPS), and diagnostic interviews. Following a 2-round screening process, 201 participants with SAD were randomly assigned into a shame WCBT group, a normal WCBT group, and a waiting group. After the 8-week WCBT intervention, the participants were asked to complete posttest evaluations, including the ESS, SIAS and SPS. Results: Participants in the shame WCBT group experienced significant reductions in shame levels after the intervention (ESS: P<.001; ?p2=0.22), and the reduction was greater in the shame intervention group compared to normal WCBT (P<.001; mean deviation ?12.50). Participants in both the shame WCBT and normal WCBT groups experienced significant reductions in social anxiety symptoms (SIAS: P<.001; ?p2=0.32; SPS: P<.001; ?p2=0.19) compared to the waiting group after intervention. Furthermore, in the experience of social interaction anxiety (SIAS), the shame WCBT group showed a higher reduction compared to the normal WCBT group (P<.001; mean deviation ?9.58). Problem-solving (SE 0.049, 95% CI 0.025-0.217) and self-blame (SE 0.082, 95% CI 0.024-0.339) mediated the effect between ESS and SIAS. Conclusions: This is the first study to design and incorporate a shame intervention component in WCBT and to validate its efficacy via a randomized controlled trial. The shame WCBT group showed a significant reduction in both shame and social anxiety after treatment compared to the normal WCBT and waiting groups. Problem-solving and self-blame mediated the effect of shame on social anxiety. In conclusion, this study supports previous findings that a direct shame-specific intervention component could enhance the efficacy of WCBT. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300072184; https://www.chictr.org.cn/showproj.html?proj=152757 UR - https://mental.jmir.org/2024/1/e50535 UR - http://dx.doi.org/10.2196/50535 ID - info:doi/10.2196/50535 ER - TY - JOUR AU - Andree, Rosa AU - Mujcic, Ajla AU - den Hollander, Wouter AU - van Laar, Margriet AU - Boon, Brigitte AU - Engels, Rutger AU - Blankers, Matthijs PY - 2024/6/20 TI - Digital Smoking Cessation Intervention for Cancer Survivors: Analysis of Predictors and Moderators of Engagement and Outcome Alongside a Randomized Controlled Trial JO - JMIR Cancer SP - e46303 VL - 10 KW - smoking cessation KW - cancer survivors KW - engagement KW - digital intervention KW - eHealth KW - smoking KW - intervention KW - randomized controlled trial KW - predictor KW - RCT KW - smoker KW - addict KW - cessation KW - quit KW - cancer KW - oncology N2 - Background: Recent studies have shown positive, though small, clinical effects of digital smoking cessation (SC) interventions for cancer survivors. However, research on associations among participant characteristics, intervention engagement, and outcomes is limited. Objective: This study aimed to explore the predictors and moderators of engagement and outcome of MyCourse-Quit Smoking (in Dutch: ?MijnKoers-Stoppen met Roken?), a digital minimally guided intervention for cancer survivors. Methods: A secondary analysis of data from the randomized controlled trial was performed. The number of cigarettes smoked in the past 7 days at 6-month follow-up was the primary outcome measure. We analyzed interactions among participant characteristics (11 variables), intervention engagement (3 variables), and outcome using robust linear (mixed) modeling. Results: In total, 165 participants were included in this study. Female participants accessed the intervention less often than male participants (B=?11.12; P=.004). A higher Alcohol Use Disorders Identification Test score at baseline was associated with a significantly higher number of logins (B=1.10; P<.001) and diary registrations (B=1.29; P<.001). A higher Fagerström Test for Nicotine Dependence score at baseline in the intervention group was associated with a significantly larger reduction in tobacco use after 6 months (B=?9.86; P=.002). No other associations and no moderating effects were found. Conclusions: Overall, a limited number of associations was found between participant characteristics, engagement, and outcome, except for gender, problematic alcohol use, and nicotine dependence. Future studies are needed to shed light on how this knowledge can be used to improve the effects of digital SC programs for cancer survivors. Trial Registration: Netherlands Trial register NTR6011/NL5434; https://onderzoekmetmensen.nl/nl/trial/22832 UR - https://cancer.jmir.org/2024/1/e46303 UR - http://dx.doi.org/10.2196/46303 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/46303 ER - TY - JOUR AU - Koelen, Jurrijn AU - Klein, Anke AU - Wolters, Nine AU - Bol, Eline AU - De Koning, Lisa AU - Roetink, Samantha AU - Van Blom, Jorien AU - Boutin, Bruno AU - Schaaf, Jessica AU - Grasman, Raoul AU - Van der Heijde, Maria Claudia AU - Salemink, Elske AU - Riper, Heleen AU - Karyotaki, Eirini AU - Cuijpers, Pim AU - Schneider, Silvia AU - Rapee, Ronald AU - Vonk, Peter AU - Wiers, Reinout PY - 2024/6/19 TI - Web-Based, Human-Guided, or Computer-Guided Transdiagnostic Cognitive Behavioral Therapy in University Students With Anxiety and Depression: Randomized Controlled Trial JO - JMIR Ment Health SP - e50503 VL - 11 KW - internet-based cognitive behavioral intervention KW - iCBT KW - university students KW - transdiagnostic KW - human guidance KW - technological guidance N2 - Background: Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting. Objective: This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT. Methods: A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use?related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test?10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months. Results: In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002). Conclusions: The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials. Trial Registration: International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795 UR - https://mental.jmir.org/2024/1/e50503 UR - http://dx.doi.org/10.2196/50503 UR - http://www.ncbi.nlm.nih.gov/pubmed/38896474 ID - info:doi/10.2196/50503 ER - TY - JOUR AU - Chan, Pok Chin AU - Lee, Shan Shui AU - Kwan, Ho Tsz AU - Wong, Shan Samuel Yeung AU - Yeoh, Eng-Kiong AU - Wong, Sze Ngai PY - 2024/6/19 TI - Population Behavior Changes Underlying Phasic Shifts of SARS-CoV-2 Exposure Settings Across 3 Omicron Epidemic Waves in Hong Kong: Prospective Cohort Study JO - JMIR Public Health Surveill SP - e51498 VL - 10 KW - exposure risk KW - contact setting KW - social distancing KW - epidemic control KW - participatory surveillance KW - SARS-CoV-2 KW - COVID-19 N2 - Background: Exposure risk was shown to have affected individual susceptibility and the epidemic spread of COVID-19. The dynamics of risk by and across exposure settings alongside the variations following the implementation of social distancing interventions are understudied. Objective: This study aims to examine the population?s trajectory of exposure risk in different settings and its association with SARS-CoV-2 infection across 3 consecutive Omicron epidemic waves in Hong Kong. Methods: From March to June 2022, invitation letters were posted to 41,132 randomly selected residential addresses for the recruitment of households into a prospective population cohort. Through web-based monthly surveys coupled with email reminders, a representative from each enrolled household self-reported incidents of SARS-CoV-2 infections, COVID-19 vaccination uptake, their activity pattern in the workplace, and daily and social settings in the preceding month. As a proxy of their exposure risk, the reported activity trend in each setting was differentiated into trajectories based on latent class growth analyses. The associations of different trajectories of SARS-CoV-2 infection overall and by Omicron wave (wave 1: February-April; wave 2: May-September; wave 3: October-December) in 2022 were evaluated by using Cox proportional hazards models and Kaplan-Meier analysis. Results: In total, 33,501 monthly responses in the observation period of February-December 2022 were collected from 5321 individuals, with 41.7% (2221/5321) being male and a median age of 46 (IQR 34-57) years. Against an expanding COVID-19 vaccination coverage from 81.9% to 95.9% for 2 doses and 20% to 77.7% for 3 doses, the cumulative incidence of SARS-CoV-2 infection escalated from <0.2% to 25.3%, 32.4%, and 43.8% by the end of waves 1, 2, and 3, respectively. Throughout February-December 2022, 52.2% (647/1240) of participants had worked regularly on-site, 28.7% (356/1240) worked remotely, and 19.1% (237/1240) showed an assorted pattern. For daily and social settings, 4 and 5 trajectories were identified, respectively, with 11.5% (142/1240) and 14.6% (181/1240) of the participants gauged to have a high exposure risk. Compared to remote working, working regularly on-site (adjusted hazard ratio [aHR] 1.47, 95% CI 1.19-1.80) and living in a larger household (aHR 1.12, 95% CI 1.06-1.18) were associated with a higher risk of SARS-CoV-2 infection in wave 1. Those from the highest daily exposure risk trajectory (aHR 1.46, 95% CI 1.07-2.00) and the second highest social exposure risk trajectory (aHR 1.52, 95% CI 1.18-1.97) were also at an increased risk of infection in waves 2 and 3, respectively, relative to the lowest risk trajectory. Conclusions: In an infection-naive population, SARS-CoV-2 transmission was predominantly initiated at the workplace, accelerated in the household, and perpetuated in the daily and social environments, as stringent restrictions were scaled down. These patterns highlight the phasic shift of exposure settings, which is important for informing the effective calibration of targeted social distancing measures as an alternative to lockdown. UR - https://publichealth.jmir.org/2024/1/e51498 UR - http://dx.doi.org/10.2196/51498 UR - http://www.ncbi.nlm.nih.gov/pubmed/38896447 ID - info:doi/10.2196/51498 ER - TY - JOUR AU - Kerry, Camrie AU - Mann, Prabhdeep AU - Babaei, Nazanin AU - Katz, Joel AU - Pirbaglou, Meysam AU - Ritvo, Paul PY - 2024/6/12 TI - Web-Based Therapist-Guided Mindfulness-Based Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Pilot Randomized Controlled Trial JO - JMIR Ment Health SP - e55283 VL - 11 KW - body dysmorphic disorder KW - BDD KW - dysmorphophobia KW - obsessive-compulsive and related disorders KW - OCD KW - internet-delivered cognitive behavior therapy KW - iCBT KW - cognitive behavior therapy KW - mindfulness-based cognitive therapy KW - mindfulness KW - eMental health KW - randomized controlled trial N2 - Background: Internet-based cognitive behavioral therapy (CBT) and stand-alone mindfulness meditation interventions are gaining empirical support for a wide variety of mental health conditions. In this study, we test the efficacy of web-based therapist-guided mindfulness-based cognitive behavioral therapy (CBT-M) for body dysmorphic disorder (BDD), a psychiatric disorder characterized by preoccupations with perceived defects in appearance. Objective: This study aims to determine whether CBT-M for BDD delivered on the web is feasible and acceptable and whether mindfulness meditation adds to CBT treatment effects for BDD. Methods: In this 8-week, 2-arm, parallel pilot randomized controlled trial, n=28 adults (aged between 18 and 55 years) were randomly allocated to an experimental group (web-based therapist-guided CBT-M) or a control group (web-based therapist-guided CBT). Study retention, accrual, and intervention adherence were assessed, along with self-report measures for BDD, depression, anxiety, and pain intensity taken at baseline and postintervention. Results: This study was feasible to implement and deemed acceptable by participants. After 8 weeks, significant improvements were found on all outcome measures for both treatment groups, and large between-group effect sizes favoring CBT-M were found for BDD symptom severity (d=?0.96), depression (d=?1.06), pain severity (d=?1.12), and pain interference (d=?1.28). However, linear mixed models demonstrated no significant differences between the groups over 8 weeks. Conclusions: The results suggest that mindfulness meditation may add to beneficial web-based CBT treatment effects for BDD. An adequately powered randomized control trial of web-based CBT-M is warranted. Trial Registration: ClinicalTrials.gov NCT05402475, http://clinicaltrials.gov/ct2/show/NCT05402475 UR - https://mental.jmir.org/2024/1/e55283 UR - http://dx.doi.org/10.2196/55283 UR - http://www.ncbi.nlm.nih.gov/pubmed/38865704 ID - info:doi/10.2196/55283 ER - TY - JOUR AU - Walters, Clarice AU - Gratzer, David AU - Dang, Kevin AU - Laposa, Judith AU - Knyahnytska, Yuliya AU - Ortiz, Abigail AU - Gonzalez-Torres, Christina AU - Moore, P. Lindsay AU - Chen, Sheng AU - Ma, Clement AU - Daskalakis, Zafiris AU - Ritvo, Paul PY - 2024/5/31 TI - The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis JO - JMIR Form Res SP - e40275 VL - 8 KW - online intervention KW - randomized controlled trial KW - major depressive disorder KW - text message KW - online KW - cognitive KW - behavior therapy KW - treatment KW - depression KW - disorder KW - symptoms KW - young adults KW - wellness KW - procedure KW - anxiety KW - model N2 - Background: As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance. Objective: This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement. Methods: Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II). Results: Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (?=?0.029, 95% CI ?0.11 to 0.048) and in each of the 3 categories: appreciating alliance (?=?0.096, 95% CI ?0.80 to 0.61), alliance building disclosures (?=?0.098, 95% CI ?0.28 to 0.084), and agreement confirmation (?=?0.076, 95% CI ?0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement. Conclusions: The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication. Trial Registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052 UR - https://formative.jmir.org/2024/1/e40275 UR - http://dx.doi.org/10.2196/40275 UR - http://www.ncbi.nlm.nih.gov/pubmed/38820586 ID - info:doi/10.2196/40275 ER - TY - JOUR AU - Doukani, Asmae AU - Quartagno, Matteo AU - Sera, Francesco AU - Free, Caroline AU - Kakuma, Ritsuko AU - Riper, Heleen AU - Kleiboer, Annet AU - Cerga-Pashoja, Arlinda AU - van Schaik, Anneke AU - Botella, Cristina AU - Berger, Thomas AU - Chevreul, Karine AU - Matynia, Maria AU - Krieger, Tobias AU - Hazo, Jean-Baptiste AU - Draisma, Stasja AU - Titzler, Ingrid AU - Topooco, Naira AU - Mathiasen, Kim AU - Vernmark, Kristofer AU - Urech, Antoine AU - Maj, Anna AU - Andersson, Gerhard AU - Berking, Matthias AU - Baños, María Rosa AU - Araya, Ricardo PY - 2024/5/31 TI - Comparison of the Working Alliance in Blended Cognitive Behavioral Therapy and Treatment as Usual for Depression in Europe: Secondary Data Analysis of the E-COMPARED Randomized Controlled Trial JO - J Med Internet Res SP - e47515 VL - 26 KW - blended psychotherapy KW - cognitive behavioral therapy KW - depression KW - digital mental health interventions KW - psychotherapy KW - mental health KW - program usability KW - therapeutic alliance KW - usability heuristics KW - working alliance N2 - Background: Increasing interest has centered on the psychotherapeutic working alliance as a means of understanding clinical change in digital mental health interventions in recent years. However, little is understood about how and to what extent a digital mental health program can have an impact on the working alliance and clinical outcomes in a blended (therapist plus digital program) cognitive behavioral therapy (bCBT) intervention for depression. Objective: This study aimed to test the difference in working alliance scores between bCBT and treatment as usual (TAU), examine the association between working alliance and depression severity scores in both arms, and test for an interaction between system usability and working alliance with regard to the association between working alliance and depression scores in bCBT at 3-month assessments. Methods: We conducted a secondary data analysis of the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment versus Treatment-as-usual) trial, which compared bCBT with TAU across 9 European countries. Data were collected in primary care and specialized services between April 2015 and December 2017. Eligible participants aged 18 years or older and diagnosed with major depressive disorder were randomized to either bCBT (n=476) or TAU (n=467). bCBT consisted of 6-20 sessions of bCBT (involving face-to-face sessions with a therapist and an internet-based program). TAU consisted of usual care for depression. The main outcomes were scores of the working alliance (Working Alliance Inventory-Short Revised?Client [WAI-SR-C]) and depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]) at 3 months after randomization. Other variables included system usability scores (System Usability Scale-Client [SUS-C]) at 3 months and baseline demographic information. Data from baseline and 3-month assessments were analyzed using linear regression models that adjusted for a set of baseline variables. Results: Of the 945 included participants, 644 (68.2%) were female, and the mean age was 38.96 years (IQR 38). bCBT was associated with higher composite WAI-SR-C scores compared to TAU (B=5.67, 95% CI 4.48-6.86). There was an inverse association between WAI-SR-C and PHQ-9 in bCBT (B=?0.12, 95% CI ?0.17 to ?0.06) and TAU (B=?0.06, 95% CI ?0.11 to ?0.02), in which as WAI-SR-C scores increased, PHQ-9 scores decreased. Finally, there was a significant interaction between SUS-C and WAI-SR-C with regard to an inverse association between higher WAI-SR-C scores and lower PHQ-9 scores in bCBT (b=?0.030, 95% CI ?0.05 to ?0.01; P=.005). Conclusions: To our knowledge, this is the first study to show that bCBT may enhance the client working alliance when compared to evidence-based routine care for depression that services reported offering. The working alliance in bCBT was also associated with clinical improvements that appear to be enhanced by good program usability. Our findings add further weight to the view that the addition of internet-delivered CBT to face-to-face CBT may positively augment experiences of the working alliance. Trial Registration: ClinicalTrials.gov NCT02542891, https://clinicaltrials.gov/study/NCT02542891; German Clinical Trials Register DRKS00006866, https://drks.de/search/en/trial/DRKS00006866; Netherlands Trials Register NTR4962, https://www.onderzoekmetmensen.nl/en/trial/25452; ClinicalTrials.Gov NCT02389660, https://clinicaltrials.gov/study/NCT02389660; ClinicalTrials.gov NCT02361684, https://clinicaltrials.gov/study/NCT02361684; ClinicalTrials.gov NCT02449447, https://clinicaltrials.gov/study/NCT02449447; ClinicalTrials.gov NCT02410616, https://clinicaltrials.gov/study/NCT02410616; ISRCTN Registry ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725?q=ISRCTN12388725&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10; ClinicalTrials.gov NCT02796573, https://classic.clinicaltrials.gov/ct2/show/NCT02796573 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-016-1511-1 UR - https://www.jmir.org/2024/1/e47515 UR - http://dx.doi.org/10.2196/47515 UR - http://www.ncbi.nlm.nih.gov/pubmed/38819882 ID - info:doi/10.2196/47515 ER - TY - JOUR AU - Li, Jiaying AU - Fong, Tak Daniel Yee AU - Ho, Man Mandy AU - Choi, Hang Edmond Pui AU - Lok, Wan Kris Yuet AU - Lee, Jae Jung AU - Duan, WenJie AU - Wong, Ha Janet Yuen AU - Lin, Chia-Chin PY - 2024/5/28 TI - Prevalence and Factors Associated With Willingness to Sustain Pandemic-Induced Digital Work in the General Population and Moderating Effects of Screen Hours: Cross-Sectional Study JO - J Med Internet Res SP - e53321 VL - 26 KW - COVID-19 pandemic KW - digital work KW - willingness to sustain KW - screen time KW - general population N2 - Background: The pandemic has accelerated digital work transformation, yet little is known about individuals? willingness to sustain such digital modes and its associated factors. A better understanding of this willingness and its drivers is crucial for guiding the development of future digital work infrastructure, training programs, and strategies to monitor and prevent related health issues. Objective: This study aims to quantify the general population?s willingness to sustain pandemic-induced digital work, identify its associated factors, and examine how screen time moderates these relationships. Methods: A cross-sectional study was conducted targeting Hong Kong residents aged ?18 years who have increased engagement in digital work since the pandemic. Data were collected through self-reported, web-based surveys. Descriptive statistics determined prevalence rates, while structured multiphase logistic regression identified associated factors and explored the moderating effects of screen hour levels. Results: This unfunded study enrolled 1014 participants from May 2 to June 24, 2022, and completed data analysis within 3 months after data collection. A total of 391 (38.6%; 95% CI 35.6%-41.6%) participants expressed willingness to sustain digital work. Positive factors associated with this willingness included being an employee (odds ratio [OR] 3.12, 95% CI 1.59-6.45; P=.001), being health professionals (OR 3.32, 95% CI 1.49-7.82; P=.004), longer screen hours (OR 1.09, 95% CI 1.03-1.15; P=.002), and higher depression levels (OR 1.20, 95% CI 1.01-1.44; P=.04). Conversely, negatively associated factors included older age (OR 0.87, 95% CI 0.81-0.94; P=.001), extroversion (OR 0.66, 95% CI 0.51-0.86; P=.002), higher eHealth literacy (OR 0.96, 95% CI 0.93-0.98; P<.001), perceived greater susceptibility to COVID-19 (OR 0.84, 95% CI 0.74-0.96; P=.009), residence in a high-severity COVID-19 community (OR 0.73, 95% CI 0.63-0.84; P<.001), having infected individuals in the immediate social circle (OR 0.64, 95% CI 0.46-0.88; P=.006), higher BMI (OR 0.94, 95% CI 0.90-0.99; P=.02), feelings of being out of control (OR 0.96, 95% CI 0.93-0.98; P=.002), and higher fear of COVID-19 (OR 0.96, 95% CI 0.94-0.98; P=.001). In addition, a moderating effect of screen hour level (high: >8 h/d; low: ?8 h/d) influenced the association among 10 factors related to willingness to sustain pandemic-induced digital work, including age, education level, household size, needs for regular medical care, BMI, frequency of both vigorous and moderate physical activities, perceived COVID-19 severity, immediate social circle COVID-19 presence, and fear of COVID-19 (all P values for interaction <.05). Conclusions: The substantial willingness of the general population to sustain digital work after the pandemic highlights the need for robust telework infrastructure, thorough monitoring of adverse health outcomes, and the potential to expand telehealth services among this group. The identification of factors influencing this willingness and the moderating role of screen hours inform the development of personalized strategies to enhance digital work acceptance where needed. UR - https://www.jmir.org/2024/1/e53321 UR - http://dx.doi.org/10.2196/53321 UR - http://www.ncbi.nlm.nih.gov/pubmed/38805704 ID - info:doi/10.2196/53321 ER - TY - JOUR AU - Matthes, Jörg AU - Binder, Alice AU - Naderer, Brigitte AU - Forrai, Michaela AU - Spielvogel, Ines AU - Knupfer, Helena AU - Saumer, Melanie PY - 2024/5/22 TI - Effects of Food Depictions in Entertainment Media on Children?s Unhealthy Food Preferences: Content Analysis Linked With Panel Data JO - JMIR Pediatr Parent SP - e51429 VL - 7 KW - children KW - health KW - unhealthy food preferences KW - food depictions KW - centrality KW - coviewing KW - longitudinal linkage study KW - child KW - food KW - eating KW - diet KW - dietary KW - preference KW - preferences KW - nutrition KW - nutritional KW - media KW - entertainment KW - panel KW - foods KW - pediatric KW - pediatrics KW - food preference KW - food preferences N2 - Background: Entertainment media content is often mentioned as one of the roots of children?s unhealthy food consumption. This might be due to the high quantity of unhealthy foods presented in children?s media environments. However, less is known about the role of the centrality of food placement, that is, whether foods are interacted with, consumed, verbally mentioned, or appear unobtrusively. We also lack longitudinal research measuring both children?s unhealthy and healthy food consumption behaviors as outcomes. Objective: The aim is to connect content analytical data based on children?s actual media diet with panel data in order to explain children?s food preferences. Moreover, this study not only focuses on the amount of healthy and unhealthy foods children are exposed to, but also on how these foods are presented (ie, centrally or not). Furthermore, we looked at the question of how parental coviewing can diminish (or enhance) the effects of unhealthy (or healthy) food depictions, and we measured healthy and unhealthy consumption as dependent variables. Methods: We conducted a 2-wave panel study with children and one of their parents (of 2250 parents contacted, 829 responded, for a response rate of 36.84%; 648 valid cases, ie, parent-child pairs, were used for analysis), with 6 months between the 2 panel waves. We linked the 2-wave panel data for the children and their parents to content analytical data for movies (n=113) and TV series (n=134; 3 randomly chosen episodes per TV series were used) that children were exposed to over the course of 6 months. Results: There was no significant relationship between exposure to unhealthy food presentation and unhealthy (b=0.008; P=.07) or healthy (b=?0.003; P=.57) food consumption over time. Also, healthy food presentation was unrelated to unhealthy (b=0.009; P=.18) or healthy (b=0.000; P=.99) food consumption over time. However, there was a significant, positive interaction between unhealthy food presentation and presentation centrality on unhealthy food consumption (b=0.000; P=.03), suggesting that the effects of unhealthy food presentation rise with increasing levels of centrality. There was no interaction between unhealthy food presentation and presentation centrality on the consumption of healthy foods (b=0.000; P=.10). Also, exposure to healthy food presentation interacted with centrality (b=?0.001; P=.003). That is, when a healthy product was presented at maximum centrality, it led to less unhealthy food consumption in children. Coviewing did not interact with exposure to unhealthy foods when explaining unhealthy (b=0.003; P=.08) or healthy (b=?0.001; P=.70) food consumption. Conclusions: We conclude that simply presenting more healthy foods is not sufficient to combat children?s unhealthy food preferences. Further regulations may be necessary with respect to representations of unhealthy foods in children?s media. UR - https://pediatrics.jmir.org/2024/1/e51429 UR - http://dx.doi.org/10.2196/51429 ID - info:doi/10.2196/51429 ER - TY - JOUR AU - Kepper, Maura AU - Walsh-Bailey, Callie AU - Miller, M. Zoe AU - Zhao, Min AU - Zucker, Kianna AU - Gacad, Angeline AU - Herrick, Cynthia AU - White, H. Neil AU - Brownson, C. Ross AU - Foraker, E. Randi PY - 2024/5/17 TI - The Impact of Behavior Change Counseling Delivered via a Digital Health Tool Versus Routine Care Among Adolescents With Obesity: Pilot Randomized Feasibility Study JO - JMIR Form Res SP - e55731 VL - 8 KW - digital health KW - obesity KW - clinical care KW - adolescents KW - physical activity KW - diet KW - clinical trial N2 - Background: Youth overweight and obesity is a public health crisis and increases the risk of poor cardiovascular health (CVH) and chronic disease. Health care providers play a key role in weight management, yet few tools exist to support providers in delivering tailored evidence-based behavior change interventions to patients. Objective: The goal of this pilot randomized feasibility study was to determine the feasibility of implementing the Patient-Centered Real-Time Intervention (PREVENT) tool in clinical settings, generate implementation data to inform scale-up, and gather preliminary effectiveness data. Methods: A pilot randomized clinical trial was conducted to examine the feasibility, implementation, and preliminary impact of PREVENT on patient knowledge, motivation, behaviors, and CVH outcomes. The study took place in a multidisciplinary obesity management clinic at a children?s hospital within an academic medical center. A total of 36 patients aged 12 to 18 years were randomized to use PREVENT during their routine visit (n=18, 50%) or usual care control (n=18, 50%). PREVENT is a digital health tool designed for use by providers to engage patients in behavior change education and goal setting and provides resources to support change. Patient electronic health record and self-report behavior data were collected at baseline and 3 months after the intervention. Implementation data were collected via PREVENT, direct observation, surveys, and interviews. We conducted quantitative, qualitative, and mixed methods analyses to evaluate pretest-posttest patient changes and implementation data. Results: PREVENT was feasible, acceptable, easy to understand, and helpful to patients. Although not statistically significant, only PREVENT patients increased their motivation to change their behaviors as well as their knowledge of ways to improve heart health and of resources. Compared to the control group, PREVENT patients significantly improved their overall CVH and blood pressure (P<.05). Conclusions: Digital tools can support the delivery of behavior change counseling in clinical settings to increase knowledge and motivate patients to change their behaviors. An appropriately powered trial is necessary to determine the impact of PREVENT on CVH behaviors and outcomes. Trial Registration: ClinicalTrials.gov NCT06121193; https://www.clinicaltrials.gov/study/NCT06121193 UR - https://formative.jmir.org/2024/1/e55731 UR - http://dx.doi.org/10.2196/55731 UR - http://www.ncbi.nlm.nih.gov/pubmed/38758581 ID - info:doi/10.2196/55731 ER - TY - JOUR AU - Müller-Bardorff, Miriam AU - Schulz, Ava AU - Paersch, Christina AU - Recher, Dominique AU - Schlup, Barbara AU - Seifritz, Erich AU - Kolassa, Tatjana Iris AU - Kowatsch, Tobias AU - Fisher, Aaron AU - Galatzer-Levy, Isaac AU - Kleim, Birgit PY - 2024/5/14 TI - Optimizing Outcomes in Psychotherapy for Anxiety Disorders Using Smartphone-Based and Passive Sensing Features: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e42547 VL - 13 KW - cognitive behavioral therapy KW - CBT KW - transdiagnostic KW - anxiety KW - digital KW - ecological momentary assessment KW - EMA KW - passive sensing N2 - Background: Psychotherapies, such as cognitive behavioral therapy (CBT), currently have the strongest evidence of durable symptom changes for most psychological disorders, such as anxiety disorders. Nevertheless, only about half of individuals treated with CBT benefit from it. Predictive algorithms, including digital assessments and passive sensing features, could better identify patients who would benefit from CBT, and thus, improve treatment choices. Objective: This study aims to establish predictive features that forecast responses to transdiagnostic CBT in anxiety disorders and to investigate key mechanisms underlying treatment responses. Methods: This study is a 2-armed randomized controlled clinical trial. We include patients with anxiety disorders who are randomized to either a transdiagnostic CBT group or a waitlist (referred to as WAIT). We index key features to predict responses prior to starting treatment using subjective self-report questionnaires, experimental tasks, biological samples, ecological momentary assessments, activity tracking, and smartphone-based passive sensing to derive a multimodal feature set for predictive modeling. Additional assessments take place weekly at mid- and posttreatment and at 6- and 12-month follow-ups to index anxiety and depression symptom severity. We aim to include 150 patients, randomized to CBT versus WAIT at a 3:1 ratio. The data set will be subject to full feature and important features selected by minimal redundancy and maximal relevance feature selection and then fed into machine leaning models, including eXtreme gradient boosting, pattern recognition network, and k-nearest neighbors to forecast treatment response. The performance of the developed models will be evaluated. In addition to predictive modeling, we will test specific mechanistic hypotheses (eg, association between self-efficacy, daily symptoms obtained using ecological momentary assessments, and treatment response) to elucidate mechanisms underlying treatment response. Results: The trial is now completed. It was approved by the Cantonal Ethics Committee, Zurich. The results will be disseminated through publications in scientific peer-reviewed journals and conference presentations. Conclusions: The aim of this trial is to improve current CBT treatment by precise forecasting of treatment response and by understanding and potentially augmenting underpinning mechanisms and personalizing treatment. Trial Registration: ClinicalTrials.gov NCT03945617; https://clinicaltrials.gov/ct2/show/results/NCT03945617 International Registered Report Identifier (IRRID): DERR1-10.2196/42547 UR - https://www.researchprotocols.org/2024/1/e42547 UR - http://dx.doi.org/10.2196/42547 UR - http://www.ncbi.nlm.nih.gov/pubmed/38743473 ID - info:doi/10.2196/42547 ER - TY - JOUR AU - Kötting, Lukas AU - Anand-Kumar, Vinayak AU - Keller, Maria Franziska AU - Henschel, Tobias Nils AU - Lippke, Sonia PY - 2024/4/26 TI - Effective Communication Supported by an App for Pregnant Women: Quantitative Longitudinal Study JO - JMIR Hum Factors SP - e48218 VL - 11 KW - clinical care KW - health action process approach KW - HAPA KW - intention KW - communication behavior KW - patient safety KW - patient education KW - internet intervention KW - dropout KW - digital health KW - behavior change KW - prediction KW - obstetric KW - pregnant women KW - pregnancy KW - safe communication KW - health behaviors KW - obstetric care N2 - Background: In the medical field of obstetrics, communication plays a crucial role, and pregnant women, in particular, can benefit from interventions improving their self-reported communication behavior. Effective communication behavior can be understood as the correct transmission of information without misunderstanding, confusion, or losses. Although effective communication can be trained by patient education, there is limited research testing this systematically with an app-based digital intervention. Thus, little is known about the success of such a digital intervention in the form of a web-app, potential behavioral barriers for engagement, as well as the processes by which such a web-app might improve self-reported communication behavior. Objective: This study fills this research gap by applying a web-app aiming at improving pregnant women?s communication behavior in clinical care. The goals of this study were to (1) uncover the potential risk factors for early dropout from the web-app and (2) investigate the social-cognitive factors that predict self-reported communication behavior after having used the web-app. Methods: In this study, 1187 pregnant women were recruited. They all started to use a theory-based web-app focusing on intention, planning, self-efficacy, and outcome expectancy to improve communication behavior. Mechanisms of behavior change as a result of exposure to the web-app were explored using stepwise regression and path analysis. Moreover, determinants of dropout were tested using logistic regression. Results: We found that dropout was associated with younger age (P=.014). Mechanisms of behavior change were consistent with the predictions of the health action process approach. The stepwise regression analysis revealed that action planning was the best predictor for successful behavioral change over the course of the app-based digital intervention (?=.331; P<.001). The path analyses proved that self-efficacy beliefs affected the intention to communicate effectively, which in turn, elicited action planning and thereby improved communication behavior (?=.017; comparative fit index=0.994; Tucker?Lewis index=0.971; root mean square error of approximation=0.055). Conclusions: Our findings can guide the development and improvement of apps addressing communication behavior in the following ways in obstetric care. First, such tools would enable action planning to improve communication behavior, as action planning is the key predictor of behavior change. Second, younger women need more attention to keep them from dropping out. However, future research should build upon the gained insights by conducting similar internet interventions in related fields of clinical care. The focus should be on processes of behavior change and strategies to minimize dropout rates, as well as replicating the findings with patient safety measures. Trial Registration: ClinicalTrials.gov identifier: NCT03855735; https://classic.clinicaltrials.gov/ct2/show/NCT03855735 UR - https://humanfactors.jmir.org/2024/1/e48218 UR - http://dx.doi.org/10.2196/48218 UR - http://www.ncbi.nlm.nih.gov/pubmed/38669073 ID - info:doi/10.2196/48218 ER - TY - JOUR AU - Gooch, J. Helen AU - Jarvis, A. Kathryn AU - Stockley, C. Rachel PY - 2024/4/24 TI - Behavior Change Approaches in Digital Technology?Based Physical Rehabilitation Interventions Following Stroke: Scoping Review JO - J Med Internet Res SP - e48725 VL - 26 KW - behavior change KW - behavior therapy KW - digital health technology KW - digital health KW - digital technology KW - health behavior KW - physical and rehabilitation medicine KW - scoping review KW - stroke rehabilitation N2 - Background: Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. Objective: This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. Methods: Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). Results: From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. Conclusions: Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation. UR - https://www.jmir.org/2024/1/e48725 UR - http://dx.doi.org/10.2196/48725 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/48725 ER - TY - JOUR AU - Cho, Dalnim AU - Roth, Michael AU - Peterson, K. Susan AU - Jennings, Kristofer AU - Kim, Seokhun AU - Weathers, Shiao-Pei AU - Ahmed, Sairah AU - Livingston, Andrew J. AU - Barcenas, Carlos AU - You, Nancy Y. AU - Milbury, Kathrin PY - 2024/4/23 TI - Associations Between Stress, Health Behaviors, and Quality of Life in Young Couples During the Transition to Survivorship: Protocol for a Measurement Burst Study JO - JMIR Res Protoc SP - e53307 VL - 13 KW - young adult survivors KW - caregivers KW - dyadic KW - couple-based KW - stress KW - health behaviors KW - quality of life KW - transition to survivorship KW - measurement-burst N2 - Background: Cancer is a life-threatening, stressful event, particularly for young adults due to delays and disruptions in their developmental transitions. Cancer treatment can also cause adverse long-term effects, chronic conditions, psychological issues, and decreased quality of life (QoL) among young adults. Despite numerous health benefits of health behaviors (eg, physical activity, healthy eating, no smoking, no alcohol use, and quality sleep), young adult cancer survivors report poor health behavior profiles. Determining the associations of stress (either cancer-specific or day-to-day stress), health behaviors, and QoL as young adult survivors transition to survivorship is key to understanding and enhancing these survivors? health. It is also crucial to note that the effects of stress on health behaviors and QoL may manifest on a shorter time scale (eg, daily within-person level). Moreover, given that stress spills over into romantic relationships, it is important to identify the role of spouses or partners (hereafter partners) in these survivors? health behaviors and QoL. Objective: This study aims to investigate associations between stress, health behaviors, and QoL at both within- and between-person levels during the transition to survivorship in young adult cancer survivors and their partners, to identify the extent to which young adult survivors? and their partners? stress facilitates or hinders their own and each other?s health behaviors and QoL. Methods: We aim to enroll 150 young adults (aged 25-39 years at the time of cancer diagnosis) who have recently completed cancer treatment, along with their partners. We will conduct a prospective longitudinal study using a measurement burst design. Participants (ie, survivors and their partners) will complete a daily web-based survey for 7 consecutive days (a ?burst?) 9 times over 2 years, with the bursts spaced 3 months apart. Participants will self-report their stress, health behaviors, and QoL. Additionally, participants will be asked to wear an accelerometer to assess their physical activity and sleep during the burst period. Finally, dietary intake (24-hour diet recalls) will be assessed during each burst via telephone by research staff. Results: Participant enrollment began in January 2022. Recruitment and data collection are expected to conclude by December 2024 and December 2026, respectively. Conclusions: To the best of our knowledge, this will be the first study that determines the interdependence of health behaviors and QoL of young adult cancer survivors and their partners at both within- and between-person levels. This study is unique in its focus on the transition to cancer survivorship and its use of a measurement burst design. Results will guide the creation of a developmentally appropriate dyadic psychosocial or behavioral intervention that improves both young adult survivors? and their partners? health behaviors and QoL and potentially their physical health. International Registered Report Identifier (IRRID): DERR1-10.2196/53307 UR - https://www.researchprotocols.org/2024/1/e53307 UR - http://dx.doi.org/10.2196/53307 UR - http://www.ncbi.nlm.nih.gov/pubmed/38652520 ID - info:doi/10.2196/53307 ER - TY - JOUR AU - Zhou, Jinquan AU - Ho, Hong-Wai AU - Chan, ChiBiu PY - 2024/4/22 TI - Effect of the COVID-19 Pandemic on Gambling Behavior in Mainland Chinese Gamblers in Macau: Cross-Sectional Survey Study JO - JMIR Form Res SP - e45700 VL - 8 KW - Chinese gamblers KW - gambling behavior KW - online gambling KW - COVID-19 KW - Macau N2 - Background: This study examined the effects of the COVID-19 pandemic on the gambling behavior of individuals who were already actively engaged in such pursuits. We aimed to uncover the intricate consequences of the pandemic on this specific demographic, emphasizing the importance of understanding the complex connection between public health concerns such as the COVID-19 pandemic and gambling behavior from a public health perspective. In addition to identifying immediate impacts, this study holds significance in assessing potential long-term public health implications for the broader gambling industry. Objective: This study investigated how the COVID-19 pandemic has affected the gambling behavior of Mainland Chinese tourists in Macau from a public health perspective. We aimed to understand the changing patterns of gambling habits within this specific demographic by comparing their behavior before and during the pandemic, with a particular emphasis on the evolving dynamics of gambling and their public health consequences. This study provides a detailed exploration of the impact and implications of global health emergencies on this particular demographic?s gambling behaviors and preferences. Methods: This study used a robust cross-sectional analysis involving a sample of 334 Mainland Chinese gamblers with prior experiences in casinos in Macau. The sample deliberately encompassed individuals involved in gambling before and during the COVID-19 pandemic. Data were collected through carefully designed questionnaires to gather information on gambling habits, preferences, and observed behavioral changes in the sample. Results: This study unveiled a notable shift in Mainland Chinese gamblers? behavior during the COVID-19 pandemic. A considerable number of participants opted for web-based platforms over traditional land-based casinos, resulting in reduced budgets, less time spent on gambling, and decreased participation in social gambling. Remarkably, there was a notable surge in online gambling, indicating a noteworthy adaptability of gamblers to changing circumstances. These findings emphasize the dynamic nature of gambling habits during global public health emergencies, revealing the resilient and evolving preferences of Mainland Chinese gamblers in response to the challenges posed by the pandemic. Conclusions: This study highlights the negative impact of the COVID-19 pandemic on casino gambling, notably evident in a significant decline in Mainland Chinese tourists visiting Macau for gambling. There is a noticeable shift from traditional gambling to web-based alternatives, with individuals seeking options within the pandemic constraints. Furthermore, the findings point out an increase in gambling among the younger generation and behavioral changes in individuals with mood disorders. The findings of this study emphasize the critical need for proactive measures to address evolving gambling preferences and associated risks during public health crises; furthermore, these findings underscore the importance of adaptive strategies within the gambling industry, as well as the necessity for effective public health interventions and regulatory frameworks to respond to unprecedented challenges with efficacy and precision. UR - https://formative.jmir.org/2024/1/e45700 UR - http://dx.doi.org/10.2196/45700 UR - http://www.ncbi.nlm.nih.gov/pubmed/38648630 ID - info:doi/10.2196/45700 ER - TY - JOUR AU - Zhu, Yue AU - Zhang, Ran AU - Yin, Shuluo AU - Sun, Yihui AU - Womer, Fay AU - Liu, Rongxun AU - Zeng, Sheng AU - Zhang, Xizhe AU - Wang, Fei PY - 2024/4/22 TI - Digital Dietary Behaviors in Individuals With Depression: Real-World Behavioral Observation JO - JMIR Public Health Surveill SP - e47428 VL - 10 KW - dietary behaviors KW - digital marker KW - depression KW - mental health KW - appetite disturbance KW - behavioral monitoring KW - eating pattern KW - electronic record KW - digital health KW - behavioral KW - surveillance N2 - Background: Depression is often accompanied by changes in behavior, including dietary behaviors. The relationship between dietary behaviors and depression has been widely studied, yet previous research has relied on self-reported data which is subject to recall bias. Electronic device?based behavioral monitoring offers the potential for objective, real-time data collection of a large amount of continuous, long-term behavior data in naturalistic settings. Objective: The study aims to characterize digital dietary behaviors in depression, and to determine whether these behaviors could be used to detect depression. Methods: A total of 3310 students (2222 healthy controls [HCs], 916 with mild depression, and 172 with moderate-severe depression) were recruited for the study of their dietary behaviors via electronic records over a 1-month period, and depression severity was assessed in the middle of the month. The differences in dietary behaviors across the HCs, mild depression, and moderate-severe depression were determined by ANCOVA (analyses of covariance) with age, gender, BMI, and educational level as covariates. Multivariate logistic regression analyses were used to examine the association between dietary behaviors and depression severity. Support vector machine analysis was used to determine whether changes in dietary behaviors could detect mild and moderate-severe depression. Results: The study found that individuals with moderate-severe depression had more irregular eating patterns, more fluctuated feeding times, spent more money on dinner, less diverse food choices, as well as eating breakfast less frequently, and preferred to eat only lunch and dinner, compared with HCs. Moderate-severe depression was found to be negatively associated with the daily 3 regular meals pattern (breakfast-lunch-dinner pattern; OR 0.467, 95% CI 0.239-0.912), and mild depression was positively associated with daily lunch and dinner pattern (OR 1.460, 95% CI 1.016-2.100). These changes in digital dietary behaviors were able to detect mild and moderate-severe depression (accuracy=0.53, precision=0.60), with better accuracy for detecting moderate-severe depression (accuracy=0.67, precision=0.64). Conclusions: This is the first study to develop a profile of changes in digital dietary behaviors in individuals with depression using real-world behavioral monitoring. The results suggest that digital markers may be a promising approach for detecting depression. UR - https://publichealth.jmir.org/2024/1/e47428 UR - http://dx.doi.org/10.2196/47428 UR - http://www.ncbi.nlm.nih.gov/pubmed/38648087 ID - info:doi/10.2196/47428 ER - TY - JOUR AU - Paul, Margot AU - Bullock, Kim AU - Bailenson, Jeremy AU - Burns, David PY - 2024/4/15 TI - Examining the Efficacy of Extended Reality?Enhanced Behavioral Activation for Adults With Major Depressive Disorder: Randomized Controlled Trial JO - JMIR Ment Health SP - e52326 VL - 11 KW - virtual reality KW - extended reality KW - major depressive disorder KW - behavioral activation KW - depression KW - Meta Quest 2 N2 - Background: Major depressive disorder (MDD) is a global concern with increasing prevalence. While many evidence-based psychotherapies (EBPs) have been identified to treat MDD, there are numerous barriers to patients accessing them. Virtual reality (VR) has been used as a treatment enhancement for a variety of mental health disorders, but few studies have examined its clinical use in treating MDD. Behavioral activation (BA) is a simple yet effective and established first-line EBP for MDD that has the potential to be easily enhanced and adapted with VR technology. A previous report by our group explored the feasibility and acceptability of VR-enhanced BA in a small clinical proof-of-concept pilot. This study examines the clinical efficacy of a more immersive extended reality (XR)?enhanced BA (XR-BA) prototype. This is the first clinical efficacy test of an XR-BA protocol. Objective: This study examined whether XR-BA was feasible and efficacious in treating MDD in an ambulatory telemedicine clinic. Methods: A nonblinded between-subject randomized controlled trial compared XR-BA to traditional BA delivered via telehealth. The study used a previously established, brief 3-week, 4-session BA EBP intervention. The experimental XR-BA participants were directed to use a Meta Quest 2 (Reality Labs) VR headset to engage in simulated pleasant or mastery activities and were compared to a control arm, which used only real-life mastery or pleasant activities as between-session homework. The Patient Health Questionnaire (PHQ)?9 was the primary outcome measure. Independent-sample and paired-sample t tests (2-tailed) were used to determine statistical significance and confirmed using structural equation modeling. Results: Overall, 26 participants with MDD were randomized to receive either XR-BA (n=13, 50%) or traditional BA (n=13, 50%). The mean age of the 26 participants (n=6, 23% male; n=19, 73% female; n=1, 4% nonbinary or third gender) was 50.3 (SD 17.3) years. No adverse events were reported in either group, and no substantial differences in dropout rates or homework completion were observed. XR-BA was found to be statistically noninferior to traditional BA (t18.6=?0.28; P=.78). Both the XR-BA (t9=2.5; P=.04) and traditional BA (t10=2.3; P=.04) arms showed a statistically significant decrease in PHQ-9 and clinical severity from the beginning of session 1 to the beginning of session 4. There was a significant decrease in PHQ-8 to PHQ-9 scores between the phone intake and the beginning of session 1 for the XR-BA group (t11=2.6; P=.03) but not the traditional BA group (t11=1.4; P=.20). Conclusions: This study confirmed previous findings that XR-BA may be a feasible, non-inferior, and acceptable enhancement to traditional BA. Additionally, there was evidence that supports the potential of XR to enhance expectation or placebo effects. Further research is needed to examine the potential of XR to improve access, outcomes, and barriers to MDD care. Trial Registration: ClinicalTrials.gov NCT05525390; https://clinicaltrials.gov/study/NCT05525390 UR - https://mental.jmir.org/2024/1/e52326 UR - http://dx.doi.org/10.2196/52326 UR - http://www.ncbi.nlm.nih.gov/pubmed/38437873 ID - info:doi/10.2196/52326 ER - TY - JOUR AU - Kosyluk, Kristin AU - Baeder, Tanner AU - Greene, Yeona Karah AU - Tran, T. Jennifer AU - Bolton, Cassidy AU - Loecher, Nele AU - DiEva, Daniel AU - Galea, T. Jerome PY - 2024/4/12 TI - Mental Distress, Label Avoidance, and Use of a Mental Health Chatbot: Results From a US Survey JO - JMIR Form Res SP - e45959 VL - 8 KW - chatbots KW - conversational agents KW - mental health KW - resources KW - screening KW - resource referral KW - stigma KW - label avoidance KW - survey KW - training KW - behavioral KW - COVID-19 KW - pilot test KW - design KW - users KW - psychological distress KW - symptoms N2 - Background: For almost two decades, researchers and clinicians have argued that certain aspects of mental health treatment can be removed from clinicians? responsibilities and allocated to technology, preserving valuable clinician time and alleviating the burden on the behavioral health care system. The service delivery tasks that could arguably be allocated to technology without negatively impacting patient outcomes include screening, triage, and referral. Objective: We pilot-tested a chatbot for mental health screening and referral to understand the relationship between potential users? demographics and chatbot use; the completion rate of mental health screening when delivered by a chatbot; and the acceptability of a prototype chatbot designed for mental health screening and referral. This chatbot not only screened participants for psychological distress but also referred them to appropriate resources that matched their level of distress and preferences. The goal of this study was to determine whether a mental health screening and referral chatbot would be feasible and acceptable to users. Methods: We conducted an internet-based survey among a sample of US-based adults. Our survey collected demographic data along with a battery of measures assessing behavioral health and symptoms, stigma (label avoidance and perceived stigma), attitudes toward treatment-seeking, readiness for change, and technology readiness and acceptance. Participants were then offered to engage with our chatbot. Those who engaged with the chatbot completed a mental health screening, received a distress score based on this screening, were referred to resources appropriate for their current level of distress, and were asked to rate the acceptability of the chatbot. Results: We found that mental health screening using a chatbot was feasible, with 168 (75.7%) of our 222 participants completing mental health screening within the chatbot sessions. Various demographic characteristics were associated with a willingness to use the chatbot. The participants who used the chatbot found it to be acceptable. Logistic regression produced a significant model with perceived usefulness and symptoms as significant positive predictors of chatbot use for the overall sample, and label avoidance as the only significant predictor of chatbot use for those currently experiencing distress. Conclusions: Label avoidance, the desire to avoid mental health services to avoid the stigmatized label of mental illness, is a significant negative predictor of care seeking. Therefore, our finding regarding label avoidance and chatbot use has significant public health implications in terms of facilitating access to mental health resources. Those who are high on label avoidance are not likely to seek care in a community mental health clinic, yet they are likely willing to engage with a mental health chatbot, participate in mental health screening, and receive mental health resources within the chatbot session. Chatbot technology may prove to be a way to engage those in care who have previously avoided treatment due to stigma. UR - https://formative.jmir.org/2024/1/e45959 UR - http://dx.doi.org/10.2196/45959 UR - http://www.ncbi.nlm.nih.gov/pubmed/38607665 ID - info:doi/10.2196/45959 ER - TY - JOUR AU - van Mierlo, Trevor AU - Rondina, Renante AU - Fournier, Rachel PY - 2024/4/9 TI - Nudges and Prompts Increase Engagement in Self-Guided Digital Health Treatment for Depression and Anxiety: Results From a 3-Arm Randomized Controlled Trial JO - JMIR Form Res SP - e52558 VL - 8 KW - behavioral economics KW - digital health KW - attrition KW - engagement KW - nudges KW - depression KW - anxiety KW - mood disorders N2 - Background: Accessible and effective approaches to mental health treatment are important because of common barriers such as cost, stigma, and provider shortage. The effectiveness of self-guided treatment is well established, and its use has intensified because of the COVID-19 pandemic. Engagement remains important as dose-response relationships have been observed. Platforms such as Facebook (Meta Platform, Inc), LinkedIn (Microsoft Corp), and X Corp (formerly known as Twitter, Inc) use principles of behavioral economics to increase engagement. We hypothesized that similar concepts would increase engagement in self-guided digital health. Objective: This 3-arm randomized controlled trial aimed to test whether members of 2 digital self-health courses for anxiety and depression would engage with behavioral nudges and prompts. Our primary hypothesis was that members would click on 2 features: tips and a to-do checklist. Our secondary hypothesis was that members would prefer to engage with directive tips in arm 2 versus social proof and present bias tips in arm 3. Our tertiary hypothesis was that rotating tips and a to-do checklist would increase completion rates. The results of this study will form a baseline for future artificial intelligence?directed research. Methods: Overall, 13,224 new members registered between November 2021 and May 2022 for Evolution Health?s self-guided treatment courses for anxiety and depression. The control arm featured a member home page without nudges or prompts. Arm 2 featured a home page with a tip-of-the-day section. Arm 3 featured a home page with a tip-of-the-day section and a to-do checklist. The research protocol for this study was published in JMIR Research Protocols on August 15, 2022. Results: Arm 3 had significantly younger members (F2,4564=40.97; P<.001) and significantly more female members (?24=92.2; P<.001) than the other 2 arms. Control arm members (1788/13,224, 13.52%) completed an average of 1.5 course components. Arm 2 members (865/13,224, 6.54%) clicked on 5% of tips and completed an average of 1.8 course components. Arm 3 members (1914/13,224, 14.47%) clicked on 5% of tips, completed 2.7 of 8 to-do checklist items, and completed an average of 2.11 course components. Completion rates in arm 2 were greater than those in arm 1 (z score=3.37; P<.001), and completion rates in arm 3 were greater than those in arm 1 (z score=12.23; P<.001). Engagement in all 8 components in arm 3 was higher than that in arm 2 (z score=1.31; P<.001). Conclusions: Members engaged with behavioral nudges and prompts. The results of this study may be important because efficacy is related to increased engagement. Due to its novel approach, the outcomes of this study should be interpreted with caution and used as a guideline for future research in this nascent field. International Registered Report Identifier (IRRID): RR2-10.2196/37231 UR - https://formative.jmir.org/2024/1/e52558 UR - http://dx.doi.org/10.2196/52558 UR - http://www.ncbi.nlm.nih.gov/pubmed/38592752 ID - info:doi/10.2196/52558 ER - TY - JOUR AU - Stefana, Alberto AU - Vieta, Eduard AU - Fusar-Poli, Paolo AU - Youngstrom, A. Eric PY - 2024/4/8 TI - Enhancing Psychotherapy Outcomes by Encouraging Patients to Regularly Self-Monitor, Reflect on, and Share Their Affective Responses Toward Their Therapist: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e55369 VL - 13 KW - adult patients KW - evidence-based assessment KW - patient?s perspective KW - psychotherapy KW - randomized controlled trial KW - systematic client feedback KW - therapeutic relationship KW - treatment outcome N2 - Background: The quality of the therapeutic relationship is pivotal in determining psychotherapy outcomes. However, facilitating patients? self-awareness, reflection on, and sharing of their affective responses toward their therapist remains underexplored as a potential tool for enhancing this relationship and subsequent treatment outcomes. Objective: The primary objective of this study is to examine whether and how the patients? regular self-monitoring and self-reflection (fostered by the systematic compilation of a brief postsession battery) on their affective reactions toward the psychotherapist impact the quality of the therapeutic relationship and treatment outcomes in individual psychotherapy. Secondary objectives are to (1) explore whether and how the characteristics of the patient, the therapist, and the process moderate the effect of regular self-monitoring on the therapeutic relationship and outcomes; (2) examine the relationships between the affective response of the patient, the alliance, and the result of the therapy session outcome; and (3) explore how the affective responses of the patient unfold or change throughout the course of the therapy. Methods: We conducted a 1:1 randomized controlled trial of adults in individual psychotherapy versus individual psychotherapy plus self-monitoring. Participants will be enrolled through the web-based recruitment platforms ?ResearchMatch? and ?Research for Me,? and data will be collected through web-based surveys. Participants in the control group will receive only their regular individual psychotherapy (treatment as usual) and will not complete postsession questionnaires. Participants in the intervention group will continue their regular individual psychotherapy sessions and complete the ?in-Session Patient Affective Reactions Questionnaire? and the ?Rift In-Session Questionnaire? following each therapy session in the 10 weeks of the trial. Additionally, after completion of the postsession battery, they will receive general written feedback encouraging them to discuss their feelings and reflections with their therapist. Participants in both groups will complete a comprehensive psychological assessment at baseline, midtrial (week 5), and end-of-trial (week 10). The primary outcome measure of the trial is the ?Clinical Outcomes in Routine Evaluation-Outcome Measure,? while the secondary outcomes are the ?Real Relationship Inventory-Client-Short Form,? the ?Working Alliance Inventory-Short Revised,? and the number of scheduled therapy sessions that the patient has missed or canceled. Results: The trial was approved by the institutional review board of the University of North Carolina at Chapel Hill. Recruitment started in September 2023. A total of 475 individuals completed the baseline assessment. Data collection was completed in February 2024. The results are expected to be published in the autumn of 2024. Conclusions: This study could reveal key information on how regular self-monitoring and introspection can influence both the therapeutic relationship and treatment outcomes. Findings have the potential to shape interventions, enhance the efficacy of psychotherapeutic sessions, and possibly offer a cost-effective strategy for improving patients? well-being. Trial Registration: ClinicalTrials.gov NCT06038747; https://classic.clinicaltrials.gov/ct2/show/NCT06038747 International Registered Report Identifier (IRRID): DERR1-10.2196/55369 UR - https://www.researchprotocols.org/2024/1/e55369 UR - http://dx.doi.org/10.2196/55369 UR - http://www.ncbi.nlm.nih.gov/pubmed/38587881 ID - info:doi/10.2196/55369 ER - TY - JOUR AU - Anastasiadou, Dimitra AU - Herrero, Pol AU - Garcia-Royo, Paula AU - Vázquez-De Sebastián, Julia AU - Slater, Mel AU - Spanlang, Bernhard AU - Álvarez de la Campa, Elena AU - Ciudin, Andreea AU - Comas, Marta AU - Ramos-Quiroga, Antoni Josep AU - Lusilla-Palacios, Pilar PY - 2024/4/5 TI - Assessing the Clinical Efficacy of a Virtual Reality Tool for the Treatment of Obesity: Randomized Controlled Trial JO - J Med Internet Res SP - e51558 VL - 26 KW - obesity KW - virtual reality KW - psychological treatment KW - embodiment KW - motivational interviewing KW - self-conversation N2 - Background: Virtual reality (VR) interventions, based on cognitive behavioral therapy principles, have been proven effective as complementary tools in managing obesity and have been associated with promoting healthy behaviors and addressing body image concerns. However, they have not fully addressed certain underlying causes of obesity, such as a lack of motivation to change, low self-efficacy, and the impact of weight stigma interiorization, which often impede treatment adherence and long-term lifestyle habit changes. To tackle these concerns, this study introduces the VR self-counseling paradigm, which incorporates embodiment and body-swapping techniques, along with motivational strategies, to help people living with obesity effectively address some of the root causes of their condition. Objective: This study aims to assess the clinical efficacy of ConVRself (Virtual Reality self-talk), a VR platform that allows participants to engage in motivational self-conversations. Methods: A randomized controlled trial was conducted with 68 participants from the bariatric surgery waiting list from the obesity unit of the Vall d?Hebron University Hospital in Barcelona, Spain. Participants were assigned to 1 of 3 groups: a control group (CG), which only received treatment as usual from the obesity unit; experimental group 1 (EG1), which, after intensive motivational interviewing training, engaged in 4 sessions of VR-based self-conversations with ConVRself, and underwent embodiment and body-swapping techniques; and experimental group 2 (EG2), which engaged in 4 VR-based sessions led by a virtual counselor with a prerecorded discourse, and only underwent the embodiment technique. In the case of both EG1 and EG2, the VR interventions were assisted by a clinical researcher. Readiness to change habits, eating habits, and psychological variables, as well as adherence and satisfaction with ConVRself were measured at baseline, after the intervention, 1 week after the intervention, and 4 weeks after the intervention. Results: Regarding the primary outcomes, EG1 (24/68, 35%) and EG2 (22/68, 32%) showed significant improvements in confidence to lose weight compared to the CG (22/68, 32%) at all assessment points (?=?.16; P=.02). Similarly, EG1 demonstrated a significant increase after the intervention in readiness to exercise more compared to the CG (?=?.17; P=.03). Regarding the secondary outcomes, EG1 participants showed a significant reduction in uncontrolled eating (?=.71; P=.01) and emotional eating (?=.29; P=.03) compared to the CG participants, as well as in their anxiety levels compared to EG2 and CG participants (?=.65; P=.01). In addition, participants from the experimental groups reported high adherence and satisfaction with the VR platform (EG1: mean 59.82, SD 4.00; EG2: mean 58.43, SD 5.22; d=0.30, 95% CI ?0.30 to 0.89). Conclusions: This study revealed that using VR self-conversations, based on motivational interviewing principles, may have benefits in helping people with obesity to enhance their readiness to change habits and self-efficacy, as well as reduce dysfunctional eating behaviors and anxiety. Trial Registration: ClinicalTrials.gov NCT05094557; https://www.clinicaltrials.gov/study/NCT05094557 UR - https://www.jmir.org/2024/1/e51558 UR - http://dx.doi.org/10.2196/51558 UR - http://www.ncbi.nlm.nih.gov/pubmed/38578667 ID - info:doi/10.2196/51558 ER - TY - JOUR AU - Moreira, Rui AU - Silveira, Augusta AU - Sequeira, Teresa AU - Durão, Nuno AU - Lourenço, Jessica AU - Cascais, Inês AU - Cabral, Maria Rita AU - Taveira Gomes, Tiago PY - 2024/4/4 TI - Gamification and Oral Health in Children and Adolescents: Scoping Review JO - Interact J Med Res SP - e35132 VL - 13 KW - gamification KW - mechanisms of gamification KW - gamification components KW - intrinsic and extrinsic motivators KW - oral health care KW - health behavior KW - oral health care applications N2 - Background: Oral health is a determinant of overall well-being and quality of life. Individual behaviors, such as oral hygiene and dietary habits, play a central role in oral health. Motivation is a crucial factor in promoting behavior change, and gamification offers a means to boost health-related knowledge and encourage positive health behaviors. Objective: This study aims to evaluate the impact of gamification and its mechanisms on oral health care of children and adolescents. Methods: A systematic search covered multiple databases: PubMed/MEDLINE, PsycINFO, the Cochrane Library, ScienceDirect, and LILACS. Gray literature, conference proceedings, and WHOQOL internet resources were considered. Studies from January 2013 to December 2022 were included, except for PubMed/MEDLINE, which was searched until January 2023. A total of 15 studies were selected following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The eligibility criteria were peer-reviewed, full-text, and empirical research related to gamification in oral health care, reports of impact, and oral health care outcomes. The exclusion criteria encompassed duplicate articles; unavailable full texts; nonoriginal articles; and non?digital game?related, non?oral health?related, and protocol studies. Selected studies were scrutinized for gamification mechanisms and outcomes. Two main questions were raised: ?Does gamification in oral health care impact oral health?? and ?Does oral health care gamification enhance health promotion and literacy?? The PICO (Patient, Intervention, Comparison, Outcome) framework guided the scoping review. Results: Initially, 617 records were obtained from 5 databases and gray literature sources. After applying exclusion criteria, 15 records were selected. Sample size in the selected studies ranged from 34 to 190 children and adolescents. A substantial portion (11/15, 73%) of the studies discussed oral self-care apps supported by evidence-based oral health. The most clearly defined data in the apps were ?brushing time? (11/11, 100%) and ?daily amount brushing? (10/11, 91%). Most studies (11/15, 73%) mentioned oral health care behavior change techniques and included ?prompt intention formation? (11/26, 42%), ?providing instructions? (11/26, 42%), ?providing information on the behavior-health link? (10/26, 38%), ?providing information on consequences? (9/26, 35%), ?modeling or demonstrating behavior? (9/26, 35%), ?providing feedback on performance? (8/26, 31%), and ?providing contingent rewards? (8/26, 31%). Furthermore, 80% (12/15) of the studies identified game design elements incorporating gamification features in oral hygiene applications. The most prevalent gamification features were ?ideological incentives? (10/12, 83%) and ?goals? (9/16, 56%), which were found in user-specific and challenge categories, respectively. Conclusions: Gamification in oral health care shows potential as an innovative approach to promote positive health behaviors. Most studies reported evidence-based oral health and incorporated oral health care behavior change techniques. UR - https://www.i-jmr.org/2024/1/e35132 UR - http://dx.doi.org/10.2196/35132 UR - http://www.ncbi.nlm.nih.gov/pubmed/38573750 ID - info:doi/10.2196/35132 ER - TY - JOUR AU - Borrelli, Belinda AU - Bartlett, Kiera Y. AU - Fulford, Daniel AU - Frasco, Greg AU - Armitage, J. Christopher AU - Wearden, Alison PY - 2024/4/4 TI - Behavioral Activation Mobile App to Motivate Smokers to Quit: Feasibility and Pilot Randomized Controlled Trial JO - JMIR Form Res SP - e54912 VL - 8 KW - smoking cessation KW - mobile app KW - motivation KW - depressed mood KW - depression KW - behavioral activation KW - negative affect KW - positive affect KW - quit smoking KW - health behavior change N2 - Background: Behavioral activation (BA) is an evidence-based treatment for depression that fosters engagement in values-based activities to increase access to positive reinforcement. Depressed mood has been shown to hinder smoking cessation. Objective: This study determined the feasibility and preliminary efficacy of a mobile app to motivate smokers to quit by using BA and integrating motivational messages to quit smoking. Methods: Adult smokers (N=56; mean age 34.5, SD 9.52 years) who were not ready to quit smoking within 30 days were recruited from advertisements and randomized to either 8 weeks of the BA app (set 2 values-based activities per week+motivational messages+feedback on changes in smoking, mood, and values-based activities) or the control group (no app; received resources for quitting smoking). All participants completed the baseline and end-of-treatment web-based questionnaires. Controls also completed weekly web-based assessments, and BA app participants completed assessments through the app. Results: There were no dropouts and only 2 participants in each condition did not complete the end-of-treatment questionnaire. The results demonstrated that it is feasible to recruit smokers who are unmotivated to quit into a smoking cessation induction trial: 86% (57/66) of eligible participants were randomized (BA app: n=27; control: n=29). Participants reported high levels of satisfaction: 80% (20/25) of participants said they would recommend the BA app, there were moderate-to-high scores on the Mobile App Rating Scale, and 88% (22/25) of participants rated the app 3 stars or higher (out of 5). There were high levels of BA app engagement: 96% (26/27) of participants planned activities, and 67% (18/27) of participants planned 7 or more activities. High engagement was found even among those who were at the highest risk for continued smoking (low motivation to quit, low confidence to quit, and high negative affect). The results provided support for the hypothesized relationships between BA constructs: greater pleasant activity completion was associated with greater positive affect (b=0.37, SE 0.21; 95% CI ?0.05 to 0.79; P=.08), and greater positive affect tended to predict fewer cigarettes smoked the next day (b=?0.19, SE 0.10; 95% CI ?0.39 to 0.01; P=.06). Additionally, a greater number of activities planned was associated with lower negative affect (b=?0.26, SE 0.15; 95% CI ?0.55 to 0.04; P=.09). Overall, 16% (4/25) of BA app participants set a quit date versus 4% (1/27) among controls, and there were promising (but not significant) trends for motivation and confidence to quit. Conclusions: The findings suggest that a mobile app intervention can be made appealing to smokers who are unmotivated to quit by focusing on aspects most important to them, such as mood management. This theory-based intervention has shown some initial support for the underlying theoretical constructs, and further efficacy testing is warranted in a fully powered trial. UR - https://formative.jmir.org/2024/1/e54912 UR - http://dx.doi.org/10.2196/54912 UR - http://www.ncbi.nlm.nih.gov/pubmed/38573739 ID - info:doi/10.2196/54912 ER - TY - JOUR AU - Avila-Montiel, Diana AU - Vilchis-Gil, Jenny AU - Miranda-Lora, Liliana América AU - Velázquez-López, Lubia AU - Klünder-Klünder, Miguel PY - 2024/4/1 TI - The Effects of an Educational Intervention About Front-of-Package Labeling on Food and Beverage Selection Among Children and Their Caregivers: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e54783 VL - 13 KW - e-Health nutrition education KW - ultraprocessed foods KW - malnutrition KW - children KW - Mexico KW - intervention KW - obesity KW - food KW - food selection KW - labeling KW - package labeling N2 - Background: Overweight and obesity pose a global public health challenge and have a multifactorial origin. One of these factors includes obesogenic environments, which promote ultraprocessed foods characterized by being high in calories, saturated fats, added sugars, and sodium. In Mexico, it has been estimated that 30% of the total energy consumed comes from processed foods. The Modification to the Official Mexican Standards introduces nutritional information through black octagonal seals that alert consumers about products with excessive amounts of some components for a better food selection in the population. However, the effects of warning labels on processed food selection and purchases among children remain unknown. Objective: We aimed to evaluate the impact of a digital educational intervention focusing on front-of-package warning labels on the food selection and purchasing behavior of elementary schoolchildren and their caregivers. Methods: Children from 4 elementary schools in Mexico City, 2 public and 2 private schools, will participate in a randomized controlled trial. The schools will be chosen by simple random sampling. Schools will be randomized into 2 groups: intervention and control. In the control group, the dyads (caregiver-schoolchildren) will receive general nutritional education, and in the intervention group, they will receive guidance on reading labels and raising awareness about the impact of consuming ultraprocessed products on health. The educational intervention will be conducted via a website. Baseline measurements will be taken for both groups at 3 and 6 months. All participants will have access to an online store through the website, allowing them to engage in exercises for selecting and purchasing food and beverages. In addition, other measures will include a brief 5-question exam to evaluate theoretical understanding, a 24-hour reminder, a survey on food habits and consumption, application of a food preference scale, anthropometric measurements, and recording of school lunch choices. Results: Registration and funding were authorized in 2022, and we will begin data collection in September 2024. Recruitment has not yet taken place, but the status of data analysis and expected results will be published in April 2025. Conclusions: The study is expected to contribute to evaluating whether reinforcing front-of-package warning labels with education enhances its effects and makes them more sustainable. Conducting this study will allow us to propose whether or not it is necessary to develop new intervention strategies related to front-of-package labeling for a better understanding of the population, improved food choices, and better health outcomes. Trial Registration: ClinicalTrials.gov NCT06102473; https://clinicaltrials.gov/study/NCT06102473 International Registered Report Identifier (IRRID): PRR1-10.2196/54783 UR - https://www.researchprotocols.org/2024/1/e54783 UR - http://dx.doi.org/10.2196/54783 UR - http://www.ncbi.nlm.nih.gov/pubmed/38557591 ID - info:doi/10.2196/54783 ER - TY - JOUR AU - Huang, Siyi AU - Gu, Yuxuan AU - Ali, H. Shahmir AU - Xue, Jingjing AU - Zhang, Ronghua AU - Wen, Xu PY - 2024/3/27 TI - Association Between Adherence to 24-Hour Movement Guidelines and Noncommunicable Disease Risk in Chinese Adults: Prospective Cohort Study JO - JMIR Public Health Surveill SP - e47517 VL - 10 KW - chronic diseases KW - 24-hour movement guidelines KW - obesity KW - noncommunicable disease KW - sleep KW - risk KW - overweight N2 - Background: The increasing annual global deaths are attributable to noncommunicable chronic diseases (NCDs). Adhering to healthy lifestyle behaviors is associated with lower NCD risk, particularly among individuals with ample movement, enough sleep, and reduced sedentariness. Nevertheless, there are only few prospective assessments on the association of interactions between daily activities with NCD prevention, while the associations between adhering to Canadian 24-Hour Movement Guidelines (24HGs) for adults and NCD risks are still unknown. Compared to the general population, obese and overweight populations are at a higher risk of developing NCDs. Currently, it is unclear whether the health benefits of adhering to 24HGs differ between the general population and the obese population. Objective: This study explores prospective associations between adherence to 24HGs and NCD risks by weight status among overweight and obese adults in China. Methods: This decadal study consists of 9227 adults aged 35 years and older without any major NCDs at enrolment in the China Health and Nutrition Survey (2004-2011) and followed up until 2015. The exposure of interest was the overall score of compliance with 24HGs measured by participants? self-report, wherein 1 point was assigned for compliance to each component, resulting in an aggregated score ranging from 0 to 3. The primary outcome was the first occurrence of major NCDs (high blood pressure, stroke, diabetes, cancer, and acute myocardial infarction). Log-binomial regression models were used to evaluate the associations. Results: : Overall, 4315 males and 4912 females, with 25,175 person-years of follow-up, were included in our analyses. The average baseline age was 50.21 (SD 11.04) years. Among the overweight and obese groups, those adhering to 1 (risk ratio [RR] 0.37, 95% CI 0.19-0.74; P=.004), 2 (RR 0.37, 95% CI 0.19-0.72; P=.003), and 3 (RR 0.32, 95% CI 0.14-0.73; P=.006) recommendations of 24HGs had a significantly lower NCD risk than those not adhering to any of the activity guidelines. Among the normal or underweight groups, those adhering to 1 (RR 0.49, 95% CI 0.27-0.96; P=.03) and 3 (RR 0.40, 95% CI 0.17-0.94; P=.03) components had a significantly lower NCD risk than those not adhering to any of the activity guidelines. Conclusions: In this prospective study, we found that active adherence to recommendations of 24HGs was associated with lower risks of NCDs, especially among overweight and obese participants. Additionally, overweight and obese individuals who met at least 1 component of 24HGs were at a significantly lower risk for NCDs, but this protective effect was not found among individuals in the normal and underweight groups. Individuals with excess body weight who tend to be more susceptible to health risks may gain greater health benefits than the general population by adhering to the recommendations of 24HGs. UR - https://publichealth.jmir.org/2024/1/e47517 UR - http://dx.doi.org/10.2196/47517 UR - http://www.ncbi.nlm.nih.gov/pubmed/38536210 ID - info:doi/10.2196/47517 ER - TY - JOUR AU - Ulfsdotter Gunnarsson, Katarina AU - Henriksson, Martin AU - Bendtsen, Marcus PY - 2024/3/27 TI - Digital Alcohol Interventions Could Be Part of the Societal Response to Harmful Consumption, but We Know Little About Their Long-Term Costs and Health Outcomes JO - J Med Internet Res SP - e44574 VL - 26 KW - alcohol KW - health economics KW - telemedicine KW - psychological harm KW - eHealth KW - digital intervention KW - decision-making UR - https://www.jmir.org/2024/1/e44574 UR - http://dx.doi.org/10.2196/44574 UR - http://www.ncbi.nlm.nih.gov/pubmed/38536228 ID - info:doi/10.2196/44574 ER - TY - JOUR AU - Lieder, Falk AU - Chen, Pin-Zhen AU - Prentice, Mike AU - Amo, Victoria AU - To?i?, Mateo PY - 2024/3/22 TI - Gamification of Behavior Change: Mathematical Principle and Proof-of-Concept Study JO - JMIR Serious Games SP - e43078 VL - 12 KW - gamification KW - points KW - feedback KW - behavior change KW - habit formation KW - chatbot KW - digital interventions KW - mobile phone KW - artificial intelligence N2 - Background: Many people want to build good habits to become healthier, live longer, or become happier but struggle to change their behavior. Gamification can make behavior change easier by awarding points for the desired behavior and deducting points for its omission. Objective: In this study, we introduced a principled mathematical method for determining how many points should be awarded or deducted for the enactment or omission of the desired behavior, depending on when and how often the person has succeeded versus failed to enact it in the past. We called this approach optimized gamification of behavior change. Methods: As a proof of concept, we designed a chatbot that applies our optimized gamification method to help people build healthy water-drinking habits. We evaluated the effectiveness of this gamified intervention in a 40-day field experiment with 1 experimental group (n=43) that used the chatbot with optimized gamification and 2 active control groups for which the chatbot?s optimized gamification feature was disabled. For the first control group (n=48), all other features were available, including verbal feedback. The second control group (n=51) received no feedback or reminders. We measured the strength of all participants? water-drinking habits before, during, and after the intervention using the Self-Report Habit Index and by asking participants on how many days of the previous week they enacted the desired habit. In addition, all participants provided daily reports on whether they enacted their water-drinking intention that day. Results: A Poisson regression analysis revealed that, during the intervention, users who received feedback based on optimized gamification enacted the desired behavior more often (mean 14.71, SD 6.57 times) than the active (mean 11.64, SD 6.38 times; P<.001; incidence rate ratio=0.80, 95% CI 0.71-0.91) or passive (mean 11.64, SD 5.43 times; P=.001; incidence rate ratio=0.78, 95% CI 0.69-0.89) control groups. The Self-Report Habit Index score significantly increased in all conditions (P<.001 in all cases) but did not differ between the experimental and control conditions (P>.11 in all cases). After the intervention, the experimental group performed the desired behavior as often as the 2 control groups (P?.17 in all cases). Conclusions: Our findings suggest that optimized gamification can be used to make digital behavior change interventions more effective. Trial Registration: Open Science Framework (OSF) H7JN8; https://osf.io/h7jn8 UR - https://games.jmir.org/2024/1/e43078 UR - http://dx.doi.org/10.2196/43078 UR - http://www.ncbi.nlm.nih.gov/pubmed/38517466 ID - info:doi/10.2196/43078 ER - TY - JOUR AU - Rizvi, Fatima Rubina AU - Schoephoerster, Ann Jamee AU - Desphande, Satish Sagar AU - Usher, Michael AU - Oien, Elaine Andy AU - Peters, Marie Maya AU - Loth, Scott Matthew AU - Bahr, William Matthew AU - Ventz, Steffen AU - Koopmeiners, Stephen Joseph AU - Melton, B. Genevieve PY - 2024/3/8 TI - Decreasing Opioid Addiction and Diversion Using Behavioral Economics Applied Through a Digital Engagement Solution: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e52882 VL - 13 KW - opioid abuse KW - opioid naïve patients KW - opioid addiction KW - behavioral economics KW - nudges KW - MyChart KW - personal health record KW - post-operative care KW - opioid KW - opioid use KW - randomized controlled trial KW - RCT KW - digital engagement KW - health crisis KW - overdose KW - acute pain KW - pain KW - tool KW - tools KW - phone app KW - website KW - application N2 - Background: Despite strong and growing interest in ending the ongoing opioid health crisis, there has been limited success in reducing the prevalence of opioid addiction and the number of deaths associated with opioid overdoses. Further, 1 explanation for this is that existing interventions target those who are opiate-dependent but do not prevent opioid-naïve patients from becoming addicted. Objective: Leveraging behavioral economics at the patient level could help patients successfully use, discontinue, and dispose of their opioid medications in an acute pain setting. The primary goal of this project is to evaluate the effect of the 3 versions of the Opioid Management for You (OPY) tool on measures of opioid use relative to the standard of care by leveraging a pragmatic randomized controlled trial (RCT). Methods: A team of researchers from the Center for Learning Health System Sciences (CLHSS) at the University of Minnesota partnered with M Health Fairview to design, build, and test the 3 versions of the OPY tool: social influence, precommitment, and testimonial version. The tool is being built using the Epic Care Companion (Epic Inc) platform and interacts with the patient through their existing MyChart (Epic Systems Corporation) personal health record account, and Epic patient portal, accessed through a phone app or the MyChart website. We have demonstrated feasibility with pilot data of the social influence version of the OPY app by targeting our pilot to a specific cohort of patients undergoing upper-extremity procedures. This study will use a group sequential RCT design to test the impact of this important health system initiative. Patients who meet OPY inclusion criteria will be stratified into low, intermediate, and high risk of opiate use based on their type of surgery. Results: This study is being funded and supported by the CLHSS Rapid Prospective Evaluation and Digital Technology Innovation Programs, and M Health Fairview. Support and coordination provided by CLHSS include the structure of engagement, survey development, data collection, statistical analysis, and dissemination. The project was initially started in August 2022. The pilot was launched in February 2023 and is still running, with the data last counted in August 2023. The actual RCT is planned to start by early 2024. Conclusions: Through this RCT, we will test our hypothesis that patient opioid use and diverted prescription opioid availability can both be improved by information delivery applied through a behavioral economics lens via sending nudges directly to the opioid users through their personal health record. Trial Registration: ClinicalTrials.gov NCT06124079; https://clinicaltrials.gov/study/NCT06124079 International Registered Report Identifier (IRRID): PRR1-10.2196/52882 UR - https://www.researchprotocols.org/2024/1/e52882 UR - http://dx.doi.org/10.2196/52882 UR - http://www.ncbi.nlm.nih.gov/pubmed/38457203 ID - info:doi/10.2196/52882 ER - TY - JOUR AU - Rodriguez, V. Danissa AU - Lawrence, Katharine AU - Gonzalez, Javier AU - Brandfield-Harvey, Beatrix AU - Xu, Lynn AU - Tasneem, Sumaiya AU - Levine, L. Defne AU - Mann, Devin PY - 2024/3/6 TI - Leveraging Generative AI Tools to Support the Development of Digital Solutions in Health Care Research: Case Study JO - JMIR Hum Factors SP - e52885 VL - 11 KW - digital health KW - GenAI KW - generative KW - artificial intelligence KW - ChatGPT KW - software engineering KW - mHealth KW - mobile health KW - app KW - apps KW - application KW - applications KW - diabetes KW - diabetic KW - diabetes prevention KW - digital prescription KW - software KW - engagement KW - behaviour change KW - behavior change KW - developer KW - developers KW - LLM KW - LLMs KW - language model KW - language models KW - NLP KW - natural language processing N2 - Background: Generative artificial intelligence has the potential to revolutionize health technology product development by improving coding quality, efficiency, documentation, quality assessment and review, and troubleshooting. Objective: This paper explores the application of a commercially available generative artificial intelligence tool (ChatGPT) to the development of a digital health behavior change intervention designed to support patient engagement in a commercial digital diabetes prevention program. Methods: We examined the capacity, advantages, and limitations of ChatGPT to support digital product idea conceptualization, intervention content development, and the software engineering process, including software requirement generation, software design, and code production. In total, 11 evaluators, each with at least 10 years of experience in fields of study ranging from medicine and implementation science to computer science, participated in the output review process (ChatGPT vs human-generated output). All had familiarity or prior exposure to the original personalized automatic messaging system intervention. The evaluators rated the ChatGPT-produced outputs in terms of understandability, usability, novelty, relevance, completeness, and efficiency. Results: Most metrics received positive scores. We identified that ChatGPT can (1) support developers to achieve high-quality products faster and (2) facilitate nontechnical communication and system understanding between technical and nontechnical team members around the development goal of rapid and easy-to-build computational solutions for medical technologies. Conclusions: ChatGPT can serve as a usable facilitator for researchers engaging in the software development life cycle, from product conceptualization to feature identification and user story development to code generation. Trial Registration: ClinicalTrials.gov NCT04049500; https://clinicaltrials.gov/ct2/show/NCT04049500 UR - https://humanfactors.jmir.org/2024/1/e52885 UR - http://dx.doi.org/10.2196/52885 UR - http://www.ncbi.nlm.nih.gov/pubmed/38446539 ID - info:doi/10.2196/52885 ER - TY - JOUR AU - Maltz, Amnon AU - Rashkovich, Stella AU - Sarid, Adi AU - Cohen, Yafit AU - Landau, Tamar AU - Saifer, Elina AU - Amorai Belkin, Neta AU - Alcalay, Tamar PY - 2024/3/6 TI - The Framing Effect of Digital Textual Messages on Uptake Rates of Medical Checkups: Field Study JO - JMIR Public Health Surveill SP - e45379 VL - 10 KW - field experiment KW - nudge KW - cancer screening KW - mammography KW - vaccination KW - framing KW - fecal occult blood test (FOBT) KW - behavior change N2 - Background: Health care authorities often use text messages to enhance compliance with medical recommendations. The effectiveness of different message framings has been studied extensively over the past 3 decades. Recently, health care providers have begun using digital media platforms to disseminate health-related messages. Objective: This study aimed to examine the effectiveness of some of the most widely used message framings on the uptake rates of medical checkups. Methods: This study used a large-scale digital outreach campaign conducted by Maccabi Healthcare Services (MHS) during 2020-2021, involving a total of 113,048 participants. MHS members aged 50-74 years were invited to take their recommended medical actions from the following list: human papillomavirus (HPV), mammography, abdominal aortic aneurysm, fecal occult blood test (FOBT), and pneumococcal vaccination. Each member was randomly assigned to receive 1 of 6 message framings: control (neutrally framed; n=20,959, 18.5%), gains (benefits of compliance; n=20,393, 18%), losses (negative consequences of noncompliance; n=15,165, 13.4%), recommendation (a recommendation by an authoritative figure, in this context by a physician; n=20,584, 18.2%), implementation intentions (linking potential outcomes to future reactions; n=20,701, 18.3%), and empowerment (emphasizing personal responsibility for maintaining good health; n=15,246, 13.5%). The time frames for measuring a successful intervention were 14 days for scheduling screenings (ie, HPV, mammography, or abdominal aortic aneurysm), 30 days for performing the FOBT, and 60 days for receiving pneumococcal vaccination. We also examined the effectiveness of media channels (text message or email) on uptake rates and whether the subject-line length is correlated with message-opening rates. Results: No significant effect of message framing on uptake rates of medical checkups was observed. The rates of appointments for screening ranged from 12.9% to 14.1% across treatments. Based on a chi-square test, there was no evidence to reject the null hypothesis that these compliance rates are independent of the treatments (P=.35). The uptake rates for the FOBT and pneumococcal vaccination ranged from 23.3% to 23.8% across treatments, and we could not reject the hypothesis that they are independent of the treatments (P=.88). We also found that emails are more effective than text messages (P<.001) and that the subject-line length is negatively correlated with message-opening rates. Conclusions: No evidence was found for an effect of the 5 message framings on uptake rates of medical checkups. To enhance compliance rates, public health officials may consider alternative framings. Furthermore, media channels and the subject-line length should be given careful consideration in the planning stages of health care campaigns. Trial Registration: AEA RCT Registry AEARCTR-0006317; https://www.socialscienceregistry.org/trials/6317/history/201365 UR - https://publichealth.jmir.org/2024/1/e45379 UR - http://dx.doi.org/10.2196/45379 UR - http://www.ncbi.nlm.nih.gov/pubmed/38446543 ID - info:doi/10.2196/45379 ER - TY - JOUR AU - Xiang, Xiaoling AU - Kayser, Jay AU - Turner, Skyla AU - Ash, Samson AU - Himle, A. Joseph PY - 2024/3/4 TI - Layperson-Supported, Web-Delivered Cognitive Behavioral Therapy for Depression in Older Adults: Randomized Controlled Trial JO - J Med Internet Res SP - e53001 VL - 26 KW - internet-based cognitive behavioral therapy KW - iCBT KW - digital mental health interventions KW - older adults KW - depression N2 - Background: Depression is the most prevalent mental health condition in older adults. However, not all evidence-based treatments are easily accessible. Web-delivered cognitive behavioral therapy (wCBT) facilitated by laypersons is a viable treatment alternative. Objective: This randomized controlled trial aims to evaluate the efficacy of a novel wCBT program, Empower@Home, supported by trained lay coaches, against a waitlist attention control. Empower@Home is among the very few existing wCBT programs specifically designed for older adults. The primary objective was to assess the efficacy of the intervention compared with attention control. The secondary objective was to evaluate the program?s impact on secondary psychosocial outcomes and explore potential change mechanisms. Methods: Older adults (N=70) were recruited via web-based research registries, social media advertisements, and community agency referrals and randomly assigned to either the intervention or control group in a 1:1 allocation ratio. The intervention group received access to Empower@Home, which included 9 web-delivered self-help lessons and weekly telephone coaching sessions by a trained layperson over 10 weeks. The control group received weekly friendly phone calls and depressive symptom monitoring. The primary clinical outcome was the severity of depressive symptoms assessed using the Patient Health Questionnaire-9. The secondary clinical outcomes included anxiety, anger, social isolation, insomnia, pain intensity, and quality of life. Linear mixed modeling was used to determine the treatment effects on depression, and 2-tailed t tests were used to assess within-group changes and between-group differences. Results: Most participants in the intervention group completed all 9 sessions (31/35, 89%). The usability and acceptability ratings were excellent. The intervention group had a large within-group change in depressive symptoms (Cohen d=1.22; P<.001), whereas the attention control group experienced a medium change (Cohen d=0.57; P<.001). The between-group effect size was significant, favoring the intervention group over the control group (Cohen d=0.72; P<.001). In the linear mixed model, the group-by-time interaction was statistically significant (b=?0.68, 95% CI ?1.00 to ?0.35; P<.001). The treatment effects were mediated by improvements in cognitive behavioral therapy skills acquisition; behavioral activation; and satisfaction with the basic psychological needs of autonomy, competence, and relatedness. Furthermore, the intervention group showed significant within-group improvements in secondary psychosocial outcomes, including anxiety (P=.001), anger (P<.001), social isolation (P=.02), insomnia (P=.007), and pain (P=.03). By contrast, the control group did not experience significant changes in these outcome domains. However, the between-group differences in secondary outcomes were not statistically significant, owing to the small sample size. Conclusions: Empower@Home, a wCBT program supported by lay coaches, was more efficacious in reducing depressive symptoms than friendly telephone calls and depression symptom monitoring. Future studies should examine the effectiveness of the intervention in community and practice settings using nonclinician staff already present in these real-world settings as coaches. Trial Registration: ClinicalTrials.gov NCT05593276; https://clinicaltrials.gov/ct2/show/NCT05593276 International Registered Report Identifier (IRRID): RR2-10.2196/44210 UR - https://www.jmir.org/2024/1/e53001 UR - http://dx.doi.org/10.2196/53001 UR - http://www.ncbi.nlm.nih.gov/pubmed/38437013 ID - info:doi/10.2196/53001 ER - TY - JOUR AU - Hakim, Hina AU - Driedger, Michelle S. AU - Gagnon, Dominique AU - Chevrier, Julien AU - Roch, Geneviève AU - Dubé, Eve AU - Witteman, O. Holly PY - 2024/2/29 TI - Digital Gamification Tools to Enhance Vaccine Uptake: Scoping Review JO - JMIR Serious Games SP - e47257 VL - 12 KW - digital gamified tools KW - digital game KW - vaccination KW - gamification KW - vaccine uptake KW - scoping review KW - review method KW - vaccine KW - gamified KW - COVID-19 KW - COVID KW - SARS-CoV-2 KW - health behaviour KW - health behavior KW - health promotion KW - behavior change KW - behaviour change N2 - Background: Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health. Objective: In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools. Methods: We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively. Results: Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature. Conclusions: Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts. UR - https://games.jmir.org/2024/1/e47257 UR - http://dx.doi.org/10.2196/47257 UR - http://www.ncbi.nlm.nih.gov/pubmed/38421688 ID - info:doi/10.2196/47257 ER - TY - JOUR AU - Shinno, Seina AU - Matsumoto, Kazuki AU - Hamatani, Sayo AU - Inaba, Yosuke AU - Ozawa, Yoshihito AU - Kawasaki, Yohei AU - Ikai, Tomoki AU - Sutoh, Chihiro AU - Hayashi, Hiroyuki AU - Shimizu, Eiji PY - 2024/2/29 TI - Feasibility of Guided Internet-Based Cognitive Behavioral Therapy for Panic Disorder and Social Anxiety Disorder in Japan: Pilot Single-Arm Trial JO - JMIR Form Res SP - e53659 VL - 8 KW - cognitive behavioral therapy KW - internet intervention KW - panic disorder KW - social anxiety KW - feasibility trail KW - adult KW - adults KW - anxiety disorder KW - internet-based KW - e-learning KW - Japan KW - statistical analyses KW - therapist KW - therapists KW - intervention KW - severity KW - symptoms KW - therapeutic alliance KW - mobile phone N2 - Background: Cognitive behavioral therapy (CBT) is effective in treating anxiety disorders. Accessibility to CBT has been limited in Japan due to the shortage of therapists. While an open-source e-learning system can be used to create a simple internet-based cognitive behavioral therapy (ICBT) program, the safety and outpatient acceptance of this treatment approach have not been explored in Japan. Objective: The aim of this study was to investigate whether outpatients with anxiety disorders could accept and successfully complete the ICBT program with guidance by CBT therapists when implementing therapeutic modules and CBT tasks. Due to being in the initial phase of a novel treatment in Japan, this study was intended for verification with a small sample size. Methods: In total, 6 adults, including 4 male participants and 2 female participants, were enrolled in a single-arm trial. The intervention involved guided ICBT comprising 12 sessions, including CBT text, comprehension confirmation tests, and explanatory videos about cognitive behavioral models, accessible through a website. The therapist guided the participants in accessing the ICBT program and answering their questions using a chat tool. The primary outcome was anxiety severity assessed using the State-Trait Anxiety Inventory-Trait. Secondary outcomes included the Panic Disorder Severity Scale, Liebowitz Social Anxiety Scale (LSAS), Beck Anxiety Inventory (BAI), Patient Health Questionnaire?9, Generalized Anxiety Disorder?7, and Working Alliance Inventory?Short Form (WAI-SF). Statistical analyses were performed using paired 2-tailed t tests to assess the changes in clinical symptoms. The total WAI-SF score at the final session was used to evaluate the therapeutic alliance. For statistical analyses, mean changes for total State-Trait Anxiety Inventory-Trait, BAI, Panic Disorder Severity Scale, LSAS, Patient Health Questionnaire?9, and Generalized Anxiety Disorder?7 scores were analyzed using the paired 2-tailed t test. The 2-sided significance level for hypothesis testing was set at 5%, and 2-sided 95% CIs were calculated. Results: Most participants diligently engaged with the ICBT program. No adverse events were reported. The mean total scores for the primary outcome decreased by 11.0 (SD 9.6) points (95% CI ?22.2 to 0.20; Hedges g=0.95), but it was not statistically significant. The mean total scores for the secondary outcomes that assess clinical symptoms decreased, with a significant reduction observed in the BAI of 15.7 (SD 12.1) points (95% CI ?28.4 to ?3.0; P=.03; Hedges g=1.24). The mean total scores for PDSS and LSAS decreased significantly, by 12.0 (SD 4.24) points (95% CI ?50.1 to 26.1; P=.16; Hedges g=1.79) and 32.4 (SD 11.1) points (95% CI ?59.7 to ?4.3; P=.04; Hedges g=1.38), respectively. Of the participants, 67% (n=4) showed treatment response, and 50% (n=3) achieved remission after the intervention. The therapeutic alliance, measured using the WAI-SF, was moderate. Conclusions: Guided ICBT may be feasible for the treatment of outpatients with panic disorder and social anxiety disorder in Japan. Trial Registration: University Hospital Medical Information Network Clinical Trials Registry UMIN0000038118; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000043439 UR - https://formative.jmir.org/2024/1/e53659 UR - http://dx.doi.org/10.2196/53659 UR - http://www.ncbi.nlm.nih.gov/pubmed/38421717 ID - info:doi/10.2196/53659 ER - TY - JOUR AU - Jiang, Shan AU - Ng, Y. Johan Y. AU - Chong, Hau Kar AU - Peng, Bo AU - Ha, S. Amy PY - 2024/2/21 TI - Effects of eHealth Interventions on 24-Hour Movement Behaviors Among Preschoolers: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e52905 VL - 26 KW - preschooler KW - movement behaviors KW - eHealth KW - physical activity KW - sedentary behavior KW - sleep KW - mobile phone KW - review KW - systematic review N2 - Background: The high prevalence of unhealthy movement behaviors among young children remains a global public health issue. eHealth is considered a cost-effective approach that holds great promise for enhancing health and related behaviors. However, previous research on eHealth interventions aimed at promoting behavior change has primarily focused on adolescents and adults, leaving a limited body of evidence specifically pertaining to preschoolers. Objective: This review aims to examine the effectiveness of eHealth interventions in promoting 24-hour movement behaviors, specifically focusing on improving physical activity (PA) and sleep duration and reducing sedentary behavior among preschoolers. In addition, we assessed the moderating effects of various study characteristics on intervention effectiveness. Methods: We searched 6 electronic databases (PubMed, Ovid, SPORTDiscus, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials) for experimental studies with a randomization procedure that examined the effectiveness of eHealth interventions on 24-hour movement behaviors among preschoolers aged 2 to 6 years in February 2023. The study outcomes included PA, sleep duration, and sedentary time. A meta-analysis was conducted to assess the pooled effect using a random-effects model, and subgroup analyses were conducted to explore the potential effects of moderating factors such as intervention duration, intervention type, and risk of bias (ROB). The included studies underwent a rigorous ROB assessment using the Cochrane ROB tool. Moreover, the certainty of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) assessment. Results: Of the 7191 identified records, 19 (0.26%) were included in the systematic review. The meta-analysis comprised a sample of 2971 preschoolers, which was derived from 13 included studies. Compared with the control group, eHealth interventions significantly increased moderate to vigorous PA (Hedges g=0.16, 95% CI 0.03-0.30; P=.02) and total PA (Hedges g=0.37, 95% CI 0.02-0.72; P=.04). In addition, eHealth interventions significantly reduced sedentary time (Hedges g=?0.15, 95% CI ?0.27 to ?0.02; P=.02) and increased sleep duration (Hedges g=0.47, 95% CI 0.18-0.75; P=.002) immediately after the intervention. However, no significant moderating effects were observed for any of the variables assessed (P>.05). The quality of evidence was rated as ?moderate? for moderate to vigorous intensity PA and sedentary time outcomes and ?low? for sleep outcomes. Conclusions: eHealth interventions may be a promising strategy to increase PA, improve sleep, and reduce sedentary time among preschoolers. To effectively promote healthy behaviors in early childhood, it is imperative for future studies to prioritize the development of rigorous comparative trials with larger sample sizes. In addition, researchers should thoroughly examine the effects of potential moderators. There is also a pressing need to comprehensively explore the long-term effects resulting from these interventions. Trial Registration: PROSPERO CRD42022365003; http://tinyurl.com/3nnfdwh3 UR - https://www.jmir.org/2024/1/e52905 UR - http://dx.doi.org/10.2196/52905 UR - http://www.ncbi.nlm.nih.gov/pubmed/38381514 ID - info:doi/10.2196/52905 ER - TY - JOUR AU - Robertson, C. Michael AU - Cox-Martin, Emily AU - Basen-Engquist, Karen AU - Lyons, J. Elizabeth PY - 2024/2/9 TI - Reflective Engagement With a Digital Physical Activity Intervention Among People Living With and Beyond Breast Cancer: Mixed Methods Study JO - JMIR Mhealth Uhealth SP - e51057 VL - 12 KW - survivors of cancer KW - exercise KW - acceptance and commitment therapy KW - fatigue KW - mindfulness KW - motivation KW - behavioral sciences N2 - Background: People living with and beyond breast cancer can face internal barriers to physical activity (eg, fatigue and pain). Digital interventions that promote psychological acceptance and motivation may help this population navigate these barriers. The degree to which individuals (1) adhere to intervention protocols and (2) reflect on and internalize intervention content may predict intervention efficacy. Objective: The objective of this study was to characterize the nature of reflective processes brought about by an 8-week acceptance- and mindfulness-based physical activity intervention for insufficiently active survivors of breast cancer (n=75). Furthermore, we explored the potential utility of a metric of reflective processes for predicting study outcomes. Methods: Of the intervention?s 8 weekly modules, 7 (88%) included an item that asked participants to reflect on what they found to be most useful. Two coders conducted directed content analysis on participants? written responses. They assessed each comment?s depth of reflection using an existing framework (ranging from 0 to 4, with 0=simple description and 4=fundamental change with consideration of social and ethical issues). The coders identified themes within the various levels of reflection. We fit multiple linear regression models to evaluate whether participants? (1) intervention adherence (ie, number of modules completed) and (2) the mean level of the depth of reflection predicted study outcomes. Results: Participants were aged on average 57.2 (SD 11.2) years, mostly non-Hispanic White (58/75, 77%), and mostly overweight or obese (54/75, 72%). Of the 407 responses to the item prompting personal reflection, 70 (17.2%) were rated as reflection level 0 (ie, description), 247 (60.7%) were level 1 (ie, reflective description), 74 (18.2%) were level 2 (ie, dialogic reflection), 14 (3.4%) were level 3 (ie, transformative reflection), and 2 (0.5%) were level 4 (ie, critical reflection). Lower levels of reflection were characterized by the acquisition of knowledge or expressing intentions. Higher levels were characterized by personal insight, commentary on behavior change processes, and a change of perspective. Intervention adherence was associated with increases in self-reported weekly bouts of muscle-strengthening exercise (B=0.26, SE 0.12, 95% CI 0.02-0.50) and decreases in sleep disturbance (B=?1.04, SE 0.50, 95% CI ?0.06 to ?2.02). The mean level of reflection was associated with increases in psychological acceptance (B=3.42, SE 1.70, 95% CI 0.09-6.75) and motivation for physical activity (ie, integrated regulation: B=0.55, SE 0.25, 95% CI 0.06-1.04). Conclusions: We identified a useful method for understanding the reflective processes that can occur during digital behavior change interventions serving people living with and beyond breast cancer. Intervention adherence and the depth of reflection each predicted changes in study outcomes. Deeper reflection on intervention content was associated with beneficial changes in the determinants of sustained behavior change. More research is needed to investigate the relations among digital behavior change intervention use, psychological processes, and intervention efficacy. UR - https://mhealth.jmir.org/2024/1/e51057 UR - http://dx.doi.org/10.2196/51057 UR - http://www.ncbi.nlm.nih.gov/pubmed/38335025 ID - info:doi/10.2196/51057 ER - TY - JOUR AU - Buss, Helen Vera AU - Barr, Margo AU - Parker, M. Sharon AU - Kabir, Alamgir AU - Lau, S. Annie Y. AU - Liaw, Siaw-Teng AU - Stocks, Nigel AU - Harris, F. Mark PY - 2024/2/9 TI - Mobile App Intervention of a Randomized Controlled Trial for Patients With Obesity and Those Who Are Overweight in General Practice: User Engagement Analysis Quantitative Study JO - JMIR Mhealth Uhealth SP - e45942 VL - 12 KW - health literacy KW - primary health care KW - mobile application KW - overweight KW - vulnerable populations KW - health behavior KW - mHealth KW - obesity KW - weight loss KW - mysnapp app KW - mobile phone N2 - Background: The Health eLiteracy for Prevention in General Practice trial is a primary health care?based behavior change intervention for weight loss in Australians who are overweight and those with obesity from lower socioeconomic areas. Individuals from these areas are known to have low levels of health literacy and are particularly at risk for chronic conditions, including diabetes and cardiovascular disease. The intervention comprised health check visits with a practice nurse, a purpose-built patient-facing mobile app (mysnapp), and a referral to telephone coaching. Objective: This study aimed to assess mysnapp app use, its user profiles, the duration and frequency of use within the Health eLiteracy for Prevention in General Practice trial, its association with other intervention components, and its association with study outcomes (health literacy and diet) to determine whether they have significantly improved at 6 months. Methods: In 2018, a total of 22 general practices from 2 Australian states were recruited and randomized by cluster to the intervention or usual care. Patients who met the main eligibility criteria (ie, BMI>28 in the previous 12 months and aged 40-74 years) were identified through the clinical software. The practice staff then provided the patients with details about this study. The intervention consisted of a health check with a practice nurse and a lifestyle app, a telephone coaching program, or both depending on the participants? choice. Data were collected directly through the app and combined with data from the 6-week health check with the practice nurses, the telephone coaching, and the participants? questionnaires at baseline and 6-month follow-up. The analyses comprised descriptive and inferential statistics. Results: Of the 120 participants who received the intervention, 62 (52%) chose to use the app. The app and nonapp user groups did not differ significantly in demographics or prior recent hospital admissions. The median time between first and last app use was 52 (IQR 4-95) days, with a median of 5 (IQR 2-10) active days. App users were significantly more likely to attend the 6-week health check (2-sided Fisher exact test; P<.001) and participate in the telephone coaching (2-sided Fisher exact test; P=.007) than nonapp users. There was no association between app use and study outcomes shown to have significantly improved (health literacy and diet) at 6 months. Conclusions: Recruitment and engagement were difficult for this study in disadvantaged populations with low health literacy. However, app users were more likely to attend the 6-week health check and participate in telephone coaching, suggesting that participants who opted for several intervention components felt more committed to this study. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617001508369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373505 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2018-023239 UR - https://mhealth.jmir.org/2024/1/e45942 UR - http://dx.doi.org/10.2196/45942 UR - http://www.ncbi.nlm.nih.gov/pubmed/38335014 ID - info:doi/10.2196/45942 ER - TY - JOUR AU - Jagayat, Kaur Jasleen AU - Kumar, Anchan AU - Shao, Yijia AU - Pannu, Amrita AU - Patel, Charmy AU - Shirazi, Amirhossein AU - Omrani, Mohsen AU - Alavi, Nazanin PY - 2024/2/9 TI - Incorporating a Stepped Care Approach Into Internet-Based Cognitive Behavioral Therapy for Depression: Randomized Controlled Trial JO - JMIR Ment Health SP - e51704 VL - 11 KW - internet-based cognitive behavioral therapy KW - i-CBT KW - major depressive disorder KW - MDD KW - stepped care KW - digital mental health care KW - mobile phone N2 - Background: Depression is a hidden burden, yet it is a leading cause of disability worldwide. Despite the adverse effects of depression, fewer than one-third of patients receive care. Internet-based cognitive behavioral therapy (i-CBT) is an effective treatment for depression, and combining i-CBT with supervised care could make the therapy scalable and effective. A stepped care model is a framework for beginning treatment with an effective and low-intensity intervention while adapting care based on the patient?s needs. Objective: This study investigated the efficacy of a stepped care i-CBT model for depression based on changes in self-reported depressive symptoms. Methods: In this single-blinded, randomized controlled trial, participants were allocated to either the i-CBT?only group (28/56, 50%) or the i-CBT with stepped care group (28/56, 50%). Both groups received a 13-week i-CBT program tailored for depression. The i-CBT program was provided through a secure, online mental health clinic called the Online Psychotherapy Tool. Participants read through the sessions and completed the assignments related to each session. Participants in the stepped care group received additional interventions from their care provider based on standard questionnaire scores (ie, Patient Health Questionnaire?9 [PHQ-9], Quick Inventory of Depressive Symptomatology [QIDS], and Quality of Life Enjoyment and Satisfaction Questionnaire?Short Form) and their assignment responses. From lowest to highest intensity, the additional interventions included SMS text messages, phone calls, video calls, or a video call with a psychiatrist. Results: For this study, 56 participants were recruited to complete an i-CBT program (n=28, 50%; mean age 37.9; SD 13.08 y; 7/28, 27% were men) or an i-CBT with stepped care program (n=28, 50%; mean age 40.6; SD 14.28 y; 11/28, 42% were men). The results of this study indicate that the i-CBT program was effective in significantly reducing depressive symptoms, as measured by the PHQ-9 (F4,80=9.95; P<.001) and QIDS (F2,28=5.73; P=.008); however, there were no significant differences in the reduction of depressive symptoms between the 2 groups (PHQ-9: F4,80=0.43; P=.78; QIDS: F2,28=3.05; P=.06). The stepped care group was not significantly better in reducing depressive symptoms than the i-CBT group (PHQ-9, P=.79; QIDS, P=.06). Although there were no significant differences observed between the number of participants who completed the program between the groups (?21=2.6; P=.10), participants in the stepped care group, on average, participated in more sessions than those who prematurely terminated participation in the i-CBT group (t55=?2; P=.03; 95% CI ?4.83 to ?0.002). Conclusions: Implementing a stepped care approach in i-CBT is an effective treatment for depression, and the stepped care model can assist patients to complete more sessions in their treatment. Trial Registration: Clinicaltrials.gov NCT04747873; https://clinicaltrials.gov/study/NCT04747873 UR - https://mental.jmir.org/2024/1/e51704 UR - http://dx.doi.org/10.2196/51704 UR - http://www.ncbi.nlm.nih.gov/pubmed/38173167 ID - info:doi/10.2196/51704 ER - TY - JOUR AU - Lee, Hyerim AU - Choi, Ho Eung AU - Shin, U. Jung AU - Kim, Tae-Gyun AU - Oh, Jooyoung AU - Shin, Bokyoung AU - Sim, Yeon Jung AU - Shin, Jaeyong AU - Kim, Meelim PY - 2024/2/9 TI - The Impact of Intervention Design on User Engagement in Digital Therapeutics Research: Factorial Experiment With a Mixed Methods Study JO - JMIR Form Res SP - e51225 VL - 8 KW - atopic KW - dermatitis KW - experimental design KW - mobile health KW - patient engagement KW - research methodology N2 - Background: User engagement is crucial for digital therapeutics (DTx) effectiveness; due to variations in the conceptualization of engagement and intervention design, assessment and retention of engagement remain challenging. Objective: We investigated the influence of the perceived acceptability of experimental intervention components and satisfaction with core intervention components in DTx on user engagement, while also identifying potential barriers and facilitators to user engagement. Methods: We conducted a mixed methods study with a 2 × 2 factorial design, involving 12 outpatients with atopic dermatitis. Participants were randomized into 4 experimental groups based on push notification (?basic? or ?advanced?) and human coach (?on? or ?off?) experimental intervention components. All participants engaged in self-monitoring and learning courses as core intervention components within an app-based intervention over 8 weeks. Data were collected through in-app behavioral data, physician- and self-reported questionnaires, and semistructured interviews assessed at baseline, 4 weeks, and 8 weeks. Descriptive statistics and thematic analysis were used to evaluate user engagement, perceived acceptability of experimental intervention components (ie, push notification and human coach), satisfaction with core intervention components (ie, self-monitoring and learning courses), and intervention effectiveness through clinical outcomes. Results: The primary outcome indicated that group 4, provided with ?advanced-level push notifications? and a ?human coach,? showed higher completion rates for self-monitoring forms and learning courses compared to the predetermined threshold of clinical significance. Qualitative data analysis revealed three key themes: (1) perceived acceptability of the experimental intervention components, (2) satisfaction with the core intervention components, and (3) suggestions for improvement in the overall intervention program. Regarding clinical outcomes, the Perceived Stress Scale and Dermatology Life Quality Index scores presented the highest improvement in group 4. Conclusions: These findings will help refine the intervention and inform the design of a subsequent randomized trial to test its effectiveness. Furthermore, this design may serve as a model for broadly examining and optimizing overall engagement in DTx and for future investigation into the complex relationship between engagement and clinical outcomes. Trial Registration: Clinical Research Information Service KCT0007675; http://tinyurl.com/2m8rjrmv UR - https://formative.jmir.org/2024/1/e51225 UR - http://dx.doi.org/10.2196/51225 UR - http://www.ncbi.nlm.nih.gov/pubmed/38335015 ID - info:doi/10.2196/51225 ER - TY - JOUR AU - Appel, Lora AU - Appel, Eva AU - Kisonas, Erika AU - Lewis-Fung, Samantha AU - Pardini, Susanna AU - Rosenberg, Jarred AU - Appel, Julian AU - Smith, Christopher PY - 2024/1/30 TI - Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT) JO - J Med Internet Res SP - e51758 VL - 26 KW - digital therapies KW - nonpharmacological KW - cognitive impairment KW - behavioral and psychological symptoms of dementia KW - BPSDs KW - randomized controlled trial KW - virtual reality N2 - Background: Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings. Objective: The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention?s feasibility in terms of acceptability, safety, and patient experience. Methods: A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ?65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses? daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method. Results: VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy. Conclusions: Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments. Trial Registration: ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119 International Registered Report Identifier (IRRID): RR2-10.2196/22406 UR - https://www.jmir.org/2024/1/e51758 UR - http://dx.doi.org/10.2196/51758 UR - http://www.ncbi.nlm.nih.gov/pubmed/38289666 ID - info:doi/10.2196/51758 ER - TY - JOUR AU - Landry, A. Caeleigh AU - McCall, C. Hugh AU - Beahm, D. Janine AU - Titov, Nickolai AU - Dear, Blake AU - Carleton, Nicholas R. AU - Hadjistavropoulos, D. Heather PY - 2024/1/30 TI - Web-Based Mindfulness Meditation as an Adjunct to Internet-Delivered Cognitive Behavioral Therapy for Public Safety Personnel: Mixed Methods Feasibility Evaluation Study JO - JMIR Form Res SP - e54132 VL - 8 KW - public safety personnel KW - PSP KW - internet therapy KW - mindfulness KW - meditation KW - internet-delivered cognitive behavioral therapy KW - iCBT N2 - Background: Public safety personnel (PSP) are individuals who work to ensure the safety and security of communities (eg, correctional workers, firefighters, paramedics, and police officers). PSP have a high risk of developing mental disorders and face unique barriers to traditional mental health treatments. The PSP Wellbeing Course is a transdiagnostic, internet-delivered cognitive behavioral therapy (iCBT) course tailored to assist PSP with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). The initial course outcomes are promising, but some clients report some challenges with learning skills and recommend adding additional resources. Mindfulness meditations, which help people to experience the world and their reactions to the world in open and nonjudgmental ways, may complement the existing PSP Wellbeing Course. Objective: This study aims to examine the feasibility of mindfulness meditations in iCBT tailored for PSP. Information was gathered to evaluate engagement and client experiences with mindfulness meditations, symptom change, and the relationship between mindfulness meditation use and symptom change. Methods: A mixed methods study was conducted on PSP enrolled in the PSP Wellbeing Course who were offered 5 mindfulness meditations during the program (ie, 1/lesson). Clients completed questionnaires on depression, anxiety, PTSD, anger, insomnia, resilience, and mindfulness at pretreatment and at 8 weeks; an 8-week treatment satisfaction questionnaire; and brief weekly measures of mindfulness meditation engagement. We used paired sample t tests (2-tailed) to assess changes in outcomes over time and partial correlations to assess whether mindfulness meditation use predicted outcomes at posttreatment. A total of 12 clients were interviewed about their perceptions of the mindfulness meditations, and interviews were analyzed using directed content analysis. Results: Among the 40 clients enrolled, 27 (68%) reported using the mindfulness meditations, practicing for an average of 4.8 (SD 8.1) minutes each week. Most interviewees described the mindfulness meditations as beneficial but also reported challenges, such as discomfort while sitting with their feelings. Clients provided suggestions for better integration of mindfulness into iCBT. Overall, clients who completed the PSP Wellbeing Course with mindfulness meditations experienced statistically significant improvements in symptoms of anxiety (P=.001), depression (P=.001), PTSD (P=.001), and anger (P=.001) but not insomnia (P=.02). Clients also experienced improvements in resilience (P=.01) and mindfulness (P=.001). Self-reported time spent meditating was not associated with changes in symptoms over time. Conclusions: This study provides new insight into the integration of mindfulness meditations with iCBT for PSP. It demonstrates the partial feasibility of adding mindfulness meditations to iCBT, revealing that some, but not all, PSP engaged with the meditations and reported benefits. PSP reported using the mindfulness meditations inconsistently and described challenges with the meditations. Improvements can be made to better integrate mindfulness meditation into iCBT, including offering mindfulness meditation as an optional resource, providing more psychoeducation on managing challenges, and offering shorter meditations. UR - https://formative.jmir.org/2024/1/e54132 UR - http://dx.doi.org/10.2196/54132 UR - http://www.ncbi.nlm.nih.gov/pubmed/38289655 ID - info:doi/10.2196/54132 ER - TY - JOUR AU - Vanderkruik, C. Rachel AU - Ferguson, Craig AU - Kobylski, A. Lauren AU - Locascio, J. Joseph AU - Hamlett, E. Gabriella AU - Killenberg, C. Parker AU - Lewis, Robert AU - Jones, Noah AU - Rossa, T. Ella AU - Dineen, Hannah AU - Picard, Rosalind AU - Cohen, S. Lee PY - 2024/1/26 TI - Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study JO - JMIR Form Res SP - e44029 VL - 8 KW - perinatal depression KW - pregnancy KW - behavioral activation KW - mobile app KW - digital intervention KW - mobile phone N2 - Background: Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services. Objective: The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms. Methods: This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews. Results: The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (?=?.35; t61=?3.05; P=.003), number of activities completed (?=?.12; t61=?2.05; P=.04), days played (?=?.12; t58=?2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (?=?3.05; t45=?2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications. Conclusions: Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression. UR - https://formative.jmir.org/2024/1/e44029 UR - http://dx.doi.org/10.2196/44029 UR - http://www.ncbi.nlm.nih.gov/pubmed/38277191 ID - info:doi/10.2196/44029 ER - TY - JOUR AU - Rotondi, J. Armando AU - Belnap, Herbeck Bea AU - Rothenberger, Scott AU - Feldman, Robert AU - Hanusa, Barbara AU - Rollman, L. Bruce PY - 2024/1/17 TI - Predictors of Use and Drop Out From a Web-Based Cognitive Behavioral Therapy Program and Health Community for Depression and Anxiety in Primary Care Patients: Secondary Analysis of a Randomized Controlled Trial JO - JMIR Ment Health SP - e52197 VL - 11 KW - e-mental health KW - user engagement KW - initiation KW - discontinue KW - depression KW - anxiety KW - cognitive behavioral therapy KW - computerized CBT KW - online health community KW - collaborative care KW - internet support group N2 - Background: A previously reported study examined the treatment of primary care patients with at least moderate severity depressive or anxiety symptoms via an evidence-based computerized cognitive behavioral therapy (CCBT) program (Beating the Blues) and an online health community (OHC) that included a moderated internet support group. The 2 treatment arms proved to be equally successful at 6-month follow-up. Objective: Although highly promising, e-mental health treatment programs have encountered high rates of noninitiation, poor adherence, and discontinuation. Identifying ways to counter these tendencies is critical for their success. To further explore these issues, this study identified the primary care patient characteristics that increased the chances patients would not initiate the use of an intervention, (ie, not try it even once), initiate use, and go on to discontinue or continue to use an intervention. Methods: The study had 3 arms: one received access to CCBT (n=301); another received CCBT plus OHC (n=302), which included a moderated internet support group; and the third received usual care (n=101). Participants in the 2 active intervention arms of the study were grouped together for analyses of CCBT use (n=603) because both arms had access to CCBT, and there were no differences in outcomes between the 2 arms. Analyses of OHC use were based on 302 participants who were randomized to that arm. Results: Several baseline patient characteristics were associated with failure to initiate the use of CCBT, including having worse physical health (measured by the Short Form Health Survey Physical Components Score, P=.01), more interference from pain (by the Patient-Reported Outcomes Measurement Information System Pain Interference score, P=.048), less formal education (P=.02), and being African American or another US minority group (P=.006). Characteristics associated with failure to initiate use of the OHC were better mental health (by the Short Form Health Survey Mental Components Score, P=.04), lower use of the internet (P=.005), and less formal education (P=.001). Those who initiated the use of the CCBT program but went on to complete less of the program had less formal education (P=.01) and lower severity of anxiety symptoms (P=.03). Conclusions: This study found that several patient characteristics predicted whether a patient was likely to not initiate use or discontinue the use of CCBT or OHC. These findings have clear implications for actionable areas that can be targeted during initial and ongoing engagement activities designed to increase patient buy-in, as well as increase subsequent use and the resulting success of eHealth programs. Trial Registration: ClinicalTrials.gov NCT01482806; https://clinicaltrials.gov/study/NCT01482806 UR - https://mental.jmir.org/2024/1/e52197 UR - http://dx.doi.org/10.2196/52197 UR - http://www.ncbi.nlm.nih.gov/pubmed/38231552 ID - info:doi/10.2196/52197 ER - TY - JOUR AU - Daros, R. Alexander AU - Guimond, H. Timothy AU - Yager, Christina AU - Palermo, H. Emma AU - Wilks, R. Chelsey AU - Quilty, C. Lena PY - 2024/1/16 TI - Feasibility, Acceptability, and Potential Efficacy of a Self-Guided Internet-Delivered Dialectical Behavior Therapy Intervention for Substance Use Disorders: Randomized Controlled Trial JO - JMIR Ment Health SP - e50399 VL - 11 KW - depression KW - anxiety KW - emotion dysregulation KW - digital interventions KW - dialectical behavior therapy KW - substance use disorder KW - alcohol use disorder KW - randomized controlled trial KW - eHealth KW - mobile phone N2 - Background: People with alcohol and substance use disorders (SUDs) often have underlying difficulties in regulating emotions. Although dialectical behavioral therapy is effective for SUDs, it is often difficult to access. Self-guided, internet-delivered dialectical behavioral therapy (iDBT) allows for expanded availability, but few studies have rigorously evaluated it in individuals with SUDs. Objective: This study examines the feasibility, acceptability, and potential efficacy of an iDBT intervention in treatment-seeking adults with SUDs. We hypothesized that iDBT would be feasible, credible, acceptable, and engaging to people with SUDs. We also hypothesized that the immediate versus delayed iDBT group would show comparatively greater improvements and that both groups would show significant improvements over time. Methods: A 12-week, single-blinded, parallel-arm, randomized controlled trial was implemented, with assessments at baseline and at 4 (acute), 8, and 12 weeks (follow-up). A total of 72 community adults aged 18 to 64 years were randomized. The immediate group (n=38) received access to iDBT at baseline, and the delayed group (n=34) received access after 4 weeks. The intervention (Pocket Skills 2.0) was a self-guided iDBT via a website, with immediate access to all content, additional text and email reminders, and additional support meetings as requested. Our primary outcome was substance dependence, with secondary outcomes pertaining to feasibility, clinical outcomes, functional disability, and emotion dysregulation, among other measures. All outcomes were assessed using self-report questionnaires. Results: iDBT was perceived as a credible and acceptable treatment. In terms of feasibility, 94% (68/72) of the participants started iDBT, 13% (9/68) were early dropouts, 35% (24/68) used it for the recommended 8 days in the first month, and 50% (34/68) were still active 4 weeks later. On average, the participants used iDBT for 2 hours and 24 minutes across 10 separate days. In the acute period, no greater benefit was found for the immediate group on substance dependence, although we did find lower depression (b=?2.46; P=.02) and anxiety (b=?2.22; P=.02). At follow-up, there were greater benefits in terms of reduced alcohol (b=?2.00; P=.02) and nonalcoholic substance (b=?3.74; P=.01) consumption in the immediate access group. Both groups demonstrated improvements in substance dependence in the acute (b=?1.73; P<.001) and follow-up period (b=?2.09; P<.001). At follow-up, both groups reported reduced depression, anxiety, suicidal behaviors, emotional dysregulation, and functional disability. Conclusions: iDBT is a feasible and acceptable intervention for patients with SUDs, although methods for improving engagement are warranted. Although results did not support efficacy for the primary outcome at 4 weeks, findings support reductions in substance dependence and other mental health concerns at 12 weeks. Notwithstanding the limitations of this study, the results suggest the potential value of iDBT in the treatment of SUDs and other mental health conditions. Trial Registration: ClinicalTrials.gov NCT05094440; https://clinicaltrials.gov/show/NCT05094440 UR - https://mental.jmir.org/2024/1/e50399 UR - http://dx.doi.org/10.2196/50399 UR - http://www.ncbi.nlm.nih.gov/pubmed/38227362 ID - info:doi/10.2196/50399 ER - TY - JOUR AU - Farrand, Paul AU - Raue, J. Patrick AU - Ward, Earlise AU - Repper, Dean AU - Areán, Patricia PY - 2024/1/10 TI - Use and Engagement With Low-Intensity Cognitive Behavioral Therapy Techniques Used Within an App to Support Worry Management: Content Analysis of Log Data JO - JMIR Mhealth Uhealth SP - e47321 VL - 12 KW - cognitive behavioral therapy KW - low-intensity KW - mCBT KW - app KW - log data KW - worry management KW - CBT KW - management KW - application KW - therapy KW - implementation KW - treatment KW - symptoms KW - anxiety KW - worry KW - engagement N2 - Background: Low-intensity cognitive behavioral therapy (LICBT) has been implemented by the Improving Access to Psychological Therapies services across England to manage excessive worry associated with generalized anxiety disorder and support emotional well-being. However, barriers to access limit scalability. A solution has been to incorporate LICBT techniques derived from an evidence-based protocol within the Iona Mind Well-being app for Worry management (IMWW) with support provided through an algorithmically driven conversational agent. Objective: This study aims to examine engagement with a mobile phone app to support worry management with specific attention directed toward interaction with specific LICBT techniques and examine the potential to reduce symptoms of anxiety. Methods: Log data were examined with respect to a sample of ?engaged? users who had completed at least 1 lesson related to the Worry Time and Problem Solving in-app modules that represented the ?minimum dose.? Paired sample 2-tailed t tests were undertaken to examine the potential for IMWW to reduce worry and anxiety, with multivariate linear regressions examining the extent to which completion of each of the techniques led to reductions in worry and anxiety. Results: There was good engagement with the range of specific LICBT techniques included within IMWW. The vast majority of engaged users were able to interact with the cognitive behavioral therapy model and successfully record types of worry. When working through Problem Solving, the conversational agent was successfully used to support the user with lower levels of engagement. Several users engaged with Worry Time outside of the app. Forgetting to use the app was the most common reason for lack of engagement, with features of the app such as completion of routine outcome measures and weekly reflections having lower levels of engagement. Despite difficulties in the collection of end point data, there was a significant reduction in severity for both anxiety (t53=5.5; P<.001; 95% CI 2.4-5.2) and low mood (t53=2.3; P=.03; 95% CI 0.2-3.3). A statistically significant linear model was also fitted to the Generalized Anxiety Disorder?7 (F2,51=6.73; P<.001), while the model predicting changes in the Patient Health Questionnaire?8 did not reach significance (F2,51=2.33; P=.11). This indicates that the reduction in these measures was affected by in-app engagement with Worry Time and Problem Solving. Conclusions: Engaged users were able to successfully interact with the LICBT-specific techniques informed by an evidence-based protocol although there were lower completion rates of routine outcome measures and weekly reflections. Successful interaction with the specific techniques potentially contributes to promising data, indicating that IMWW may be effective in the management of excessive worry. A relationship between dose and improvement justifies the use of log data to inform future developments. However, attention needs to be directed toward enhancing interaction with wider features of the app given that larger improvements were associated with greater engagement. UR - https://mhealth.jmir.org/2024/1/e47321 UR - http://dx.doi.org/10.2196/47321 UR - http://www.ncbi.nlm.nih.gov/pubmed/38029300 ID - info:doi/10.2196/47321 ER - TY - JOUR AU - Shaw Jr, George AU - Castro, A. Bianca AU - Gunn, H. Laura AU - Norris, Keith AU - Thorpe Jr, J. Roland PY - 2024/1/10 TI - The Association of eHealth Literacy Skills and mHealth Application Use Among US Adults With Obesity: Analysis of Health Information National Trends Survey Data JO - JMIR Mhealth Uhealth SP - e46656 VL - 12 KW - accessibility KW - eHealth literacy KW - mHealth KW - multivariable logistic regression KW - obesity KW - smartphones N2 - Background: Physical inactivity and a poor diet are modifiable behaviors that contribute to obesity. Obesity is a well-recognized risk factor for chronic diseases, including diabetes. Mobile health (mHealth) apps can play an important adjuvant role in preventing and treating chronic diseases and promoting positive health behavior change among people with obesity, and eHealth literacy skills have the potential to impact mHealth app use. Objective: The purpose of this study was to explore the associations between the 2 dimensions, access and application, of eHealth literacy skills and mHealth app use among US adults (?18 years of age) with obesity (BMI ?30 kg/m2). Methods: Data were obtained from February to June 2020 using the Health Information National Trends Survey 5. A total of 1079 respondents met the inclusion criteria of adults with obesity and owners of smartphones. Individual associations between mHealth app use and sociodemographic variables were explored using weighted chi-square and 2-tailed t tests. A multivariable weighted logistic regression model was fitted, and adjusted odds ratios (ORs) of using mHealth apps with corresponding 95% CIs were reported across multiple sociodemographic variables. An Ising model-weighted network visualization was produced. A receiver operating characteristic curve was calculated, and the area under the curve was reported with the corresponding Delong 95% CI. Results: A majority of respondents were female (550/923, 59.6%) or non-Hispanic White (543/923, 58.8%). Individuals in households earning less than US $50,000 comprised 41.4% (382/923) of the sample. All sociodemographic variables were found to be univariately significant at the 5% level, except employment and region. Results from the multivariable weighted logistic regression model showed that the adjusted odds of using an mHealth app are 3.13 (95% CI 1.69-5.80) and 2.99 (95% CI 1.67-5.37) times higher among those with an access eHealth literacy skill of using an electronic device to look for health or medical information for themselves and an application eHealth literacy skill of using electronic communications with a doctor or doctor?s office, respectively. Several sociodemographic variables were found to be significant, such as education, where adjusted ORs comparing subgroups to the lowest educational attainment were substantial (ORs ?7.77). The network visualization demonstrated that all eHealth literacy skills and the mHealth app use variable were positively associated to varying degrees. Conclusions: This work provides an initial understanding of mHealth app use and eHealth literacy skills among people with obesity, identifying people with obesity subpopulations who are at risk of a digital health divide. Future studies should identify equitable solutions for people with obesity (as well as other groups) and their use of mHealth apps. UR - https://mhealth.jmir.org/2024/1/e46656 UR - http://dx.doi.org/10.2196/46656 UR - http://www.ncbi.nlm.nih.gov/pubmed/38198196 ID - info:doi/10.2196/46656 ER - TY - JOUR AU - Cooray, Nipuna AU - Ho, Catherine AU - Bestman, Amy AU - Adams, Susan AU - Nassar, Natasha AU - Keay, Lisa AU - Brown, Julie PY - 2024/1/3 TI - Exploring the Potential of a Behavior Theory?Informed Digital Intervention for Infant Fall Prevention: Mixed Methods Longitudinal Study JO - JMIR Pediatr Parent SP - e47361 VL - 7 KW - child injury KW - digital behavior change interventions KW - user experience KW - falls KW - infant fall KW - injury KW - mobile app KW - digital intervention KW - users KW - mixed methods longitudinal study KW - behavior KW - development KW - fall risk KW - fall prevention KW - acceptability KW - app KW - children KW - internet KW - parents KW - maternal, paternal KW - accidents KW - infancy KW - infant KW - accidental fall KW - accidental falls KW - infant behavior KW - longitudinal design KW - mixed methods KW - parent KW - mobile phone N2 - Background: Falls are the most common hospitalized injury mechanism in children aged ?1 years, and currently, there are no targeted prevention interventions. The prevention of falls in children of this age requires changes in the behavior of their caregivers, and theoretically informed digital behavior change interventions (DBCIs) may provide a unique mechanism for achieving effective intervention. However, user acceptance and the ability of DBCIs to effect the required changes in behavior are critical to their likelihood of success. Objective: This study aims to evaluate a behavior theory?informed digital intervention developed following a user-centered approach for user experience, the potential for this intervention to prevent infant falls, and its impact on behavioral drivers underpinning fall risk in young children. Methods: Parents of infants aged <1 year were recruited and asked to use the intervention for 3 months. A pre-post longitudinal design was used to examine the change in the potential to reduce the risk of falls after a 3-month exposure to the intervention. Postintervention data on behavioral drivers for fall prevention, user acceptability, and engagement with the app were also collected. Interviews were conducted to explore user experiences and identify areas for further improvement of the intervention. Results: A total of 62 parents participated in the study. A statistically significant effect on the potential to reduce falls was observed after the intervention. This effect was higher for new parents. Parents agreed that the intervention targeted most of the target behavior drivers. The impact of behavior drivers and intervention on the potential for fall prevention had a positive correlation. The intervention demonstrated good levels of acceptability. Feedback from participants was mostly positive, and the primary area identified for further improvement was widening the scope of the intervention. Conclusions: This study demonstrated the promise of a newly developed digital intervention to reduce the risk of infant falls, particularly among new parents. It also showed a positive influence of the DBCI on the drivers of parental behaviors that are important for fall reduction among infants. The acceptability of the app was high, and important insights were gained from users about how to further improve the app. UR - https://pediatrics.jmir.org/2024/1/e47361 UR - http://dx.doi.org/10.2196/47361 UR - http://www.ncbi.nlm.nih.gov/pubmed/38170580 ID - info:doi/10.2196/47361 ER - TY - JOUR AU - Pandya, Apurvakumar AU - K S, Mythri AU - Mishra, Shweta AU - Bajaj, Kriti PY - 2023/12/29 TI - Effectiveness of the QuitSure Smartphone App for Smoking Cessation: Findings of a Prospective Single Arm Trial JO - JMIR Form Res SP - e51658 VL - 7 KW - smoking KW - nicotine dependence KW - smoking cessation KW - QuitSure app KW - smartphone application KW - mHealth KW - mobile health KW - app KW - apps KW - application KW - applications KW - nicotine KW - smoke KW - smoker KW - quit KW - quitting KW - cessation KW - abstinence KW - mobile phone N2 - Background: Digital therapies, especially smartphone apps for active and continuous smoking cessation support, are strongly emerging as an alternative smoking cessation therapy. In the Indian context, there is a growing interest in the use of app-based smoking cessation programs; however, there is limited evidence regarding their effectiveness in achieving long-term continuous abstinence. Objective: This study aimed to evaluate the long-term abstinence effect (up to 30-d abstinence postprogram completion) of a smartphone app, QuitSure, for smoking cessation in active smokers from India. Methods: In this prospective single-arm study, participants who signed up for the QuitSure app were enrolled in this study. The primary end point was the prolonged abstinence (PA) rate from weeks 1 to 4 (day 7 to day 30). Furthermore, data for withdrawal symptoms, relapse reasons, and reasons for not continuing the program were also assessed. Results: The quit rate was calculated considering only the participants who followed up and completed the survey sent to them (per protocol) at day 7 and at day 30, respectively. The PA rate at day 7 was found to be 64.5% (111/172; 95% CI 56% to 72%), and the PA rate at day 30 was found to be 55.8% (72/129; 95% CI 45% to 65%). Within the 7-day abstinence period, 60.4% (67/111) of the participants did not have any withdrawal symptoms. The most common mild withdrawal symptoms were mild sleep disturbance (21/111, 18.9%), mild digestive changes (19/111, 17.1%), and coughing (17/111, 15.3%). Severe withdrawal symptoms were rare, with only 5.4% (6/111) experiencing them. For those achieving 30-day postprogram abstinence, 85% (61/72) had no mild withdrawal symptoms, and 99% (71/72) had no severe withdrawal symptoms. Among successful quitters at day 7, a total of 72.1% (80/111) reported minimal to no cravings, which increased to 88% (63/72) at day 30. Furthermore, 78% (56/72) of those with PA at day 30 reported no change in weight or reduced weight. Among participants experiencing relapse, 48% (28/58) cited intense cravings, 28% (16/58) mentioned facing a tragedy, and 26% (15/58) reported relapsing due to alcohol consumption. The PA rates as a result of the QuitSure program were found to be better than those reported in the results of other smoking-cessation app programs? studies. Conclusions: The QuitSure app yields high PA rates and ameliorates symptoms associated with smoking cessation. In order to obtain conclusive evidence regarding the effectiveness and efficacy of the QuitSure program, future research should include appropriate control measures. Nevertheless, the QuitSure program can serve as a valuable adjunct to a conventional smoking cessation treatment program to aid sustained abstinence. UR - https://formative.jmir.org/2023/1/e51658 UR - http://dx.doi.org/10.2196/51658 UR - http://www.ncbi.nlm.nih.gov/pubmed/38157243 ID - info:doi/10.2196/51658 ER - TY - JOUR AU - Breare, Hayley AU - Mullan, Barbara AU - Kerr, A. Deborah AU - Maxwell-Smith, Chloe PY - 2023/12/4 TI - Training Australian Dietitians in Behavior Change Techniques Through Educational Workshops: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e49723 VL - 12 KW - BCT KW - behavior change KW - COM-B KW - continuing education KW - dietitians KW - health professional KW - intervention KW - professional development KW - psychology KW - randomized controlled trial KW - training KW - workshop N2 - Background: The use of education alone as a technique to change behavior in interventions is usually insufficient, particularly in health interventions. Behavior change techniques have been shown to be effective in fostering positive changes in health behaviors such as diet and physical activity. The upskilling of health professionals can increase perceived capability and motivation toward eliciting change in clients? behaviors. However, to date, dietitians have received limited training in behavior change and have expressed a need for continuous professional development. Objective: The study objectives are to (1) develop and evaluate the effectiveness and acceptability of two 2-hour behavior change workshops on changing dietitians behavior (ie, range of behavior change techniques used and frequency of use) across 3 time points; (2) determine if participation in these workshops will elicit changes in dietitians? perceived capability, opportunity, and motivation toward using behavior change techniques; and (3) determine the acceptability of the training and its application in practice by dietitians. Methods: We will recruit registered dietitians (N=140) in Australia to participate in this randomized controlled trial. Participants will be randomly assigned to either the intervention or 3-month waitlist control condition and complete outcome measures at 3 time points: baseline, after the workshop, and follow-up at 3 months. Both groups will complete 2 workshops on behavior change that are guided by the COM-B (Capability, Opportunity, Motivation, and Behavior) Model and embedded with behavior change techniques. The primary outcome is changes in behavior, (ie, the range of behavior change techniques used and their frequency of use). Secondary outcomes include changes in perceived capability, opportunity, motivation, and preparedness as a health professional toward delivering behavior change techniques. The acceptability of the workshops will also be assessed after the workshop through the postworkshop survey and semistructured interviews. A series of 2-way repeated measures ANOVAs and regressions will be used. Qualitative data will be analyzed using thematic analysis. Results: Participant recruitment commenced in June 2023. The results of the study are expected to be published in November 2024. The results will allow us to assess comparisons between the intervention and waitlist control groups, as well as changes in perceived capability, opportunity, motivation, and preparedness over a 3-month period. It will also provide an understanding of the acceptability of the training as a form of continuous professional development for dietitians. Conclusions: If found to be effective, the results of this 2-arm randomized controlled trial will guide future training and continuous professional development for health professionals in changing behavior in practice. Our findings will contribute to our understanding of the application of behavior change techniques in practice with clients and identify components of COM-B where dietitians may need future support. Trial Registration: ACTRN12623000525684; https://www.anzctr.org.au/ACTRN12623000525684.aspx International Registered Report Identifier (IRRID): PRR1-10.2196/49723 UR - https://www.researchprotocols.org/2023/1/e49723 UR - http://dx.doi.org/10.2196/49723 UR - http://www.ncbi.nlm.nih.gov/pubmed/38048151 ID - info:doi/10.2196/49723 ER - TY - JOUR AU - Chen, Dandan AU - Zhang, Hui AU - Wu, Jingjie AU - Xue, Erxu AU - Guo, Pingping AU - Tang, Leiwen AU - Shao, Jing AU - Cui, Nianqi AU - Wang, Xiyi AU - Chen, Liying AU - Ye, Zhihong PY - 2023/11/29 TI - Effects of an Individualized mHealth-Based Intervention on Health Behavior Change and Cardiovascular Risk Among People With Metabolic Syndrome Based on the Behavior Change Wheel: Quasi-Experimental Study JO - J Med Internet Res SP - e49257 VL - 25 KW - metabolic syndrome KW - health behavior KW - cardiovascular risk KW - mobile health KW - behavior change wheel N2 - Background: Metabolic syndrome (MetS) is a common public health challenge. Health-promoting behaviors such as diet and physical activity are central to preventing and controlling MetS. However, the adoption of diet and physical activity behaviors has always been challenging. An individualized mobile health (mHealth)?based intervention using the Behavior Change Wheel is promising in promoting health behavior change and reducing atherosclerotic cardiovascular disease (ASCVD) risk. However, the effects of this intervention are not well understood among people with MetS in mainland China. Objective: We aimed to evaluate the effects of the individualized mHealth-based intervention using the Behavior Change Wheel on behavior change and ASCVD risk in people with MetS. Methods: We conducted a quasi-experimental, nonrandomized study. Individuals with MetS were recruited from the health promotion center of a tertiary hospital in Zhejiang province, China. The study involved 138 adults with MetS, comprising a control group of 69 participants and an intervention group of 69 participants. All participants received health education regarding diet and physical activity. The intervention group additionally received a 12-week individualized intervention through a WeChat mini program and a telephone follow-up in the sixth week of the intervention. Primary outcomes included diet, physical activity behaviors, and ASCVD risk. Secondary outcomes included diet self-efficacy, physical activity self-efficacy, knowledge of MetS, quality of life, and the quality and efficiency of health management services. The Mann-Whitney U test and Wilcoxon signed rank test were primarily used for data analysis. Data analysis was conducted based on the intention-to-treat principle using SPSS (version 25.0; IBM Corp). Results: Baseline characteristics did not differ between the 2 groups. Compared with the control group, participants in the intervention group showed statistically significant improvements in diet behavior, physical activity behavior, diet self-efficacy, physical activity self-efficacy, knowledge of MetS, physical health, and mental health after a 12-week intervention (P=.04, P=.001, P=.04, P=.04, P=.001, P=.04, P=.04, and P<.05). The intervention group demonstrated a statistically significant improvement in outcomes from pre- to postintervention evaluations (P<.001, P=.03, P<.001, P=.04, P<.001, P<.001, and P<.001). The intervention also led to enhanced health management services and quality. Conclusions: The individualized mHealth-based intervention using the Behavior Change Wheel was effective in promoting diet and physical activity behaviors in patients with MetS. Nurses and other health care professionals may incorporate the intervention into their health promotion programs. UR - https://www.jmir.org/2023/1/e49257 UR - http://dx.doi.org/10.2196/49257 UR - http://www.ncbi.nlm.nih.gov/pubmed/38019579 ID - info:doi/10.2196/49257 ER - TY - JOUR AU - Klein Schaarsberg, E. Renée AU - Ribberink, Z. Amber AU - Osinga, Babette AU - van Dam, Levi AU - Lindauer, L. Ramón J. AU - Popma, Arne PY - 2023/11/28 TI - Treatment Responsivity in Adolescents With Disruptive Behavior Problems: Co-Creation of a Virtual Reality?Based Add-On Intervention JO - JMIR Form Res SP - e46592 VL - 7 KW - virtual reality KW - role-playing KW - cognitive behavioral therapy KW - co-creation KW - disruptive behavior KW - mentalization KW - adolescence KW - mental health KW - child KW - youth KW - clinical practice KW - intervention N2 - Background: We developed Street Temptations (ST) as an add-on intervention to increase the treatment responsivity of adolescents with disruptive behavior problems. ST?s primary aim is to improve adolescents? mentalizing abilities in order to help them engage in and benefit from psychotherapy. Additionally, virtual reality (VR) is used to work in a more visual, less verbal, fashion. Objective: By recapping the lessons learned while developing ST so far, we aim to design the following study on ST. Furthermore, we aim to enhance the development and study of new health care interventions in clinical practice, together with adolescents as their end users. Methods: We followed an iterative co-creation process to develop a prototype of ST, in collaboration with adolescents and professionals from a secured residential facility in Amsterdam, the Netherlands. The prototype was tested during a pilot phase, involving 2 test runs, in which 4 adolescents and 4 professionals participated. Qualitative data were collected through interviews with the adolescents and by conducting a group interview with the professionals, in order to gain first insights into ST?s usability, feasibility, and its added value to clinical practice. In between the first and second test runs, the prototype was enhanced. On the basis of the complete pilot phase, we reflected on the future development and implementation of ST to design a subsequent study. Results: Over the course of 6 months, ST?s first prototype was developed during multiple creative sessions. Included was the development of a short 360° VR video, to serve as a base for the mentalization exercises. The final version of ST consisted of 7 individual therapy sessions, incorporating both the VR video and a VR StreetView app. On the basis of the qualitative data collected during the pilot phase, we found preliminary signs of ST?s potential to support adolescents? perspective-taking abilities specifically. Additionally, using VR to focus on real-life situations that adolescents encounter in their daily lives possibly helps to facilitate communication. However, several challenges and requests concerning the VR hardware and software and the implementation of ST emerged, pointing toward further development of ST as an add-on intervention. These challenges currently limit large-scale implementation, resulting in specific requirements regarding a subsequent study. Conclusions: In order to gather more extensive information to shape further development and study treatment effects, a small-scale and individually oriented research design seems currently more suitable than a more standard between-subjects design. Using the reflection on the lessons learned described in this report, a research protocol for a forthcoming study on ST has been developed. By presenting our co-creation journey thus far, we hope to be of inspiration for a more co-creative mindset and in that way contribute to the mutual reinforcement of science and clinical practice. UR - https://formative.jmir.org/2023/1/e46592 UR - http://dx.doi.org/10.2196/46592 UR - http://www.ncbi.nlm.nih.gov/pubmed/38015607 ID - info:doi/10.2196/46592 ER - TY - JOUR AU - Alluhaidan, Saleh Ala AU - Chatterjee, Samir AU - Drew, E. David AU - Ractham, Peter AU - Kaewkitipong, Laddawan PY - 2023/11/22 TI - Empowerment Enabled by Information and Communications Technology and Intention to Sustain a Healthy Behavior: Survey of General Users JO - JMIR Hum Factors SP - e47103 VL - 10 KW - empowerment KW - behavior change KW - information and communications technology KW - ICT KW - sustaining health behavior KW - long-term health behavior KW - mobile phone N2 - Background: Most people with chronic conditions fail to adhere to self-management behavioral guidelines. In the last 2 decades, several mobile health apps and IT-based systems have been designed and developed to help patients change and sustain their healthy behaviors. However, these systems often lead to short-term behavior change or adherence while the goal is to engage the population toward long-term behavior change. Objective: This study aims to contribute to the development of long-term health behavior changes or to help people sustain their healthy behavior. For this purpose, we built and tested a theoretical model that includes enablers of empowerment and an intention to sustain a healthy behavior when patients are assisted by information and communications technology. Methods: Structural equation modeling was used to analyze 427 survey returns collected from a diverse population of participants and patients. Notably, the model testing was performed for physical activity as a generally desirable healthy goal. Results: Message aligned with personal goals, familiarity with technology tools, high self-efficacy, social connection, and community support played a significant role (P<.001) in empowering individuals to maintain a healthy behavior. The feeling of being empowered exhibited a strong influence, with a path coefficient of 0.681 on an intention to sustain healthy behavior. Conclusions: The uniqueness of this model is its recognition of needs (ie, social connection, community support, and self-efficacy) to sustain a healthy behavior. Individuals are empowered when they are assisted by family and community, specifically when they possess the knowledge, skills, and self-awareness to ascertain and achieve their goals. This nascent theory explains what might lead to more sustainable behavior change and is meant to help designers build better apps that enable people to conduct self-care routines and sustain their behavior. UR - https://humanfactors.jmir.org/2023/1/e47103 UR - http://dx.doi.org/10.2196/47103 UR - http://www.ncbi.nlm.nih.gov/pubmed/37991814 ID - info:doi/10.2196/47103 ER - TY - JOUR AU - Miller, Ian AU - Peake, Emily AU - Strauss, Gabriel AU - Vierra, Elise AU - Koepsell, Xin AU - Shalchi, Brandon AU - Padmanabhan, Aarthi AU - Lake, Jessica PY - 2023/11/22 TI - Self-Guided Digital Intervention for Depression in Adolescents: Feasibility and Preliminary Efficacy Study JO - JMIR Form Res SP - e43260 VL - 7 KW - depression KW - adolescents KW - young adults KW - cognitive behavioral therapy KW - behavioral activation KW - digital health KW - mobile interventions KW - mobile phone N2 - Background: Depression in adolescents is a large and growing problem; however, access to effective mental health care continues to be a challenge. Digitally based interventions may serve to bridge this access gap for adolescents in need of care. Digital interventions that deliver components of cognitive behavioral therapy (CBT) have been shown to reduce symptoms of depression, and virtual reality (VR) may be a promising adjunctive component. However, research on these types of treatments in adolescents and young adults is limited. Objective: This study aims to evaluate the feasibility, acceptability, and preliminary efficacy of Spark (v1.0), a 5-week, self-guided, CBT-based digital program using a mobile app and VR experiences to target symptoms of depression in adolescents. Methods: A single-arm, open-label study of the Spark program was conducted with a community sample of 30 adolescents and young adults aged 12 to 21 years with self-reported moderate to severe depression symptoms. Participants completed a weekly depression assessment (Patient Health Questionnaire-8) in the app during the 5-week intervention period as well as web-based baseline, postintervention, and 1-month follow-up self-report assessments. The participants also completed a qualitative postintervention interview. For participants aged <18 years, caregivers completed assessments at baseline and postintervention time points. Feasibility outcomes included recruitment rate (the proportion of participants who enrolled in the study divided by the total number of participants screened for eligibility) and retention rate (the proportion of participants who completed postintervention assessments divided by the total number of participants who received the intervention). Acceptability outcomes included engagement with the program and quantitative and qualitative feedback about the program. Preliminary efficacy was evaluated based on the Patient Health Questionnaire-8. Results: The study recruitment (31/66, 47%) and retention (29/30, 97%) rates were high. Participants provided higher ratings for the ease of use of the Spark program (8.76 out of 10) and their enjoyment of both the mobile app (7.00 out of 10) and VR components (7.48 out of 10) of the program, whereas they provided lower ratings for the program?s ability to improve mood (4.38 out of 10) or fit into their daily routines (5.69 out of 10). We observed a clinically and statistically significant reduction in depression scores at postintervention (mean difference 5.36; P<.001) and 1-month follow-up (mean difference 6.44; P<.001) time points. Conclusions: The Spark program was found to be a feasible and acceptable way to deliver a self-guided CBT-focused intervention to adolescents and young adults with symptoms of depression. Preliminary data also indicated that the Spark program reduced the symptoms of depression in adolescents and young adults. Future studies should evaluate the efficacy of this intervention in an adequately powered randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04165681; https://classic.clinicaltrials.gov/ct2/show/NCT04165681 UR - https://formative.jmir.org/2023/1/e43260 UR - http://dx.doi.org/10.2196/43260 UR - http://www.ncbi.nlm.nih.gov/pubmed/37991839 ID - info:doi/10.2196/43260 ER - TY - JOUR AU - Bravata, M. Dena AU - Kim, Joseph AU - Russell, W. Daniel AU - Goldman, Ron AU - Pace, Elizabeth PY - 2023/11/6 TI - Digitally Enabled Peer Support Intervention to Address Loneliness and Mental Health: Prospective Cohort Analysis JO - JMIR Form Res SP - e48864 VL - 7 KW - peer-support KW - social isolation KW - loneliness KW - companionship KW - depression KW - anxiety KW - quality of life KW - occupational health N2 - Background: Social isolation and loneliness affect 61% of US adults and are associated with significant increases in excessive mental and physical morbidity and mortality. Annual health care spending is US $1643 higher for socially isolated individuals than for those not socially isolated. Objective: We prospectively evaluated the effects of participation with a digitally enabled peer support intervention on loneliness, depression, anxiety, and health-related quality of life among adults with loneliness. Methods: Adults aged 18 years and older living in Colorado were recruited to participate in a peer support program via social media campaigns. The intervention included peer support, group coaching, the ability to become a peer helper, and referral to other behavioral health resources. Participants were asked to complete surveys at baseline, 30, 60, and 90 days, which included questions from the validated University of California, Los Angeles Loneliness Scale, Patient Health Questionnaire 2-Item Scale, General Anxiety Disorder 7-Item Scale, and a 2-item measure assessing unhealthy days due to physical condition and mental condition. A growth curve modeling procedure using multilevel regression analyses was conducted to test for linear changes in the outcome variables from baseline to the end of the intervention. Results: In total, 815 ethnically and socially diverse participants completed registration (mean age 38, SD 12.7; range 18-70 years; female: n=310, 38%; White: n=438, 53.7%; Hispanic: n=133, 16.3%; Black: n=51, 6.3%; n=263, 56.1% had a high social vulnerability score). Participants most commonly joined the following peer communities: loneliness (n=220, 27%), building self-esteem (n=187, 23%), coping with depression (n=179, 22%), and anxiety (n=114, 14%). Program engagement was high, with 90% (n=733) engaged with the platform at 60 days and 86% (n=701) at 90 days. There was a statistically (P<.001 for all outcomes) and clinically significant improvement in all clinical outcomes of interest: a 14.6% (mean 6.47) decrease in loneliness at 90 days; a 50.1% (mean 1.89) decline in depression symptoms at 90 days; a 29% (mean 1.42) reduction in anxiety symptoms at 90 days; and a 13% (mean 21.35) improvement in health-related quality of life at 90 days. Based on changes in health-related quality of life, we estimated a reduction in annual medical costs of US $615 per participant. The program was successful in referring participants to behavioral health educational resources, with 27% (n=217) of participants accessing a resource about how to best support those experiencing psychological distress and 15% (n=45) of women accessing a program about the risks of excessive alcohol use. Conclusions: Our results suggest that a digitally enabled peer support program can be effective in addressing loneliness, depression, anxiety, and health-related quality of life among a diverse population of adults with loneliness. Moreover, it holds promise as a tool for identifying and referring members to relevant behavioral health resources. UR - https://formative.jmir.org/2023/1/e48864 UR - http://dx.doi.org/10.2196/48864 UR - http://www.ncbi.nlm.nih.gov/pubmed/37930770 ID - info:doi/10.2196/48864 ER - TY - JOUR AU - Müller, Fabiola AU - van Dongen, Sophie AU - van Woezik, Rosalie AU - Tibosch, Marijke AU - Tuinman, A. Marrit AU - Schellekens, J. Melanie P. AU - Laurenceau, Jean-Philippe AU - van der Lee, Marije AU - Hagedoorn, Mariët PY - 2023/11/6 TI - A Web-Based Mindfulness-Based Cognitive Therapy for Couples Dealing With Chronic Cancer-Related Fatigue: Protocol for a Single-Arm Pilot Trial JO - JMIR Res Protoc SP - e48329 VL - 12 KW - acceptability KW - cancer KW - chronic cancer-related fatigue KW - couple intervention KW - eMBCT KW - fatigue KW - feasibility KW - partners KW - pilot trial KW - web-based mindfulness-based cognitive therapy N2 - Background: Chronic fatigue is a common symptom among patients who have been treated for cancer. Current psychosocial interventions typically target the patient alone, despite growing evidence suggesting that a couples? approach can increase and broaden the efficacy of an intervention. Therefore, based on an existing web-based mindfulness-based cognitive therapy for patients, the couple intervention COMPANION was developed. Objective: The primary objectives of this study are to determine the acceptability of COMPANION and its potential efficacy in reducing fatigue in patients with cancer. Our secondary objectives are to examine the feasibility of the trial procedures and the potential working mechanisms of the couple intervention. Methods: We will conduct a single-arm pilot trial for couples (ie, patients with cancer with chronic fatigue and their partners). All couples are allocated to the web-based couple intervention that consists of psychoeducation, mindfulness, and cognitive-behavioral exercises. The 9 sessions of the intervention are supervised remotely by a trained therapist. Patients and partners will complete questionnaires before starting the intervention (T0), 2 weeks after completing the intervention (T1), and 1 month after T1 (T2). They will also fill out weekly diaries during the intervention period. A subsample of patients (n?5) and partners (n?5) as well as all the therapists providing COMPANION will participate in the final focus groups. Benchmark values have been defined to determine the acceptability (ie, ?60% of couples complete the intervention and/or ?70% of the participants are satisfied with the intervention) and potential efficacy (ie, a significant improvement in fatigue and/or a clinically relevant improvement in fatigue in 45% of the patients between T0 and T1) of the intervention. The trial procedures are deemed feasible if an average of at least three couples are included per recruiting month and/or adherence to the assessments is at least 65% for T1 and the diaries and 60% for T2. To establish potential working mechanisms, changes in affect, sleep, catastrophizing, partner communication and interactions, self-efficacy, mindfulness, and closeness will be examined. Quantitative outcomes will be interpreted along with the results from the focus groups. Results: Data collection is expected to be completed by March 2024. Conclusions: This pilot trial will test the first web-based mindfulness-based cognitive therapy for couples targeting chronic cancer-related fatigue. Findings will indicate whether proceeding with a randomized controlled trial is warranted. Trial Registration: ClinicalTrials.gov NCT05636696; https://clinicaltrials.gov/study/NCT05636696 International Registered Report Identifier (IRRID): DERR1-10.2196/48329 UR - https://www.researchprotocols.org/2023/1/e48329 UR - http://dx.doi.org/10.2196/48329 UR - http://www.ncbi.nlm.nih.gov/pubmed/37930767 ID - info:doi/10.2196/48329 ER - TY - JOUR AU - Dahne, Jennifer AU - Wahlquist, E. Amy AU - Kustanowitz, Jacob AU - Natale, Noelle AU - Fahey, Margaret AU - Graboyes, M. Evan AU - Diaz, A. Vanessa AU - Carpenter, J. Matthew PY - 2023/11/1 TI - Behavioral Activation?Based Digital Smoking Cessation Intervention for Individuals With Depressive Symptoms: Randomized Clinical Trial JO - J Med Internet Res SP - e49809 VL - 25 KW - smoking cessation KW - depression KW - digital health KW - decentralized trial KW - mental health KW - depressive KW - RCT KW - randomized KW - controlled trial KW - smoking KW - smoke KW - smoker KW - quit KW - quitting KW - cessation KW - eHealth KW - e-health KW - NRT KW - nicotine KW - mobile health KW - mHealth KW - app KW - apps KW - application KW - applications N2 - Background: Depression is common among adults who smoke cigarettes. Existing depression-specific cessation interventions have limited reach and are unlikely to improve smoking prevalence rates among this large subgroup of smokers. Objective: This study aimed to determine whether a mobile app?based intervention tailored for depression paired with a mailed sample of nicotine replacement therapy (NRT) is efficacious for treating depression and promoting smoking cessation. Methods: A 2-arm nationwide remote randomized clinical trial was conducted in the United States. Adults (N=150) with elevated depressive symptoms (Patient Health Questionnaire-8?10) who smoked were enrolled. The mobile app (?Goal2Quit?) provided behavioral strategies for treating depression and quitting smoking based on Behavioral Activation Treatment for Depression. Goal2Quit participants also received a 2-week sample of combination NRT. Treatment as usual participants received a self-help booklet for quitting smoking that was not tailored for depression. Primary end points included Goal2Quit usability, change in depression (Beck Depression Inventory-II) across 12 weeks, and smoking cessation including reduction in cigarettes per day, incidence of 24-hour quit attempts, floating abstinence, and 7-day point prevalence abstinence (PPA). Results: In total, 150 participants were enrolled between June 25, 2020, and February 23, 2022, of which 80 were female (53.3%) and the mean age was 38.4 (SD 10.3) years. At baseline, participants on average reported moderate depressive symptoms and smoked a mean of 14.7 (SD 7.5) cigarettes per day. Goal2Quit usability was strong with a mean usability rating on the System Usability Scale of 78.5 (SD 16.9), with 70% scoring above the ?68 cutoff for above-average usability. Retention data for app use were generally strong immediately following trial enrollment and declined in subsequent weeks. Those who received Goal2Quit and the NRT sample reported lower mean depressive symptoms over the trial duration as compared to treatment as usual (difference of mean 3.72, SE 1.37 points less; P=.01). Across time points, all cessation outcomes favored Goal2Quit. Regarding abstinence, Goal2Quit participants reported significantly higher rates of 7-day PPA at weeks 4 (11% vs 0%; P=.02), 8 (7-day PPA: 12% vs 0%; P=.02), and 12 (16% vs 2%; P=.02). Conclusions: A mobile app intervention tailored for depression paired with a sample of NRT was effective for depression treatment and smoking cessation. Findings support the utility of this intervention approach for addressing the currently unmet public health treatment need for tailored, scalable depression-specific cessation treatments. Trial Registration: ClinicalTrials.gov NCT03837379; https://clinicaltrials.gov/ct2/show/NCT03837379 UR - https://www.jmir.org/2023/1/e49809 UR - http://dx.doi.org/10.2196/49809 UR - http://www.ncbi.nlm.nih.gov/pubmed/37910157 ID - info:doi/10.2196/49809 ER - TY - JOUR AU - Liu, Miao AU - Zhu, Yicheng AU - Xu, Zihan AU - Meng, Sitong PY - 2023/10/25 TI - Social Presence, Negative Emotions, and Self-Protective Behavioral Intentions of Nonsmokers in Response to Secondhand Smoking in Virtual Reality: Quasi-Experimental Design JO - JMIR Serious Games SP - e46243 VL - 11 KW - virtual reality KW - VR KW - social presence KW - emotions KW - secondhand smoking N2 - Background: The application of virtual reality (VR) in health care has grown rapidly in China, where approximately half of the population is directly exposed to secondhand smoke (SHS). As VR headsets have become increasingly popular and short video platforms have incorporated 360° videos in China, new formats and opportunities for health campaigns about SHS have emerged. Objective: In a simulated environment of exposure to SHS, this study aims to explore the emotional and behavioral responses to enhanced social presence brought about by VR in contrast to flat-screen videos. It also aims to examine whether and to what extent video modality (360° video vs flat-screen video) and contextual cues (high threat vs low threat) influence psychometric and intentional variables among viewers. Methods: A total of 245 undergraduate and graduate students who were nonsmokers and from a large university in China participated in this study between October 2020 and January 2021. This study created 4 different versions of a SHS experience in a café with a 2 (360° video on a head-mounted display vs flat-screen display) × 2 (high threat vs low threat) experimental design. It developed and tested a path model examining the effects of experience modality and threat levels on social presence, emotions (anger and disgust), and eventually behavioral intentions (staying away and asking for help). Results: We found that both video modality (P<.001) and threat level (P=.005) significantly influenced social presence, whereas the interaction of video modality and threat level did not have a statistically significant effect on social presence (P=.55). Negative emotions mediated the relationships between social presence and SHS-related self-protective behaviors. Specifically, anger positively predicted the intention to ask smokers to stop smoking through the waitress (P<.001). Disgust and fear both positively predicted the intention to stay away from the SHS environment (P<.001 for disgust; P=.002 for fear). Conclusions: This study explored the potential mediating mechanisms that influence individuals? responses to the risks of SHS in public areas. The results demonstrated that social presence and negative emotions are 2 important mediators that underlie the relationship between video modality and behavioral intention regarding SHS in a VR setting. These findings suggest that an immersive environment could be a better stimulator of anti-SHS emotions and behaviors than flat-screen videos. UR - https://games.jmir.org/2023/1/e46243 UR - http://dx.doi.org/10.2196/46243 UR - http://www.ncbi.nlm.nih.gov/pubmed/37878358 ID - info:doi/10.2196/46243 ER - TY - JOUR AU - Prior, Katrina AU - Salemink, Elske AU - Piggott, Monique AU - Manning, Victoria AU - Wiers, W. Reinout AU - Teachman, A. Bethany AU - Teesson, Maree AU - Baillie, J. Andrew AU - Mahoney, Alison AU - McLellan, Lauren AU - Newton, C. Nicola AU - Stapinski, A. Lexine PY - 2023/10/25 TI - Web-Based Cognitive Bias Modification Program for Young People With Social Anxiety and Hazardous Alcohol Use: Feasibility, Acceptability, and Preliminary Efficacy Study JO - JMIR Form Res SP - e46008 VL - 7 KW - alcohol KW - anxiety KW - cognitive bias modification KW - interpretation bias KW - approach bias KW - young adult KW - mobile phone N2 - Background: Interpretation bias modification (IBM) and approach bias modification (ApBM) cognitive retraining interventions can be efficacious adjunctive treatments for improving social anxiety and alcohol use problems. However, previous trials have not examined the combination of these interventions in a young, comorbid sample. Objective: This study aims to describe the feasibility, acceptability, and preliminary efficacy of a web-based IBM+ApBM program for young adults with social anxiety and hazardous alcohol use (?Re-Train Your Brain?) when delivered in conjunction with treatment as usual (TAU). Methods: The study involved a 3-arm randomized controlled pilot trial in which treatment-seeking young adults (aged 18-30 y) with co-occurring social anxiety and hazardous alcohol use were randomized to receive (1) the ?integrated? Re-Train Your Brain program, where each session included both IBM and ApBM (50:50 ratio), plus TAU (35/100, 35%); (2) the ?alternating? Re-Train Your Brain program, where each session focused on IBM or ApBM in an alternating pattern, plus TAU (32/100, 32%); or (3) TAU only (33/100, 33%). Primary outcomes included feasibility and acceptability, and secondary efficacy outcomes included changes in cognitive biases, social anxiety symptoms, and alcohol use. Assessments were conducted at baseline, after the intervention period (6 weeks after baseline), and 12 weeks after baseline. Results: Both Re-Train Your Brain program formats were feasible and acceptable for young adults. When coupled with TAU, both integrated and alternating programs resulted in greater self-reported improvements than TAU only in anxiety interpretation biases (at the 6-week follow-up; Cohen d=0.80 and Cohen d=0.89) and comorbid interpretation biases (at the 12-week follow-up; Cohen d=1.53 and Cohen d=1.67). In addition, the alternating group reported larger improvements over the control group in generalized social anxiety symptoms (at the 12-week follow-up; Cohen d=0.83) and alcohol cravings (at the 6-week follow-up; Cohen d=0.81). There were null effects on all other variables and no differences between the intervention groups in efficacy outcomes. Conclusions: Should these findings be replicated in a larger randomized controlled trial, Re-Train Your Brain has the potential to be a scalable, low-cost, and non?labor-intensive adjunct intervention for targeting interpretation and comorbidity biases as well as generalized anxiety and alcohol-related outcomes in the real world. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620001273976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364131 International Registered Report Identifier (IRRID): RR2-10.2196/28667 UR - https://formative.jmir.org/2023/1/e46008 UR - http://dx.doi.org/10.2196/46008 UR - http://www.ncbi.nlm.nih.gov/pubmed/37878363 ID - info:doi/10.2196/46008 ER - TY - JOUR AU - Beintner, Ina AU - Kerber, André AU - Dominke, Clara AU - Voderholzer, Ulrich PY - 2023/10/25 TI - Improving Mild to Moderate Depression With an App-Based Self-Guided Intervention: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e46651 VL - 12 KW - depression KW - mobile app KW - intervention KW - unguided KW - transdiagnostic KW - randomized controlled trial KW - e-mental health KW - digital app KW - self-management KW - mental health KW - mHealth KW - mobile health KW - unguided digital intervention KW - public health KW - digital intervention KW - mobile phone N2 - Background: Depression is one of the most prevalent mental disorders and frequently co-occurs with other mental disorders. Despite the high direct and indirect costs to both individuals and society, more than 80% of those diagnosed with depression remain with their primary care physician and do not receive specialized treatment. Self-guided digital interventions have been shown to improve depression and, due to their scalability, have a large potential public health impact. Current digital interventions often focus on specific disorders, while recent research suggests that transdiagnostic approaches are more suitable. Objective: This paper presents the protocol for a study that aims to assess the efficacy of a self-guided transdiagnostic app-based self-management intervention in patients with mild or moderate depression with and without comorbid mental disorders. Specifically, we are investigating the impact of the intervention on symptoms of depression, quality of life, anxiety symptoms, and mental health?related patient empowerment and self-management skills. Methods: The intervention under investigation, MindDoc with Prescription, is a self-guided digital intervention aimed at supporting individuals with mild to moderate mental disorders from the internalizing spectrum, including depression. The app can be used as a low-threshold psychosocial intervention. Up to 570 adult patients will be randomized to either receive the intervention in addition to care as usual or only care as usual. We are including adults with a permanent residency in Germany and mild or moderate depression according to International Classification of Diseases, 10th Revision, criteria (F32.0, F32.1, F33.0, and F33.1). Clinical interviews will be conducted to confirm the diagnosis. Data will be collected at baseline as well as 8 weeks and 6 months after randomization. The primary outcome will be depression symptom severity after 8 weeks. Secondary outcomes will be quality of life, anxiety symptom severity, and patient empowerment and self-management behaviors. Data will be analyzed using multiple imputations, using the intention-to-treat principle, while sensitivity analyses will be based on additional imputation strategies and a per-protocol analysis. Results: Recruitment for the trial started on February 7, 2023, and the first participant was randomized on February 14, 2023. As of September 5, 2023, 275 participants have been included in the trial and 176 have provided the primary outcome. The rate of missing values in the primary outcome is approximately 20%. Conclusions: Data from this efficacy trial will be used to establish whether access to the intervention is associated with an improvement in depression symptoms in individuals diagnosed with mild or moderate depression. The study will contribute to expanding the evidence base on transdiagnostic digital interventions. Trial Registration: German Registry of Clinical Trials DRKS00030852; https://drks.de/search/de/trial/DRKS00030852 International Registered Report Identifier (IRRID): DERR1-10.2196/46651 UR - https://www.researchprotocols.org/2023/1/e46651 UR - http://dx.doi.org/10.2196/46651 UR - http://www.ncbi.nlm.nih.gov/pubmed/37878374 ID - info:doi/10.2196/46651 ER - TY - JOUR AU - Chen, Bi-Lian AU - Lien, Han-Chung AU - Yang, Shyh-Sheng AU - Wu, Shiao-Chi AU - Chiang, Hsien-Hsien AU - Lin, Li-Chan PY - 2023/10/20 TI - Impact of Mobile Apps in Conjunction With Percutaneous Endoscopic Gastrostomy on Patients' Complications, Quality of Life, and Health-Related Self-Care Behaviors: Randomized Clinical Trial JO - JMIR Mhealth Uhealth SP - e48970 VL - 11 KW - percutaneous endoscopic gastrostomy KW - mobile applications tracking system KW - self-care KW - complications KW - quality of life KW - mobile application KW - mHealth app KW - mHealth intervention KW - health promotion KW - health education KW - endoscopy KW - application KW - education KW - gastrostomy KW - care KW - prevention KW - behavior KW - tracking KW - utilization N2 - Background: Percutaneous endoscopic gastrostomy (PEG) is commonly chosen for long-term enteral nutrition support. However, common complications of PEG include wound infection, leakage, obstruction, bleeding, dislodgement, pneumonia, peritonitis, and more. The anticipation of these complications by both patients and their family caregivers underscores the essential requirement of ongoing technical guidance for the daily care of PEG and the adoption of preventative strategies. Objective: This study aimed to establish and compare a health education program utilizing a tracking system for PEG using a mobile app (PEG app) and instant messaging software versus a paper-based health education program with instant messaging software. Their effectiveness to prevent complications, avoid hospital readmissions, improve self-care practices, and enhance quality of life outcomes was assessed. Methods: A randomized controlled trial design was used, and the study sample consisted of patients from a medical center in central Taiwan who underwent thoracic surgery or gastroenterology procedures. Inclusion criteria were being a new case undergoing his or her first gastric tube insertion and having the ability to operate a smartphone. Exclusion criteria were cases requiring tube replacement or nasogastric tubes. A total of 74 participants were enrolled, with 37 participants in the experimental group and 37 participants in the control group. Data collection took place from hospitalization until 1 month after discharge. The experimental group received care utilizing the gastric tube tracking system (PEG app) and the Line app that included phone, text, and photo capture capabilities, while the control group received routine nursing care and used the Line app. Results: The experimental group demonstrated a significant reduction in the occurrence of complications compared with the control group (?21=12.087, P=.001). Specifically, the occurrence of leakage events was significantly lower in the experimental group than in the control group (?21=12.906, P=.001). However, the experimental group exhibited superior self-care ability compared with the control group (t72=2.203, P=.03). There was no significant difference in overall quality of life scores between the experimental and control groups (t72=1.603, P=.11). However, the experimental group showed better social aspects of quality of life than the control group (t72=2.164, P=.03). Conclusions: Integration of the PEG app with instant messaging can enhance self-care ability, improve social aspects of quality of life, and reduce complications. The study results suggest that the PEG app could be used as an adjunct tool to promote patients? self-directed management of their gastric tube at home, particularly for patients who have undergone their first PEG placement and are being discharged from the hospital. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300071271; https://tinyurl.com/4vvy584e UR - https://mhealth.jmir.org/2023/1/e48970/ UR - http://dx.doi.org/10.2196/48970 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/48970 ER - TY - JOUR AU - Hoffman, Valerie AU - Flom, Megan AU - Mariano, Y. Timothy AU - Chiauzzi, Emil AU - Williams, Andre AU - Kirvin-Quamme, Andrew AU - Pajarito, Sarah AU - Durden, Emily AU - Perski, Olga PY - 2023/10/13 TI - User Engagement Clusters of an 8-Week Digital Mental Health Intervention Guided by a Relational Agent (Woebot): Exploratory Study JO - J Med Internet Res SP - e47198 VL - 25 KW - anxiety KW - clustering KW - depression KW - digital health KW - digital mental health intervention KW - mental health KW - relational agents KW - user engagement N2 - Background: With the proliferation of digital mental health interventions (DMHIs) guided by relational agents, little is known about the behavioral, cognitive, and affective engagement components associated with symptom improvement over time. Obtaining a better understanding could lend clues about recommended use for particular subgroups of the population, the potency of different intervention components, and the mechanisms underlying the intervention?s success. Objective: This exploratory study applied clustering techniques to a range of engagement indicators, which were mapped to the intervention?s active components and the connect, attend, participate, and enact (CAPE) model, to examine the prevalence and characterization of each identified cluster among users of a relational agent-guided DMHI. Methods: We invited adults aged 18 years or older who were interested in using digital support to help with mood management or stress reduction through social media to participate in an 8-week DMHI guided by a natural language processing?supported relational agent, Woebot. Users completed assessments of affective and cognitive engagement, working alliance as measured by goal and task working alliance subscale scores, and enactment (ie, application of therapeutic recommendations in real-world settings). The app passively collected data on behavioral engagement (ie, utilization). We applied agglomerative hierarchical clustering analysis to the engagement indicators to identify the number of clusters that provided the best fit to the data collected, characterized the clusters, and then examined associations with baseline demographic and clinical characteristics as well as mental health outcomes at week 8. Results: Exploratory analyses (n=202) supported 3 clusters: (1) ?typical utilizers? (n=81, 40%), who had intermediate levels of behavioral engagement; (2) ?early utilizers? (n=58, 29%), who had the nominally highest levels of behavioral engagement in week 1; and (3) ?efficient engagers? (n=63, 31%), who had significantly higher levels of affective and cognitive engagement but the lowest level of behavioral engagement. With respect to mental health baseline and outcome measures, efficient engagers had significantly higher levels of baseline resilience (P<.001) and greater declines in depressive symptoms (P=.01) and stress (P=.01) from baseline to week 8 compared to typical utilizers. Significant differences across clusters were found by age, gender identity, race and ethnicity, sexual orientation, education, and insurance coverage. The main analytic findings remained robust in sensitivity analyses. Conclusions: There were 3 distinct engagement clusters found, each with distinct baseline demographic and clinical traits and mental health outcomes. Additional research is needed to inform fine-grained recommendations regarding optimal engagement and to determine the best sequence of particular intervention components with known potency. The findings represent an important first step in disentangling the complex interplay between different affective, cognitive, and behavioral engagement indicators and outcomes associated with use of a DMHI incorporating a natural language processing?supported relational agent. Trial Registration: ClinicalTrials.gov NCT05672745; https://classic.clinicaltrials.gov/ct2/show/NCT05672745 UR - https://www.jmir.org/2023/1/e47198 UR - http://dx.doi.org/10.2196/47198 UR - http://www.ncbi.nlm.nih.gov/pubmed/37831490 ID - info:doi/10.2196/47198 ER - TY - JOUR AU - Tsirmpas, Charalampos AU - Nikolakopoulou, Maria AU - Kaplow, Sharon AU - Andrikopoulos, Dimitrios AU - Fatouros, Panagiotis AU - Kontoangelos, Konstantinos AU - Papageorgiou, Charalabos PY - 2023/10/11 TI - A Digital Mental Health Support Program for Depression and Anxiety in Populations With Attention-Deficit/Hyperactivity Disorder: Feasibility and Usability Study JO - JMIR Form Res SP - e48362 VL - 7 KW - precision medicine KW - internet-based intervention KW - mobile apps KW - major depressive disorder KW - anxiety disorders KW - attention-deficit/hyperactivity disorder KW - personalized medicine KW - comorbidity KW - quality of life KW - mobile phone N2 - Background: A total of 1 in 2 adults with attention-deficit/hyperactivity disorder (ADHD) struggles with major depressive or anxiety disorders. The co-occurrence of these disorders adds to the complexity of finding utility in as well as adherence to a treatment option. Digital therapeutic solutions may present a promising alternative treatment option that could mitigate these challenges and alleviate symptoms. Objective: This study aims to investigate (1) the feasibility and acceptance of a digital mental health intervention, (2) participants? engagement and retention levels, and (3) the potential efficacy with respect to anxiety and depression symptoms in a population with ADHD. Our main hypothesis was that a digital, data-driven, and personalized intervention for adults with coexisting ADHD and depressive or anxiety symptoms would show high engagement and adherence, which would be accompanied by a decrease in depressive and anxiety symptoms along with an increase in quality of life and life satisfaction levels. Methods: This real-world data, single-arm study included 30 adult participants with ADHD symptomatology and coexisting depressive or anxiety symptoms who joined a 16-week digital, data-driven mental health support program. This intervention is based on a combination of evidence-based approaches such as cognitive behavioral therapy, mindfulness, and positive psychology techniques. The targeted symptomatology was evaluated using the Patient Health Questionnaire?9, Generalized Anxiety Disorder?7, and Barkley Adult ADHD Rating Scale?IV. Quality of life aspects were evaluated using the Satisfaction With Life Scale and the Life Satisfaction Questionnaire, and user feedback surveys were used to assess user experience and acceptability. Results: The study retention rate was 97% (29/30), and high engagement levels were observed, as depicted by the 69 minutes spent on the app per week, 5 emotion logs per week, and 11.5 mental health actions per week. An average decrease of 46.2% (P<.001; r=0.89) in depressive symptoms and 46.4% (P<.001; r=0.86) in anxiety symptoms was observed, with clinically significant improvement for more than half (17/30, 57% and 18/30, 60%, respectively) of the participants. This was followed by an average increase of 23% (P<.001; r=0.78) and 20% (P=.003; r=0.8) in Satisfaction With Life Scale and Life Satisfaction Questionnaire scores, respectively. The overall participant satisfaction level was 4.3 out of 5. Conclusions: The findings support the feasibility, acceptability, and value of the examined digital program for adults with ADHD symptomatology to address the coexisting depressive or anxiety symptoms. However, controlled trials with larger sample sizes and more diverse participant profiles are required to provide further evidence of clinical efficacy. UR - https://formative.jmir.org/2023/1/e48362 UR - http://dx.doi.org/10.2196/48362 UR - http://www.ncbi.nlm.nih.gov/pubmed/37819688 ID - info:doi/10.2196/48362 ER - TY - JOUR AU - Ito, Ai AU - Hiyoshi, Fumikazu AU - Kanie, Ayako AU - Maruyama, Azumi AU - Oba, S. Mari AU - Kito, Shinsuke PY - 2023/9/26 TI - Feasibility Study of Virtual Reality?Based Cognitive Behavioral Therapy for Patients With Depression: Protocol for an Open Trial and Therapeutic Intervention JO - JMIR Res Protoc SP - e49698 VL - 12 KW - depression KW - cognitive behavioral therapy KW - virtual reality KW - CBT KW - feasibility study KW - open trial KW - VR N2 - Background: The clinical usefulness of cognitive behavioral therapy (CBT) for patients with depression who do not remit with pharmacotherapy has been recognized. However, the longer time burden on health care providers associated with conducting CBT and the lack of a system for providing CBT lead to inadequate CBT provision to patients who wish to receive it. Objective: We aim to evaluate the feasibility of introducing virtual reality (VR) into CBT for patients with depression. Methods: This is a single-center, interventional, exploratory, single-arm, nonrandomized, open, pre-post?comparative feasibility study of an unapproved medical device program to evaluate the acceptability, preliminary efficacy, and safety of the study device. Eligible patients meet the diagnostic criteria of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) for major depressive disorder, have a 17-item Hamilton Depression Rating Scale (HAMD-17) score of ?12, and are aged 18-65 years. The sample will comprise 12 patients. VR-based CBT (CBT-VR) sessions will be conducted once a week in an outpatient setting. CBT-VR has been developed in accordance with 6 stages and 16 sessions in the current CBT therapist manual. VR contents and other components correspond to the themes of these 16 sessions. The flow of CBT-VR treatment is similar to that of normal CBT; however, this product replaces the in-person portion of CBT. The primary end point will be the change in the HAMD-17 score from baseline up to 16 sessions. Secondary end points will be treatment retention; psychiatrist consultation time; satisfaction with the equipment or program; ease of use; homework compliance; change in the HAMD-17 score from baseline up to 8 sessions; change in Montgomery-Åsberg Depression Rating Scale (MADRS), Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR), EQ-5D-5L, and Clinical Global Impressions (CGI) scores from baseline up to 8 and 16 sessions; and change in remission and response rates and HAMD-17, MADRS, QIDS-SR, and EQ-5D-5L scores from baseline to 3 and 6 months post intervention (or discontinuation). CBT-VR?s feasibility will be assessed at baseline, after 8 sessions, after 16 sessions, or treatment discontinuation, by measuring the time required for testing and medical care during each session and with a patient questionnaire. After intervention discontinuation, a follow-up evaluation will be conducted unless the patient withdraws consent or otherwise discontinues participation in the study after 3 and 6 months. Results: Participant recruitment started on November 30, 2022, and data collection is ongoing as of September 2023. Conclusions: This study is the first step in testing the acceptability, feasibility, and preliminary efficacy and safety of CBT-VR for patients with depression without controls in an open-label trial. If its feasibility for depression treatment is confirmed, we intend to proceed to a large-scale validation study. Trial Registration: Japan Registry of Clinical Trials jRCTs032220481; https://jrct.niph.go.jp/en-latest-detail/jRCTs032220481 International Registered Report Identifier (IRRID): DERR1-10.2196/49698 UR - https://www.researchprotocols.org/2023/1/e49698 UR - http://dx.doi.org/10.2196/49698 UR - http://www.ncbi.nlm.nih.gov/pubmed/37751242 ID - info:doi/10.2196/49698 ER - TY - JOUR AU - Stephenson, Callum AU - Kumar, Anchan AU - Malakouti, Niloufar AU - Nikjoo, Niloofar AU - Jagayat, Jasleen AU - Gizzarelli, Tessa AU - Patel, Charmy AU - Gutierrez, Gilmar AU - Shirazi, Amirhossein AU - Yang, Megan AU - Omrani, Mohsen AU - Alavi, Nazanin PY - 2023/9/20 TI - Comparing the Efficacy of an Electronically Delivered Cognitive Behavioral Therapy Program to a Mental Health Check-In Program for Generalized Anxiety Disorder: Protocol for a Randomized Trial JO - JMIR Res Protoc SP - e48899 VL - 12 KW - anxiety KW - cognitive behavioral therapy KW - eHealth KW - electronic care KW - generalized anxiety disorder KW - internet KW - mental health KW - psychotherapy KW - treatment KW - web-based N2 - Background: Generalized anxiety disorder (GAD) is a prevalent anxiety disorder, with cognitive behavioral therapy (CBT) being the gold standard treatment. However, it is inaccessible and costly to many, as the mental health industry is overwhelmed by the demand for treatment. This means effective, accessible, and time-saving strategies must be developed to combat these problems. Web-based interventions for mental health disorders are an innovative and promising way to address these barriers. While electronically delivered CBT (e-CBT) has already proved productive and scalable for treating anxiety, other less resource-intensive interventions can be innovated. Checking up on mental health face-to-face has been shown to provide similar benefits to patients with anxiety disorders previously, but more research is needed to evaluate the efficacy of web-based delivery of this intervention. Objective: This study will compare the efficacy of e-CBT and a web-based mental health check-in program to treat GAD. These programs will both be delivered through a secure, web-based care delivery platform. Methods: We will randomly allocate participants (N=100) who are 18 years or older with a confirmed diagnosis of GAD to either an e-CBT program or a mental health check-in program over 12 weeks to address their anxiety symptoms. Participants in the e-CBT arm will complete predesigned modules and homework assignments while receiving personalized feedback and asynchronous interaction with a therapist through the platform. Participants in the mental health check-in arm will be contacted weekly through the web-based platform?s written chat feature (messaging system). Therapists will ask the participants a series of predesigned questions that revolve around a different theme each week to prompt conversation. Using clinically validated questionnaires, the efficacy of the e-CBT arm will be compared to the mental health check-in arm. These questionnaires will be completed at baseline, week 6, and week 12. Results: The study received ethics approval in April 2021, and participant recruitment began in May 2021. Participant recruitment has been conducted through targeted advertisements and physician referrals. Complete data collection and analysis are expected to conclude by August 2023. Linear and binomial regression (continuous and categorical outcomes, respectively) will be conducted. Conclusions: To the research team?s knowledge, this will be the first study to date comparing the efficacy of e-CBT with a web-based mental health check-in program to treat GAD. The findings from this study can help progress the development of more scalable, accessible, and efficacious mental health treatments. Trial Registration: ClinicalTrials.gov NCT04754438; https://classic.clinicaltrials.gov/ct2/show/NCT04754438 International Registered Report Identifier (IRRID): DERR1-10.2196/48899 UR - https://www.researchprotocols.org/2023/1/e48899 UR - http://dx.doi.org/10.2196/48899 UR - http://www.ncbi.nlm.nih.gov/pubmed/37587552 ID - info:doi/10.2196/48899 ER - TY - JOUR AU - Hamatani, Sayo AU - Matsumoto, Kazuki AU - Andersson, Gerhard AU - Tomioka, Yukiko AU - Numata, Shusuke AU - Kamashita, Rio AU - Sekiguchi, Atsushi AU - Sato, Yasuhiro AU - Fukudo, Shin AU - Sasaki, Natsuki AU - Nakamura, Masayuki AU - Otani, Ryoko AU - Sakuta, Ryoichi AU - Hirano, Yoshiyuki AU - Kosaka, Hirotaka AU - Mizuno, Yoshifumi PY - 2023/9/19 TI - Guided Internet-Based Cognitive Behavioral Therapy for Women With Bulimia Nervosa: Protocol for a Multicenter Randomized Controlled Trial JO - JMIR Res Protoc SP - e49828 VL - 12 KW - bulimia nervosa KW - internet-based cognitive behavioral therapy KW - ICBT KW - randomized controlled trial KW - RCT KW - protocol KW - randomized KW - controlled trial KW - bulimia KW - eating KW - cognitive behavioral therapy KW - CBT KW - binge eating KW - purging KW - mobile phone N2 - Background: Individual face-to-face cognitive behavioral therapy is known to be effective for bulimia nervosa (BN). Since foods vary considerably between regions and cultures in which patients live, cultural adaptation of the treatment program is particularly important in cognitive behavioral therapy for BN. Recently, an internet-based cognitive behavioral therapy (ICBT) program was developed for Japanese women with BN, adapted to the Japanese food culture. However, no previous randomized controlled trial has examined the effectiveness of ICBT. Objective: This paper presents a research protocol for strategies to examine the effects of guided ICBT. Methods: This study is designed as a multicenter, prospective, assessor-blinded randomized controlled trial. The treatment groups will be divided into treatment as usual (TAU) alone as the control group and ICBT combined with TAU as the intervention group. The primary outcome is the total of binge eating and purging behaviors assessed before and after treatment by an independent assessor. Secondary outcomes will include measures of eating disorder severity, depression, anxiety, quality of life, treatment satisfaction, and working alliances. Treatment satisfaction and working alliances will be measured post assessment only. Other measures will be assessed at baseline, post intervention, and follow-up, and the outcomes will be analyzed on an intention-to-treat basis. Results: This study will be conducted at 7 different medical institutions in Japan from August 2022 to October 2026. Recruitment of participants began on August 19, 2022, and recruitment is scheduled to continue until July 2024. The first participants were registered on September 8, 2022. Conclusions: This is the first multicenter randomized controlled trial in Japan comparing the effectiveness of ICBT and TAU in patients with BN. Trial Registration: University Hospital Medical Information Network UMIN000048732; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000055522 International Registered Report Identifier (IRRID): DERR1-10.2196/49828 UR - https://www.researchprotocols.org/2023/1/e49828 UR - http://dx.doi.org/10.2196/49828 UR - http://www.ncbi.nlm.nih.gov/pubmed/37725414 ID - info:doi/10.2196/49828 ER - TY - JOUR AU - Butler, Mark AU - D?Angelo, Stefani AU - Ahn, Heejoon AU - Chandereng, Thevaa AU - Miller, Danielle AU - Perrin, Alexandra AU - Romain, N. Anne-Marie AU - Scatoni, Ava AU - Friel, P. Ciaran AU - Cheung, Ying-Kuen AU - Davidson, W. Karina PY - 2023/9/18 TI - A Series of Personalized Virtual Light Therapy Interventions for Fatigue: Feasibility Randomized Crossover Trial for N-of-1 Treatment JO - JMIR Form Res SP - e45510 VL - 7 KW - virtual light therapy interventions KW - fatigue KW - light therapy KW - primary care KW - feasibility KW - acceptability KW - effectiveness KW - usability KW - seasonal affective disorder KW - phototherapy KW - photoradiation KW - photochemotherapy KW - color therapy KW - heliotherapy KW - photothermal therapy KW - UV therapy KW - chromotherapy KW - color light therapy KW - mobile phone N2 - Background: Fatigue is one of the most common symptoms treated in primary care and can lead to deficits in mental health and functioning. Light therapy can be an effective treatment for symptoms of fatigue; however, the feasibility, scalability, and individual-level heterogeneity of light therapy for fatigue are unknown. Objective: This study aimed to evaluate the feasibility, acceptability, and effectiveness of a series of personalized (N-of-1) interventions for the virtual delivery of bright light (BL) therapy and dim light (DL) therapy versus usual care (UC) treatment for fatigue in 60 participants. Methods: Participants completed satisfaction surveys comprising the System Usability Scale (SUS) and items assessing satisfaction with the components of the personalized trial. Symptoms of fatigue were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) daily, PROMIS weekly, and ecological momentary assessment (EMA) questionnaires delivered 3 times daily. Comparisons of fatigue between the BL, DL, and UC treatment periods were conducted using generalized linear mixed model analyses between participants and generalized least squares analyses within individual participants. Results: Participants rated the usability of the personalized trial as acceptable (average SUS score=78.9, SD 15.6), and 92% (49/53) of those who completed satisfaction surveys stated that they would recommend the trial to others. The levels of fatigue symptoms measured using the PROMIS daily fatigue measure were lower or improved in the BL (B=?1.63, 95% CI ?2.63 to ?0.63) and DL (B=?1.44, 95% CI ?2.50 to ?0.38) periods relative to UC. The treatment effects of BL and DL on the PROMIS daily measure varied among participants. Similar findings were demonstrated for the PROMIS weekly and EMA measures of fatigue symptoms. Conclusions: The participant scores on the SUS and satisfaction surveys suggest that personalized N-of-1 trials of light therapy for fatigue symptoms are both feasible and acceptable. Both interventions produced significant (P<.05) reductions in participant-reported PROMIS and EMA fatigue symptoms relative to UC. However, the heterogeneity of these treatment effects across participants indicated that the effect of light therapy was not uniform. This heterogeneity along with high ratings of usability and satisfaction support the use of personalized N-of-1 research designs in evaluating the effect of light therapy on fatigue for each patient. Furthermore, the results of this trial provide additional support for the use of a series of personalized N-of-1 research trials. Trial Registration: ClinicalTrials.gov NCT04707846; https://clinicaltrials.gov/ct2/show/NCT04707846 UR - https://formative.jmir.org/2023/1/e45510 UR - http://dx.doi.org/10.2196/45510 UR - http://www.ncbi.nlm.nih.gov/pubmed/37721795 ID - info:doi/10.2196/45510 ER - TY - JOUR AU - Jones, M. Lenette AU - Piscotty Jr, J. Ronald AU - Sullivan, Stephen AU - Manzor Mitrzyk, Beatriz AU - Ploutz-Snyder, J. Robert AU - Ghosh, Bidisha AU - Veinot, Tiffany PY - 2023/9/11 TI - Psychometric Evaluation of the Modes of Health Information Acquisition, Sharing, and Use Questionnaire: Prospective Cross-Sectional Observational Study JO - J Med Internet Res SP - e44772 VL - 25 KW - psychometric evaluation KW - health information behavior KW - construct validity KW - reliability KW - chronic illness KW - MHIASU KW - hypertension N2 - Background: Health information is a critical resource for individuals with health concerns and conditions, such as hypertension. Enhancing health information behaviors may help individuals to better manage chronic illness. The Modes of Health Information Acquisition, Sharing, and Use (MHIASU) is a 23-item questionnaire that measures how individuals with health risks or chronic illness acquire, share, and use health information. Yet this measure has not been psychometrically evaluated in a large national sample. Objective: The objective of this study was to evaluate the psychometric properties of the self-administered MHIASU in a large, diverse cohort of individuals living with a chronic illness. Methods: Sharing Information, a prospective, observational study, was launched in August 2018 and used social media campaigns to advertise to Black women. Individuals who were interested in participating clicked on the advertisements and were redirected to a Qualtrics eligibility screener. To meet eligibility criteria individuals had to self-identify as a Black woman, be diagnosed with hypertension by a health care provider, and live in the United States. A total of 320 Black women with hypertension successfully completed the eligibility screener and then completed a web-based version of the MHIASU questionnaire. We conducted a psychometric evaluation of the MHIASU using exploratory factor analysis. The evaluation included item review, construct validity, and reliability. Results: Construct validity was established using exploratory factor analysis with principal axis factoring. The analysis was constricted to the expected domains. Interitem correlations were examined for possible item extraction. There were no improvements in factor structure with the removal of items with high interitem correlation (n=3), so all items of the MHIASU were retained. As anticipated, the instrument was found to have 3 subscales: acquisition, sharing, and use. Reliability was high for all 3 subscales, as evidenced by Cronbach ? scores of .81 (acquisition), .81 (sharing), and .93 (use). Factor 3 (use of health information) explained the maximum variance (74%). Conclusions: Construct validity and reliability of the web-based, self-administered MHIASU was demonstrated in a large national cohort of Black women with hypertension. Although this sample was highly educated and may have had higher digital literacy compared to other samples not recruited via social media, the population captured (Black women living with hypertension) are often underrepresented in research and are particularly vulnerable to this chronic condition. Future studies can use the MHIASU to examine health information behavior in other diverse populations managing health concerns and conditions. UR - https://www.jmir.org/2023/1/e44772 UR - http://dx.doi.org/10.2196/44772 UR - http://www.ncbi.nlm.nih.gov/pubmed/37695669 ID - info:doi/10.2196/44772 ER - TY - JOUR AU - Fernandes, J. Glenn AU - Choi, Arthur AU - Schauer, Michael Jacob AU - Pfammatter, F. Angela AU - Spring, J. Bonnie AU - Darwiche, Adnan AU - Alshurafa, I. Nabil PY - 2023/9/6 TI - An Explainable Artificial Intelligence Software Tool for Weight Management Experts (PRIMO): Mixed Methods Study JO - J Med Internet Res SP - e42047 VL - 25 KW - explainable artificial intelligence KW - explainable AI KW - machine learning KW - ML KW - interpretable ML KW - random forest KW - decision-making KW - weight loss prediction KW - mobile phone N2 - Background: Predicting the likelihood of success of weight loss interventions using machine learning (ML) models may enhance intervention effectiveness by enabling timely and dynamic modification of intervention components for nonresponders to treatment. However, a lack of understanding and trust in these ML models impacts adoption among weight management experts. Recent advances in the field of explainable artificial intelligence enable the interpretation of ML models, yet it is unknown whether they enhance model understanding, trust, and adoption among weight management experts. Objective: This study aimed to build and evaluate an ML model that can predict 6-month weight loss success (ie, ?7% weight loss) from 5 engagement and diet-related features collected over the initial 2 weeks of an intervention, to assess whether providing ML-based explanations increases weight management experts? agreement with ML model predictions, and to inform factors that influence the understanding and trust of ML models to advance explainability in early prediction of weight loss among weight management experts. Methods: We trained an ML model using the random forest (RF) algorithm and data from a 6-month weight loss intervention (N=419). We leveraged findings from existing explainability metrics to develop Prime Implicant Maintenance of Outcome (PRIMO), an interactive tool to understand predictions made by the RF model. We asked 14 weight management experts to predict hypothetical participants? weight loss success before and after using PRIMO. We compared PRIMO with 2 other explainability methods, one based on feature ranking and the other based on conditional probability. We used generalized linear mixed-effects models to evaluate participants? agreement with ML predictions and conducted likelihood ratio tests to examine the relationship between explainability methods and outcomes for nested models. We conducted guided interviews and thematic analysis to study the impact of our tool on experts? understanding and trust in the model. Results: Our RF model had 81% accuracy in the early prediction of weight loss success. Weight management experts were significantly more likely to agree with the model when using PRIMO (?2=7.9; P=.02) compared with the other 2 methods with odds ratios of 2.52 (95% CI 0.91-7.69) and 3.95 (95% CI 1.50-11.76). From our study, we inferred that our software not only influenced experts? understanding and trust but also impacted decision-making. Several themes were identified through interviews: preference for multiple explanation types, need to visualize uncertainty in explanations provided by PRIMO, and need for model performance metrics on similar participant test instances. Conclusions: Our results show the potential for weight management experts to agree with the ML-based early prediction of success in weight loss treatment programs, enabling timely and dynamic modification of intervention components to enhance intervention effectiveness. Our findings provide methods for advancing the understandability and trust of ML models among weight management experts. UR - https://www.jmir.org/2023/1/e42047 UR - http://dx.doi.org/10.2196/42047 UR - http://www.ncbi.nlm.nih.gov/pubmed/37672333 ID - info:doi/10.2196/42047 ER - TY - JOUR AU - Wang, Y. Angel AU - Vereschagin, Melissa AU - Richardson, G. Chris AU - Xie, Hui AU - Hudec, L. Kristen AU - Munthali, J. Richard AU - Munro, Lonna AU - Leung, Calista AU - Kessler, C. Ronald AU - Vigo, V. Daniel PY - 2023/8/30 TI - Evaluating the Effectiveness of a Codeveloped e-Mental Health Intervention for University Students: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e49364 VL - 12 KW - mental health KW - substance use KW - college students KW - digital interventions KW - randomized controlled trial KW - mobile phone N2 - Background: University life typically occurs during a period of life transition, where the incidence of mental health and substance use problems and disorders peaks. However, relatively few students obtain effective treatment and support. e-Interventions have proven effective in improving the psychological outcomes of university students and have the potential to provide scalable services that can easily integrate into existing models of care. Minder is a mobile app codeveloped with university students that offers users a collection of evidence-based interventions tailored to help university students maintain their mental health and well-being and manage their substance use. Objective: This paper describes the protocol for a randomized controlled trial (RCT) that aims to assess the effectiveness of the Minder app in improving the mental health and substance use outcomes of university students. Methods: This study is a 2-arm, parallel assignment, single-blinded, 30-day RCT with 1 intervention group and 1 waitlist control group. Overall, 1496 (748 per trial arm) university students from the University of British Columbia Vancouver Campus (N=54,000) who are aged ?17 years, have a smartphone with Wi-Fi or cellular data, and speak English will be recruited via a variety of web-based and offline strategies. Participants will be randomized into the intervention or control group after completing a baseline survey. Those randomized into the intervention group will gain immediate access to the Minder app and will be assessed at 2 weeks and 30 days. Those randomized into the control group will be given access to the app content after their follow-up assessment at 30 days. The primary outcomes are measured from baseline to follow-up at 30 days and include changes in general anxiety symptomology, depressive symptomology, and alcohol consumption risk measured by the General Anxiety Disorder 7-Item scale, Patient Health Questionnaire 9-Item scale, and US Alcohol Use Disorders Identification Test-Consumption Scale, respectively. Secondary outcomes include measures related to changes in the frequency of substance use, mental well-being, self-efficacy in managing mental health and substance use, readiness to change, and self-reported use of mental health services and supports (including referral) from baseline to follow-up at 30 days. Results: Trial recruitment and data collection began in September 2022, and the completion of data collection for the trial is anticipated by June 2023. As of May 10, 2023, a total of 1425 participants have been enrolled. Conclusions: The RCT described in this protocol paper will assess whether the Minder app is effective in improving the mental health and substance use outcomes of a general population of Canadian university students. Additional secondary outcome research aims to explore additional outcomes of interest for further research and better understand how to support students? general mental well-being. Trial Registration: ClinicalTrials.gov NCT05606601; https://clinicaltrials.gov/ct2/show/NCT05606601 International Registered Report Identifier (IRRID): DERR1-10.2196/49364 UR - https://www.researchprotocols.org/2023/1/e49364 UR - http://dx.doi.org/10.2196/49364 UR - http://www.ncbi.nlm.nih.gov/pubmed/37647105 ID - info:doi/10.2196/49364 ER - TY - JOUR AU - Pagoto, Sherry AU - Xu, Ran AU - Bullard, Tiffany AU - Foster, D. Gary AU - Bannor, Richard AU - Arcangel, Kaylei AU - DiVito, Joseph AU - Schroeder, Matthew AU - Cardel, I. Michelle PY - 2023/8/29 TI - An Evaluation of a Personalized Multicomponent Commercial Digital Weight Management Program: Single-Arm Behavioral Trial JO - J Med Internet Res SP - e44955 VL - 25 KW - weight loss KW - digital behavioral weight management program KW - single-arm behavioral trial KW - personalized weight loss program KW - ZeroPoint foods KW - weight management KW - digital intervention KW - diet management KW - exercise N2 - Background: Digital behavioral weight loss programs are scalable and effective, and they provide an opportunity to personalize intervention components. However, more research is needed to test the acceptability and efficacy of personalized digital behavioral weight loss interventions. Objective: In a 6-month single-arm trial, we examined weight loss, acceptability, and secondary outcomes of a digital commercial weight loss program (WeightWatchers). This digital program included a personalized weight loss program based on sex, age, height, weight, and personal food preferences, as well as synchronous (eg, virtual workshops and individual weekly check-ins) and asynchronous (eg, mobile app and virtual group) elements. In addition to a personalized daily and weekly PersonalPoints target, the program provided users with personalized lists of ?300 ZeroPoint foods, which are foods that do not need to be weighed, measured, or tracked. Methods: We conducted a pre-post evaluation of this 6-month, digitally delivered, and personalized WeightWatchers weight management program on weight loss at 3 and 6 months in adults with overweight and obesity. The secondary outcomes included participation, satisfaction, fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, self-compassion, well-being, and behavioral automaticity. Results: Of the 153 participants, 107 (69.9%) were female, and 65 (42.5%) identified as being from a minoritized racial or ethnic group. Participants? mean age was 41.09 (SD 13.78) years, and their mean BMI was 31.8 (SD 5.0) kg/m2. Participants had an average weight change of ?4.25% (SD 3.93%) from baseline to 3 months and ?5.05% (SD 5.59%) from baseline to 6 months. At 6 months, the percentages of participants who experienced ?3%, ?5%, and ?10% weight loss were 63.4% (97/153), 51% (78/153), and 14.4% (22/153), respectively. The mean percentage of weeks in which participants engaged in ?1 aspects of the program was 87.53% (SD 23.40%) at 3 months and 77.67% (SD 28.69%) at 6 months. Retention was high (132/153, 86.3%), and more than two-thirds (94/140, 67.1%) of the participants reported that the program helped them lose weight. Significant improvements were observed in fruit and vegetable intake, physical activity, sleep quality, hunger, food cravings, quality of life, and well-being (all P values <.01). Conclusions: This personalized, digital, and scalable behavioral weight management program resulted in clinically significant weight loss in half (78/153, 51%) of the participants as well as improvements in behavioral and psychosocial outcomes. Future research should compare personalized digital weight loss programs with generic programs on weight loss, participation, and acceptability. UR - https://www.jmir.org/2023/1/e44955 UR - http://dx.doi.org/10.2196/44955 UR - http://www.ncbi.nlm.nih.gov/pubmed/37642986 ID - info:doi/10.2196/44955 ER - TY - JOUR AU - Atik, Ece AU - Stricker, Johannes AU - Schückes, Magnus AU - Pittig, Andre PY - 2023/8/25 TI - Efficacy of a Brief Blended Cognitive Behavioral Therapy Program for the Treatment of Depression and Anxiety in University Students: Uncontrolled Intervention Study JO - JMIR Ment Health SP - e44742 VL - 10 KW - blended cognitive behavioral therapy KW - bCBT KW - digital mental health KW - e?mental health KW - depression KW - anxiety disorder KW - video psychotherapy KW - mobile phone N2 - Background: Blended cognitive behavioral therapy (bCBT)?the combination of cognitive behavioral therapy and digital mental health applications?has been increasingly used to treat depression and anxiety disorders. As a resource-efficient treatment approach, bCBT appears promising for addressing the growing need for mental health care services, for example, as an early intervention before the chronification of symptoms. However, further research on the efficacy and feasibility of integrated bCBT interventions is needed. Objective: This study aimed to evaluate the efficacy of a novel bCBT program comprising short (25 min), weekly face-to-face therapy sessions combined with a smartphone-based digital health app for treating mild to moderate symptoms of depression or anxiety. Methods: This prospective uncontrolled trial comprised 2 measurement points (before and after treatment) and 2 intervention groups. We recruited university students with mild to moderate symptoms of depression or anxiety. On the basis of the primary symptoms, participants were assigned to either a depression intervention group (n=67 completers) or an anxiety intervention group (n=33 completers). Participants in each group received 6 weekly individual psychotherapy sessions via videoconference and completed modules tailored to their respective symptoms in the smartphone-based digital health app. Results: The depression group displayed medium to large improvements in the symptoms of depression (Cohen d=?0.70 to ?0.90; P<.001). The anxiety group experienced significant improvements in the symptoms of generalized anxiety assessed with the Generalized Anxiety Disorder-7 scale with a large effect size (Cohen d=?0.80; P<.001) but not in symptoms of anxiety assessed with the Beck Anxiety Inventory (Cohen d=?0.35; P=.06). In addition, both groups experienced significant improvements in their perceived self-efficacy (Cohen d=0.50; P<.001 in the depression group and Cohen d=0.71; P<.001 in the anxiety group) and quality of life related to psychological health (Cohen d=0.87; P<.001 in the depression group and Cohen d=0.40; P=.03 in the anxiety group). Work and social adjustment of patients improved significantly in the depression group (Cohen d=?0.49; P<.001) but not in the anxiety group (Cohen d=?0.06; P=.72). Patients? mental health literacy improved in the anxiety group (Cohen d=0.45; P=.02) but not in the depression group (Cohen d=0.21; P=.10). Patient satisfaction with the bCBT program and ratings of the usability of the digital app were high in both treatment groups. Conclusions: This study provides preliminary evidence for the feasibility and efficacy of a novel brief bCBT intervention. The intervention effects were generalized across a broad spectrum of patient-reported outcomes. Hence, the newly developed bCBT intervention appears promising for treating mild to moderate depression and anxiety in young adults. UR - https://mental.jmir.org/2023/1/e44742 UR - http://dx.doi.org/10.2196/44742 UR - http://www.ncbi.nlm.nih.gov/pubmed/37624631 ID - info:doi/10.2196/44742 ER - TY - JOUR AU - Mitchell, Siobhan Ellen AU - Fabry, Alexander AU - Ho, Suh Annabell AU - May, N. Christine AU - Baldwin, Matthew AU - Blanco, Paige AU - Smith, Kyle AU - Michaelides, Andreas AU - Shokoohi, Mostafa AU - West, Michael AU - Gotera, Kim AU - El Massad, Omnya AU - Zhou, Anna PY - 2023/8/24 TI - The Impact of a Digital Weight Loss Intervention on Health Care Resource Utilization and Costs Compared Between Users and Nonusers With Overweight and Obesity: Retrospective Analysis Study JO - JMIR Mhealth Uhealth SP - e47473 VL - 11 KW - mobile health KW - mHealth KW - obesity KW - overweight KW - Noom Weight KW - digital weight loss intervention KW - health care resource utilization KW - costs KW - electronic health record KW - EHR KW - insurance claims KW - inverse probability of treatment weighting KW - IPTW KW - mobile phone N2 - Background: The Noom Weight program is a smartphone-based weight management program that uses cognitive behavioral therapy techniques to motivate users to achieve weight loss through a comprehensive lifestyle intervention. Objective: This retrospective database analysis aimed to evaluate the impact of Noom Weight use on health care resource utilization (HRU) and health care costs among individuals with overweight and obesity. Methods: Electronic health record data, insurance claims data, and Noom Weight program data were used to conduct the analysis. The study included 43,047 Noom Weight users and 14,555 non?Noom Weight users aged between 18 and 80 years with a BMI of ?25 kg/m² and residing in the United States. The index date was defined as the first day of a 3-month treatment window during which Noom Weight was used at least once per week on average. Inverse probability treatment weighting was used to balance sociodemographic covariates between the 2 cohorts. HRU and costs for inpatient visits, outpatient visits, telehealth visits, surgeries, and prescriptions were analyzed. Results: Within 12 months after the index date, Noom Weight users had less inpatient costs (mean difference [MD] ?US $20.10, 95% CI ?US $30.08 to ?US $10.12), less outpatient costs (MD ?US $124.33, 95% CI ?US $159.76 to ?US $88.89), less overall prescription costs (MD ?US $313.82, 95% CI ?US $565.42 to ?US $62.21), and less overall health care costs (MD ?US $450.39, 95% CI ?US $706.28 to ?US $194.50) per user than non?Noom Weight users. In terms of HRU, Noom Weight users had fewer inpatient visits (MD ?0.03, 95% CI ?0.04 to ?0.03), fewer outpatient visits (MD ?0.78, 95% CI ?0.93 to ?0.62), fewer surgeries (MD ?0.01, 95% CI ?0.01 to 0.00), and fewer prescriptions (MD ?1.39, 95% CI ?1.76 to ?1.03) per user than non?Noom Weight users. Among a subset of individuals with 24-month follow-up data, Noom Weight users incurred lower overall prescription costs (MD ?US $1139.52, 95% CI ?US $1972.21 to ?US $306.83) and lower overall health care costs (MD ?US $1219.06, 95% CI ?US $2061.56 to ?US $376.55) per user than non?Noom Weight users. The key differences were associated with reduced prescription use. Conclusions: Noom Weight use is associated with lower HRU and costs than non?Noom Weight use, with potential cost savings of up to US $1219.06 per user at 24 months after the index date. These findings suggest that Noom Weight could be a cost-effective weight management program for individuals with overweight and obesity. This study provides valuable evidence for health care providers and payers in evaluating the potential benefits of digital weight loss interventions such as Noom Weight. UR - https://mhealth.jmir.org/2023/1/e47473 UR - http://dx.doi.org/10.2196/47473 UR - http://www.ncbi.nlm.nih.gov/pubmed/37616049 ID - info:doi/10.2196/47473 ER - TY - JOUR AU - McCrae, S. Christina AU - Curtis, F. Ashley AU - Stearns, A. Melanie AU - Nair, Neetu AU - Golzy, Mojgan AU - Shenker, I. Joel AU - Beversdorf, Q. David AU - Cottle, Amelia AU - Rowe, A. Meredeth PY - 2023/8/24 TI - Development and Initial Evaluation of Web-Based Cognitive Behavioral Therapy for Insomnia in Rural Family Caregivers of People With Dementia (NiteCAPP): Mixed Methods Study JO - JMIR Aging SP - e45859 VL - 6 KW - arousal KW - caregivers KW - cognitive behavioral therapy KW - CBT: cognitive behavioral therapy for insomnia KW - CBT-I KW - dementia KW - insomnia KW - internet N2 - Background: Informal caregivers of people with dementia frequently experience chronic insomnia, contributing to stress and poor health outcomes. Rural caregivers are particularly vulnerable but have limited access to cognitive behavioral therapy for insomnia (CBT-I), a recommended frontline treatment for chronic insomnia. Web-based delivery promises to improve insomnia, particularly for rural caregivers who have limited access to traditional in-person treatments. Our team translated an efficacious 4-session standard CBT-I content protocol into digital format to create NiteCAPP. Objective: This study aimed to (1) adapt NiteCAPP for dementia caregivers to create NiteCAPP CARES, a tailored digital format with standard CBT-I content plus caregiver-focused modifications; (2) conduct usability testing and evaluate acceptability of NiteCAPP CARES? content and features; and (3) pilot-test the adapted intervention to evaluate feasibility and preliminary effects on sleep and related health outcomes. Methods: We followed Medical Research Council recommendations for evaluating complex medical interventions to explore user needs and adapt and validate content using a stepwise approach: (1) a rural dementia caregiver (n=5) and primary care provider (n=5) advisory panel gave feedback that was used to adapt NiteCAPP; (2) caregiver (n=5) and primary care provider (n=7) focus groups reviewed the newly adapted NiteCAPP CARES and provided feedback that guided further adaptations; and (3) NiteCAPP CARES was pilot-tested in caregivers (n=5) for feasibility and to establish preliminary effects. Self-report usability measures were collected following intervention. Before and after treatment, 14 daily electronic sleep diaries and questionnaires were collected to evaluate arousal, health, mood, burden, subjective cognition, and interpersonal processes. Results: The stepped approach provided user and expert feedback on satisfaction, usefulness, and content, resulting in a new digital CBT-I tailored for rural dementia caregivers: NiteCAPP CARES. The advisory panel recommended streamlining content, eliminating jargon, and including caregiver-focused content. Focus groups gave NiteCAPP CARES high usefulness ratings (mean score 4.4, SD 0.79, scored from 1=least to 5=most favorable; score range 4.2-4.8). Multiple features were evaluated positively, including the intervention?s comprehensive and engaging information, caregiver focus, good layout, easy-to-access intervention material, and easy-to-understand sleep graphs. Suggestions for improvement included the provision of day and night viewing options, collapsible text, font size options, tabbed access to videos, and a glossary of terms. Pilot-test users rated usefulness (mean score 4.3, SD 0.83; range 4.1-4.5) and satisfaction (mean score 8.4, SD 1.41, scored from 1=least to 10=most satisfied; range 7.4-9.0) highly. Preliminary effects on caregiver sleep, arousal, health, mood, burden, cognition, and interpersonal processes (all P<.05) were promising. Conclusions: Adaptations made to standard digital CBT-I created a feasible, tailored digital intervention for rural dementia caregivers. Important next steps include further examination of feasibility and efficacy in a randomized controlled trial with an active control condition, a multisite effectiveness trial, and eventual broad dissemination. Trial Registration: ClinicalTrials.gov NCT04632628; https://clinicaltrials.gov/ct2/show/NCT04632628 UR - https://aging.jmir.org/2023/1/e45859 UR - http://dx.doi.org/10.2196/45859 UR - http://www.ncbi.nlm.nih.gov/pubmed/37616032 ID - info:doi/10.2196/45859 ER - TY - JOUR AU - Ito-Masui, Asami AU - Sakamoto, Ryota AU - Matsuo, Eri AU - Kawamoto, Eiji AU - Motomura, Eishi AU - Tanii, Hisashi AU - Yu, Han AU - Sano, Akane AU - Imai, Hiroshi AU - Shimaoka, Motomu PY - 2023/8/22 TI - Effect of an Internet?Delivered Cognitive Behavioral Therapy?Based Sleep Improvement App for Shift Workers at High Risk of Sleep Disorder: Single-Arm, Nonrandomized Trial JO - J Med Internet Res SP - e45834 VL - 25 KW - shift worker sleep disorder KW - internet-based cognitive behavioral therapy KW - mobile apps KW - fitness tracker KW - subjective well-being KW - machine learning KW - mobile phone N2 - Background: Shift workers are at high risk of developing sleep disorders such as shift worker sleep disorder or chronic insomnia. Cognitive behavioral therapy (CBT) is the first-line treatment for insomnia, and emerging evidence shows that internet-based CBT is highly effective with additional features such as continuous tracking and personalization. However, there are limited studies on internet-based CBT for shift workers with sleep disorders. Objective: This study aimed to evaluate the impact of a 4-week, physician-assisted, internet-delivered CBT program incorporating machine learning?based well-being prediction on the sleep duration of shift workers at high risk of sleep disorders. We evaluated these outcomes using an internet-delivered CBT app and fitness trackers in the intensive care unit. Methods: A convenience sample of 61 shift workers (mean age 32.9, SD 8.3 years) from the intensive care unit or emergency department participated in the study. Eligible participants were on a 3-shift schedule and had a Pittsburgh Sleep Quality Index score ?5. The study comprised a 1-week baseline period, followed by a 4-week intervention period. Before the study, the participants completed questionnaires regarding the subjective evaluation of sleep, burnout syndrome, and mental health. Participants were asked to wear a commercial fitness tracker to track their daily activities, heart rate, and sleep for 5 weeks. The internet-delivered CBT program included well-being prediction, activity and sleep chart, and sleep advice. A job-based multitask and multilabel convolutional neural network?based model was used for well-being prediction. Participant-specific sleep advice was provided by sleep physicians based on daily surveys and fitness tracker data. The primary end point of this study was sleep duration. For continuous measurements (sleep duration, steps, etc), the mean baseline and week-4 intervention data were compared. The 2-tailed paired t test or Wilcoxon signed rank test was performed depending on the distribution of the data. Results: In the fourth week of intervention, the mean daily sleep duration for 7 days (6.06, SD 1.30 hours) showed a statistically significant increase compared with the baseline (5.54, SD 1.36 hours; P=.02). Subjective sleep quality, as measured by the Pittsburgh Sleep Quality Index, also showed statistically significant improvement from baseline (9.10) to after the intervention (7.84; P=.001). However, no significant improvement was found in the subjective well-being scores (all P>.05). Feature importance analysis for all 45 variables in the prediction model showed that sleep duration had the highest importance. Conclusions: The physician-assisted internet-delivered CBT program targeting shift workers with a high risk of sleep disorders showed a statistically significant increase in sleep duration as measured by wearable sensors along with subjective sleep quality. This study shows that sleep improvement programs using an app and wearable sensors are feasible and may play an important role in preventing shift work?related sleep disorders. International Registered Report Identifier (IRRID): RR2-10.2196/24799. UR - https://www.jmir.org/2023/1/e45834 UR - http://dx.doi.org/10.2196/45834 UR - http://www.ncbi.nlm.nih.gov/pubmed/37606971 ID - info:doi/10.2196/45834 ER - TY - JOUR AU - Meyer, Kylie AU - Gonzalez, Alexander AU - Benton, Donna PY - 2023/8/22 TI - Qualitative Evaluation of Family Caregivers? Experiences Participating in Knowledge and Interpersonal Skills to Develop Exemplary Relationships (KINDER): Web-Based Intervention to Improve Relationship Quality JO - JMIR Form Res SP - e42561 VL - 7 KW - aging KW - Alzheimer?s KW - Alzheimer KW - caregiver KW - caregiving KW - dementia: digital health KW - digital intervention KW - family care KW - informal care KW - intervention KW - older adult KW - quality of care N2 - Background: The onset of Alzheimer disease and related dementias (AD/ADRD) can alter relationships between family caregivers and persons living with AD/ADRD, such as through the occurrence of distressful behavioral and psychological symptoms of dementia. Poorly perceived relationship quality by caregivers contributes to negative outcomes for both care partners, such as low-quality caregiving and potential mistreatment of older adults. Knowledge and Interpersonal Skills to Develop Exemplary Relationships (KINDER) is a new, web-based, asynchronous psychoeducational intervention with content informed by focus groups with family caregivers. The program was developed to prevent low-quality caregiving and potential mistreatment of older adults by focusing on building healthy caregiving relationships. Objective: The purpose of this study is to describe caregivers? experiences participating in KINDER to understand intervention acceptability. Of particular interest was learning how comfortable caregivers were viewing content addressing potential mistreatment, as well as whether asynchronous delivery created any barriers to participating in the intervention. Findings will inform future program refinements before efficacy testing. Methods: Although 23 caregivers enrolled in the KINDER parent study, only 7 of them completed the 8-week intervention. In-depth, semistructured qualitative interviews were conducted with all participants who completed the program to understand their experiences while attending KINDER and to decipher barriers to participation. We also asked participants about which program elements were most valuable and which were least valuable to them, as well as how the program could be improved. Interview transcripts were analyzed by 2 coders using thematic analysis. Results: Our findings indicate that caregivers were overall satisfied with KINDER?s focus and content. Participants particularly liked how KINDER materials felt authentic and relevant to supporting healthy care relationships (Theme 1). The program?s multiple components were found to be valuable, especially story-based video vignettes and readings (Theme 2). Most caregivers were comfortable viewing depictions of mistreatment and understood the importance of this content (Theme 3). Notably, while caregivers appreciated the convenience of participating in an asynchronous web-based intervention, several expressed a desire for more opportunities to speak with other caregivers (Theme 4). Technology challenges, such as a lack of clarity about automated intervention activities, deterred completion. Conclusions: Findings from this study suggest an asynchronous web-based intervention covering sensitive topics such as mistreatment is acceptable for at least some AD/ADRD caregivers. Caregivers? comments that materials felt authentic may suggest that the integration of caregiver voices before intervention development enhanced the relevance of content. To make KINDER easier to deliver and participate in, the investigators plan to reduce the use of automation and integrate more group-based programming, as recommended by participants. Further, given the higher-than-expected dropout rate, in future studies, the investigators will collect data to determine the reasons for participants not completing study activities. UR - https://formative.jmir.org/2023/1/e42561 UR - http://dx.doi.org/10.2196/42561 UR - http://www.ncbi.nlm.nih.gov/pubmed/37606980 ID - info:doi/10.2196/42561 ER - TY - JOUR AU - Woo, Sarah AU - Jung, Sunho AU - Lim, Hyunjung AU - Kim, YoonMyung AU - Park, Hee Kyung PY - 2023/8/17 TI - Exploring the Effect of the Dynamics of Behavioral Phenotypes on Health Outcomes in an mHealth Intervention for Childhood Obesity: Longitudinal Observational Study JO - J Med Internet Res SP - e45407 VL - 25 KW - behavioral dynamics KW - behavioral phenotype KW - functional data analysis KW - FDA KW - machine learning analysis KW - mobile health KW - mHealth KW - obesity intervention KW - pediatric obesity KW - mobile phone N2 - Background: Advancements in mobile health technologies and machine learning approaches have expanded the framework of behavioral phenotypes in obesity treatment to explore the dynamics of temporal changes. Objective: This study aimed to investigate the dynamics of behavioral changes during obesity intervention and identify behavioral phenotypes associated with weight change using a hybrid machine learning approach. Methods: In total, 88 children and adolescents (ages 8-16 years; 62/88, 71% male) with age- and sex-specific BMI ?85th percentile participated in the study. Behavioral phenotypes were identified using a hybrid 2-stage procedure based on the temporal dynamics of adherence to the 5 behavioral goals during the intervention. Functional principal component analysis was used to determine behavioral phenotypes by extracting principal component factors from the functional data of each participant. Elastic net regression was used to investigate the association between behavioral phenotypes and weight change. Results: Functional principal component analysis identified 2 distinctive behavioral phenotypes, which were named the high or low adherence level and late or early behavior change. The first phenotype explained 47% to 69% of each factor, whereas the second phenotype explained 11% to 17% of the total behavioral dynamics. High or low adherence level was associated with weight change for adherence to screen time (?=?.0766, 95% CI ?.1245 to ?.0312), fruit and vegetable intake (?=.1770, 95% CI .0642-.2561), exercise (?=?.0711, 95% CI ?.0892 to ?.0363), drinking water (?=?.0203, 95% CI ?.0218 to ?.0123), and sleep duration. Late or early behavioral changes were significantly associated with weight loss for changes in screen time (?=.0440, 95% CI .0186-.0550), fruit and vegetable intake (?=?.1177, 95% CI ?.1441 to ?.0680), and sleep duration (?=?.0991, 95% CI ?.1254 to ?.0597). Conclusions: Overall level of adherence, or the high or low adherence level, and a gradual improvement or deterioration in health-related behaviors, or the late or early behavior change, were differently associated with weight loss for distinctive obesity-related lifestyle behaviors. A large proportion of health-related behaviors remained stable throughout the intervention, which indicates that health care professionals should closely monitor changes made during the early stages of the intervention. Trial Registration: Clinical Research Information Science KCT0004137; https://tinyurl.com/ytxr83ay UR - https://www.jmir.org/2023/1/e45407 UR - http://dx.doi.org/10.2196/45407 UR - http://www.ncbi.nlm.nih.gov/pubmed/37590040 ID - info:doi/10.2196/45407 ER - TY - JOUR AU - Karpov, Boris AU - Lipsanen, Olavi Jari AU - Ritola, Ville AU - Rosenström, Tom AU - Saarni, Suoma AU - Pihlaja, Satu AU - Stenberg, Jan-Henry AU - Laizane, Paula AU - Joffe, Grigori PY - 2023/8/17 TI - The Overall Anxiety Severity and Impairment Scale as an Outcome Measure in Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders: Observational Study JO - J Med Internet Res SP - e45362 VL - 25 KW - Overall Anxiety Severity and Impairment Scale KW - OASIS KW - internet-delivered cognitive behavioral therapy KW - iCBT KW - anxiety KW - social anxiety disorder KW - panic disorder KW - obsessive-compulsive disorder KW - OCD N2 - Background: Internet-delivered cognitive behavioral therapy (iCBT) is effective in the treatment of anxiety disorders. iCBT clinical trials use relatively long and time-consuming disorder-specific rather than transdiagnostic anxiety measurements. Overall Anxiety Severity and Impairment Scale (OASIS) is a brief self-report scale that could offer a universal, easy-to-use anxiety measurement option in disorder-specific and transdiagnostic iCBT programs. Objective: We aimed to investigate relationships between OASIS and disorder-specific instruments in iCBT. We expected these relationships to be positive. Methods: We investigated patients in original nationwide iCBT programs for generalized anxiety disorder (GAD), obsessive-compulsive disorder, panic disorder, and social anxiety disorder, which were administered by Helsinki University Hospital, Finland. In each program, anxiety symptoms were measured using both disorder-specific scales (the 7-item Generalized Anxiety Disorder scale, Penn State Worry Questionnaire, revised Obsessive-Compulsive Inventory, Panic Disorder Severity Scale, and Social Phobia Inventory) and by OASIS. A general linear model for repeated measures (mixed models) and interaction analysis were used for investigating the changes and relationships in the mean scores of OASIS and disorder-specific scales from the first session to the last one. Results: The main effect of linear mixed models indicated a distinct positive association between OASIS and disorder-specific scale scores. Interaction analysis demonstrated relatively stable associations between OASIS and the revised Obsessive-Compulsive Inventory (F822.9=0.09; 95% CI 0.090-0.277; P=.32), and OASIS and the Panic Disorder Severity Scale (F596.6=?0.02; 95% CI ?0.108 to ?0.065; P=.63) from first the session to the last one, while the 7-item Generalized Anxiety Disorder scale (F4345.8=?0.06; 95% CI ?0.109 to ?0.017; P=.007), Penn State Worry Questionnaire (F4270.8=?0.52; 95% CI ?0.620 to ?0.437; P<.001), and Social Phobia Inventory (F862.1=?0.39; 95% CI ?0.596 to ?0.187; P<.001) interrelated with OASIS more strongly at the last session than at the first one. Conclusions: OASIS demonstrates clear and relatively stable associations with disorder-specific symptom measures. Thus, OASIS might serve as an outcome measurement instrument for disorder-specific and plausibly transdiagnostic iCBT programs for anxiety disorders in regular clinical practice. UR - https://www.jmir.org/2023/1/e45362 UR - http://dx.doi.org/10.2196/45362 UR - http://www.ncbi.nlm.nih.gov/pubmed/37590055 ID - info:doi/10.2196/45362 ER - TY - JOUR AU - Lopes, T. Rodrigo AU - da Rocha, Chapetta Gustavo AU - Svacina, Adriana Maria AU - Meyer, Björn AU - ?ipka, Dajana AU - Berger, Thomas PY - 2023/8/17 TI - Effectiveness of an Internet-Based Self-Guided Program to Treat Depression in a Sample of Brazilian Users: Randomized Controlled Trial JO - JMIR Form Res SP - e46326 VL - 7 KW - depression KW - internet-based interventions KW - self-guided interventions KW - cognitive behavioral therapy N2 - Background: Depression is undertreated in Brazil. Deprexis is a self-guided internet-based program used to treat depressive symptoms based on empirically supported integrative and cognitive behavioral therapy. Evidence from a meta-analysis supports Deprexis? efficacy in German-speaking countries and the United States, but no study has been conducted using this program in countries with low literacy rates and large social disparities. Furthermore, few studies have investigated whether internet-based interventions ameliorate the psychological processes that might underlie depressive symptomatology, such as low perceived self-efficacy. Objective: The main objective of this study was to replicate in Brazil previously reported effects of Deprexis on depressive symptom reduction. Therefore, the main research question was whether Deprexis is effective in reducing depressive symptoms and the general psychological state in Brazilian users with moderate and severe depression in comparison with a control group that does not receive access to Deprexis. A secondary research question was whether the use of Deprexis affects perceptions of self-efficacy. Methods: We interviewed 312 participants recruited over the internet and randomized 189 participants with moderate to severe depression (according to the Patient Health Questionnaire?9 and a semistructured interview) to an intervention condition (treatment as usual plus immediate access to Deprexis for 90 days, n=94) or to a control condition (treatment as usual and delayed access to Deprexis, after 8 weeks, n=95). Results: Participants from the immediate access group logged in at Deprexis an average of 14.81 (SD 12.16) times. The intention-to-treat analysis using a linear mixed model showed that participants who received Deprexis improved significantly more than participants assigned to the delayed access control group on the primary depression self-assessment measure (Patient Health Questionnaire?9; Cohen d=0.80; P<.001) and secondary outcomes, such as general psychological state measure (Clinical Outcome in Routine Evaluation?Outcome Measurement; Cohen d=0.82; P<.001) and the perceived self-efficacy measure (Cohen d=0.63; P<.001). The intention-to-treat analyses showed that 21% (20/94) of the participants achieved remission compared with 7% (7/95) in the control group (P<.001). The deterioration rates were lower in the immediate access control group. The dropout rate was high, but no differences in demographic and clinical variables were found. Participants reported a medium to high level of satisfaction with Deprexis. Conclusions: These results replicate previous findings by showing that Deprexis can facilitate symptomatic improvement over 3 months in depressed samples of Brazilian users. From a public health perspective, this is important information to expand the reach of internet-based interventions for those who really need them, especially in countries with less access to mental health care. This extends previous research by showing significant effects on perceived self-efficacy. Trial Registration: Registro Brasileiro de Ensaios Clíncos (ReBec) RBR-6kk3bx UTN U1111-1212-8998; https://ensaiosclinicos.gov.br/rg/RBR-6kk3bx/ International Registered Report Identifier (IRRID): RR2-10.1590/1516-4446-2019-0582 UR - https://formative.jmir.org/2023/1/e46326 UR - http://dx.doi.org/10.2196/46326 UR - http://www.ncbi.nlm.nih.gov/pubmed/37590052 ID - info:doi/10.2196/46326 ER - TY - JOUR AU - Chang, Yen-Jung AU - Chen, Jhong-Lin PY - 2023/8/14 TI - Effectiveness of a Web-Based Intervention for Preventing Substance Use in Young Adults in Taiwan: Quasi-Experimental Study JO - J Med Internet Res SP - e40157 VL - 25 KW - controlled substances KW - health education KW - illicit drugs KW - prevention KW - substance use KW - web-based intervention KW - young adults N2 - Background: Substance use has been one of the most alarming public health problems worldwide, particularly among younger generations. Objective: This study evaluated the effectiveness of a web-based substance use prevention intervention targeted at adults aged 20-29 years. Methods: The intervention materials comprised 5 sets of infographics and 1 animation, all of which focused on mixed themes: (1) the concept of substance use and its harmful effects on health; (2) misinformation regarding new psychoactive substances; (3) regulation of illicit drugs, particularly marijuana; (4) the brain disease model of addiction; (5) critical thinking skills that improve health literacy; and (6) decision-making and communication skills that help people refuse illegal drugs. The study assigned eligible participants into experimental and control groups on the basis of the parity of their participant numbers. These participants completed web-based baseline and follow-up questionnaires that assessed their knowledge, behavioral intention, self-efficacy, and life skills related to substance use prevention. Knowledge was assessed using 8 questions concerning understanding of substance use harms and the regulation of illicit drugs. Behavioral intention and self-efficacy were assessed using 5-point Likert-type scales. Participants? ability to apply life skills to avoid substance use was assessed using 3 testing scenarios regarding substance use. The study used generalized estimating equations to examine the intervention?s effectiveness. Results: A total of 1065 participants (539 control and 526 experimental) completed the intervention and questionnaires in 2019. The average ages of the experimental and control groups were 25.68 (SD 2.71) and 25.66 (SD 2.69) years, respectively. The study observed no significant differences in the demographic variables between the 2 groups. The results of the generalized estimating equation analyses indicated that the intervention significantly improved participants? knowledge (P<.001), behavioral intention (P<.001), and self-efficacy (P<.001) but not their life skills (P=.61) related to substance use prevention. Participants in the experimental group responded to a satisfaction survey with positive feedback on the intervention. Conclusions: The web-based intervention was effective in improving participants? knowledge, behavioral intention, and self-efficacy concerning substance use prevention. The findings support continued efforts to use web-based interventions to prevent substance use among young adults. UR - https://www.jmir.org/2023/1/e40157 UR - http://dx.doi.org/10.2196/40157 UR - http://www.ncbi.nlm.nih.gov/pubmed/37578821 ID - info:doi/10.2196/40157 ER - TY - JOUR AU - White, S. Justin AU - Salem, K. Marie AU - Toussaert, Séverine AU - Westmaas, Lee J. AU - Raiff, R. Bethany AU - Crane, David AU - Warrender, Edward AU - Lyles, Courtney AU - Abroms, Lorien AU - Thrul, Johannes PY - 2023/8/11 TI - Developing a Game (Inner Dragon) Within a Leading Smartphone App for Smoking Cessation: Design and Feasibility Evaluation Study JO - JMIR Serious Games SP - e46602 VL - 11 KW - smoking cessation KW - mobile app KW - games for health KW - gamification KW - software design KW - feasibility KW - mobile phone N2 - Background: Several stand-alone smartphone apps have used serious games to provide an engaging approach to quitting smoking. So far, the uptake of these games has been modest, and the evidence base for their efficacy in promoting smoking cessation is still evolving. The feasibility of integrating a game into a popular smoking cessation app is unclear. Objective: The aim of this paper was to describe the design and iterative development of the Inner Dragon game within Smoke Free, a smartphone app with proven efficacy, and the results of a single-arm feasibility trial as part of a broad program that seeks to assess the effectiveness of the gamified app for smoking cessation. Methods: In phase 1, the study team undertook a multistep process to design and develop the game, including web-based focus group discussions with end users (n=15). In phase 2, a single-arm study of Smoke Free users who were trying to quit (n=30) was conducted to assess the feasibility and acceptability of the integrated game and to establish the feasibility of the planned procedures for a randomized pilot trial. Results: Phase 1 led to the final design of Inner Dragon, informed by principles from psychology and behavioral economics and incorporating several game mechanics designed to increase user engagement and retention. Inner Dragon users maintain an evolving pet dragon that serves as a virtual avatar for the users? progress in quitting. The phase-2 study established the feasibility of the study methods. The mean number of app sessions completed per user was 13.8 (SD 13.1; median 8; range 1-46), with a mean duration per session of 5.8 (median 1.1; range 0-81.1) minutes. Overall, three-fourths (18/24, 75%) of the participants entered the Inner Dragon game at least once and had a mean of 2.4 (SD 2.4) sessions of game use. The use of Inner Dragon was positively associated with the total number of app sessions (correlation 0.57). The mean satisfaction score of participants who provided ratings (11/24, 46%) was 4.2 (SD 0.6) on a 5-point scale; however, satisfaction ratings for Inner Dragon were only completed by 13% (3/24) of the participants. Conclusions: Findings supported further development and evaluation of Inner Dragon as a beneficial feature of Smoke Free. The next step of this study is to conduct a randomized pilot trial to determine whether the gamified version of the app increases user engagement over a standard version of the app. UR - https://games.jmir.org/2023/1/e46602 UR - http://dx.doi.org/10.2196/46602 UR - http://www.ncbi.nlm.nih.gov/pubmed/37566442 ID - info:doi/10.2196/46602 ER - TY - JOUR AU - Glympi, Alkyoni AU - Odegi, Dorothy AU - Zandian, Modjtaba AU - Södersten, Per AU - Bergh, Cecilia AU - Langlet, Billy PY - 2023/8/10 TI - Eating Behavior and Satiety With Virtual Reality Meals Compared With Real Meals: Randomized Crossover Study JO - JMIR Serious Games SP - e44348 VL - 11 KW - exposure therapy KW - eating behavior KW - anorexia nervosa KW - bulimia nervosa KW - binge eating disorder KW - overweight KW - obesity KW - immersive virtual reality KW - VR KW - virtual reality N2 - Background: Eating disorders and obesity are serious health problems with poor treatment outcomes and high relapse rates despite well-established treatments. Several studies have suggested that virtual reality technology could enhance the current treatment outcomes and could be used as an adjunctive tool in their treatment. Objective: This study aims to investigate the differences between eating virtual and real-life meals and test the hypothesis that eating a virtual meal can reduce hunger among healthy women. Methods: The study included 20 healthy women and used a randomized crossover design. The participants were asked to eat 1 introduction meal, 2 real meals, and 2 virtual meals, all containing real or virtual meatballs and potatoes. The real meals were eaten on a plate that had been placed on a scale that communicated with analytical software on a computer. The virtual meals were eaten in a room where participants were seated on a real chair in front of a real table and fitted with the virtual reality equipment. The eating behavior for both the real and virtual meals was filmed. Hunger was measured before and after the meals using questionnaires. Results: There was a significant difference in hunger from baseline to after the real meal (mean difference=61.8, P<.001) but no significant change in hunger from before to after the virtual meal (mean difference=6.9, P=.10). There was no significant difference in food intake between the virtual and real meals (mean difference=36.8, P=.07). Meal duration was significantly shorter in the virtual meal (mean difference=?5.4, P<.001), which led to a higher eating rate (mean difference=82.9, P<.001). Some participants took bites and chewed during the virtual meal, but the number of bites and chews was lower than in the real meal. The meal duration was reduced from the first virtual meal to the second virtual meal, but no significant difference was observed between the 2 real meals. Conclusions: Eating a virtual meal does not appear to significantly reduce hunger in healthy individuals. Also, this methodology does not significantly result in eating behaviors identical to real-life conditions but does evoke chewing and bite behavior in certain individuals. Trial Registration: ClinicalTrials.gov NCT05734209, https://clinicaltrials.gov/ct2/show/NCT05734209 UR - https://games.jmir.org/2023/1/e44348 UR - http://dx.doi.org/10.2196/44348 UR - http://www.ncbi.nlm.nih.gov/pubmed/37561558 ID - info:doi/10.2196/44348 ER - TY - JOUR AU - Wu, Chao-Yi AU - Tibbitts, Deanne AU - Beattie, Zachary AU - Dodge, Hiroko AU - Shannon, Jackilen AU - Kaye, Jeffrey AU - Winters-Stone, Kerri PY - 2023/8/10 TI - Using Continuous Passive Assessment Technology to Describe Health and Behavior Patterns Preceding and Following a Cancer Diagnosis in Older Adults: Proof-of-Concept Case Series Study JO - JMIR Form Res SP - e45693 VL - 7 KW - sensor KW - quality of life KW - physical activity KW - medication KW - monitoring KW - function KW - mobile phone N2 - Background: Describing changes in health and behavior that precede and follow a sentinel health event, such as a cancer diagnosis, is challenging because of the lack of longitudinal, objective measurements that are collected frequently enough to capture varying trajectories of change leading up to and following the event. A continuous passive assessment system that continuously monitors older adults? physical activity, weight, medication-taking behavior, pain, health events, and mood could enable the identification of more specific health and behavior patterns leading up to a cancer diagnosis and whether and how patterns change thereafter. Objective: In this study, we conducted a proof-of-concept retrospective analysis, in which we identified new cancer diagnoses in older adults and compared trajectories of change in health and behaviors before and after cancer diagnosis. Methods: Participants were 10 older adults (mean age 71.8, SD 4.9 years; 3/10, 30% female) with various self-reported cancer types from a larger prospective cohort study of older adults. A technology-agnostic assessment platform using multiple devices provided continuous data on daily physical activity via wearable sensors (actigraphy); weight via a Wi-Fi?enabled digital scale; daily medication-taking behavior using electronic Bluetooth-enabled pillboxes; and weekly pain, health events, and mood with online, self-report surveys. Results: Longitudinal linear mixed-effects models revealed significant differences in the pre- and postcancer trajectories of step counts (P<.001), step count variability (P=.004), weight (P<.001), pain severity (P<.001), hospitalization or emergency room visits (P=.03), days away from home overnight (P=.01), and the number of pillbox door openings (P<.001). Over the year preceding a cancer diagnosis, there were gradual reductions in step counts and weight and gradual increases in pain severity, step count variability, hospitalization or emergency room visits, and days away from home overnight compared with 1 year after the cancer diagnosis. Across the year after the cancer diagnosis, there was a gradual increase in the number of pillbox door openings compared with 1 year before the cancer diagnosis. There was no significant trajectory change from the pre? to post?cancer diagnosis period in terms of low mood (P=.60) and loneliness (P=.22). Conclusions: A home-based, technology-agnostic, and multidomain assessment platform could provide a unique approach to monitoring different types of behavior and health markers in parallel before and after a life-changing health event. Continuous passive monitoring that is ecologically valid, less prone to bias, and limits participant burden could greatly enhance research that aims to improve early detection efforts, clinical care, and outcomes for people with cancer. UR - https://formative.jmir.org/2023/1/e45693 UR - http://dx.doi.org/10.2196/45693 UR - http://www.ncbi.nlm.nih.gov/pubmed/37561574 ID - info:doi/10.2196/45693 ER - TY - JOUR AU - Beltzer, L. Miranda AU - Daniel, E. Katharine AU - Daros, R. Alexander AU - Teachman, A. Bethany PY - 2023/8/9 TI - Changes in Learning From Social Feedback After Web-Based Interpretation Bias Modification: Secondary Analysis of a Digital Mental Health Intervention Among Individuals With High Social Anxiety Symptoms JO - JMIR Form Res SP - e44888 VL - 7 KW - social anxiety KW - reinforcement learning KW - cognitive bias modification KW - interpretation bias KW - reward learning KW - probabilistic learning KW - Q-learning KW - digital intervention N2 - Background: Biases in social reinforcement learning, or the process of learning to predict and optimize behavior based on rewards and punishments in the social environment, may underlie and maintain some negative cognitive biases that are characteristic of social anxiety. However, little is known about how cognitive and behavioral interventions may change social reinforcement learning in individuals who are anxious. Objective: This study assessed whether a scalable, web-based cognitive bias modification for interpretations (CBM-I) intervention changed social reinforcement learning biases in participants with high social anxiety symptoms. This study focused on 2 types of social reinforcement learning relevant to social anxiety: learning about other people and learning about one?s own social performance. Methods: Participants (N=106) completed 2 laboratory sessions, separated by 5 weeks of ecological momentary assessment tracking emotion regulation strategy use and affect. Approximately half (n=51, 48.1%) of the participants completed up to 6 brief daily sessions of CBM-I in week 3. Participants completed a task that assessed social reinforcement learning about other people in both laboratory sessions and a task that assessed social reinforcement learning about one?s own social performance in the second session. Behavioral data from these tasks were computationally modeled using Q-learning and analyzed using mixed effects models. Results: After the CBM-I intervention, participants updated their beliefs about others more slowly (P=.04; Cohen d=?0.29) but used what they learned to make more accurate decisions (P=.005; Cohen d=0.20), choosing rewarding faces more frequently. These effects were not observed among participants who did not complete the CBM-I intervention. Participants who completed the CBM-I intervention also showed less-biased updating about their social performance than participants who did not complete the CBM-I intervention, learning similarly from positive and negative feedback and from feedback on items related to poor versus good social performance. Regardless of the intervention condition, participants at session 2 versus session 1 updated their expectancies about others more from rewarding (P=.003; Cohen d=0.43) and less from punishing outcomes (P=.001; Cohen d=?0.47), and they became more accurate at learning to avoid punishing faces (P=.001; Cohen d=0.20). Conclusions: Taken together, our results provide initial evidence that there may be some beneficial effects of both the CBM-I intervention and self-tracking of emotion regulation on social reinforcement learning in individuals who are socially anxious, although replication will be important. UR - https://formative.jmir.org/2023/1/e44888 UR - http://dx.doi.org/10.2196/44888 UR - http://www.ncbi.nlm.nih.gov/pubmed/37556186 ID - info:doi/10.2196/44888 ER - TY - JOUR AU - Stewart, Ian AU - Welch, Charles AU - An, Lawrence AU - Resnicow, Ken AU - Pennebaker, James AU - Mihalcea, Rada PY - 2023/8/1 TI - Expressive Interviewing Agents to Support Health-Related Behavior Change: Randomized Controlled Study of COVID-19 Behaviors JO - JMIR Form Res SP - e40277 VL - 7 KW - expressive writing KW - motivational interviewing KW - dialogue systems KW - counseling KW - behavior change KW - text analysis KW - COVID-19 KW - mental health KW - automated writing KW - writing system KW - stress KW - psychological health N2 - Background: Expressive writing and motivational interviewing are well-known approaches to help patients cope with stressful life events. Although these methods are often applied by human counselors, it is less well understood if an automated artificial intelligence approach can benefit patients. Providing an automated method would help expose a wider range of people to the possible benefits of motivational interviewing, with lower cost and more adaptability to sudden events like the COVID-19 pandemic. Objective: This study presents an automated writing system and evaluates possible outcomes among participants with respect to behavior related to the COVID-19 pandemic. Methods: We developed a rule-based dialogue system for ?Expressive Interviewing? to elicit writing from participants on the subject of how COVID-19 has impacted their lives. The system prompts participants to describe their life experiences and emotions and provides topic-specific prompts in response to participants? use of topical keywords. In May 2021 and June 2021, we recruited participants (N=151) via Prolific to complete either the Expressive Interviewing task or a control task. We surveyed participants immediately before the intervention, immediately after the intervention, and again 2 weeks after the intervention. We measured participants? self-reported stress, general mental health, COVID-19?related health behavior, and social behavior. Results: Participants generally wrote long responses during the task (53.3 words per response). In aggregate, task participants experienced a significant decrease in stress in the short term (~23% decrease, P<.001) and a slight difference in social activity compared with the control group (P=.03). No significant differences in short-term or long-term outcomes were detected between participant subgroups (eg, male versus female participants) except for some within-condition differences by ethnicity (eg, higher social activity among African American people participating in Expressive Interviewing vs participants of other ethnicities). For short-term effects, participants showed different outcomes based on their writing. Using more anxiety-related words was correlated with a greater short-term decrease in stress (r=?0.264, P<.001), and using more positive emotion words was correlated with a more meaningful experience (r=0.243, P=.001). As for long-term effects, writing with more lexical diversity was correlated with an increase in social activity (r=0.266, P<.001). Conclusions: Expressive Interviewing participants exhibited short-term, but not long-term, positive changes in mental health, and some linguistic metrics of writing style were correlated with positive change in behavior. Although there were no significant long-term effects observed, the positive short-term effects suggest that the Expressive Interviewing intervention could be used in cases in which a patient lacks access to traditional therapy and needs a short-term solution. Trial Registration: Clincaltrials.gov NCT05949840; https://www.clinicaltrials.gov/study/NCT05949840 UR - https://formative.jmir.org/2023/1/e40277 UR - http://dx.doi.org/10.2196/40277 UR - http://www.ncbi.nlm.nih.gov/pubmed/37074948 ID - info:doi/10.2196/40277 ER - TY - JOUR AU - Raumer-Monteith, Lauren AU - Kennedy, Madonna AU - Ball, Lauren PY - 2023/7/27 TI - Web-Based Learning for General Practitioners and Practice Nurses Regarding Behavior Change: Qualitative Descriptive Study JO - JMIR Med Educ SP - e45587 VL - 9 KW - continuing professional development KW - continuing medical education KW - web-based KW - e-learning KW - behavior change KW - general practitioner KW - practice nurse KW - nurse KW - medical education KW - professional development KW - general practice KW - web-based learning KW - remote learning KW - adoption KW - perspective KW - health care professional N2 - Background: Supporting patients to live well by optimizing behavior is a core tenet of primary health care. General practitioners and practice nurses experience barriers in providing behavior change interventions to patients for lifestyle behaviors, including low self-efficacy in their ability to enact change. Web-based learning technologies are readily available for general practitioners and practice nurses; however, opportunities to upskill in behavior change are still limited. Understanding what influences general practitioners? and practice nurses? adoption of web-based learning is crucial to enhancing the quality and impact of behavior change interventions in primary health care. Objective: This study aimed to explore general practitioners? and practice nurses? perceptions regarding web-based learning to support patients with behavior change. Methods: A qualitative, cross-sectional design was used involving web-based, semistructured interviews with general practitioners and practice nurses in Queensland, Australia. The interviews were recorded and transcribed using the built-in Microsoft Teams transcription software. Inductive coding was used to generate codes from the interview data for thematic analysis. Results: In total, there were 11 participants in this study, including general practitioners (n=4) and practice nurses (n=7). Three themes emerged from the data analysis: (1) reflecting on the provider of the Healthy Lifestyles suite; (2) valuing the web-based learning content and presentation; and (3) experiencing barriers and facilitators to using the Healthy Lifestyles suite. Conclusions: Provider reputation, awareness of availability, resources, content quality, usability, cost, and time influence adoption of web-based learning. Perceived quality is associated with culturally tailored information, resources, a balance of information and interactivity, plain language, user-friendly navigation, appealing visual presentation, communication examples, and simple models. Free web-based learning that features progress saving and module lengths of less than 2 hours alleviate perceived time and cost barriers. Learning providers may benefit by including these features in their future behavior change web-based learning for general practitioners and practice nurses. UR - https://mededu.jmir.org/2023/1/e45587 UR - http://dx.doi.org/10.2196/45587 UR - http://www.ncbi.nlm.nih.gov/pubmed/37498657 ID - info:doi/10.2196/45587 ER - TY - JOUR AU - Crane, Nicole AU - Hagerman, Charlotte AU - Horgan, Olivia AU - Butryn, Meghan PY - 2023/7/18 TI - Patterns and Predictors of Engagement With Digital Self-Monitoring During the Maintenance Phase of a Behavioral Weight Loss Program: Quantitative Study JO - JMIR Mhealth Uhealth SP - e45057 VL - 11 KW - weight loss KW - digital technology KW - diet KW - exercise KW - behavior change KW - mobile phone N2 - Background: Long-term self-monitoring (SM) of weight, diet, and exercise is commonly recommended by behavioral weight loss (BWL) treatments. However, sustained SM engagement is notoriously challenging; therefore, more must be learned about patterns of engagement with digital SM tools during weight loss maintenance (WLM). In addition, insight into characteristics that may influence SM engagement could inform tailored approaches for participants at risk for poor adherence. Objective: This study explored patterns of digital SM of weight, diet, and exercise during WLM (aim 1) and examined timing, patterns, and rates of disengagement and reengagement (aim 2). This study also assessed relationships between individual-level factors (weight-related information avoidance and weight bias internalization) and SM engagement (aim 3). Methods: Participants were 72 adults enrolled in a BWL program consisting of a 3-month period of weekly treatment designed to induce weight loss (phase I), followed by a 9-month period of less frequent contact to promote WLM (phase II). Participants were prescribed daily digital SM of weight, diet, and exercise. At baseline, self-report measures assessed weight-related information avoidance and weight bias internalization. SM adherence was objectively measured with the days per month that participants tracked weight, diet, and exercise. Repeated-measures ANOVA examined differences in adherence across SM targets. Multilevel modeling examined changes in adherence across phase II. Relationships between individual-level variables and SM adherence were assessed with Pearson correlations, 2-tailed independent samples t tests, and multilevel modeling. Results: During WLM, consistently high rates of SM (?50% of the days in each month) were observed for 61% (44/72) of the participants for exercise, 40% (29/72) of the participants for weight, and 21% (15/72) of the participants for diet. Adherence for SM of exercise was higher than that for weight or diet (P<.001). Adherence decreased over time for all SM targets throughout phase II (P<.001), but SM of exercise dropped off later in WLM (mean 10.07, SD 2.83 months) than SM of weight (mean 7.92, SD 3.23 months) or diet (mean 7.58, SD 2.92 months; P<.001). Among participants with a period of low SM adherence (ie, <50% of the days in a month), only 33% (17/51 for weight, 19/57 for diet) to 46% (13/28 for exercise) subsequently had ?1 months with high adherence. High weight-related information avoidance predicted a faster rate of decrease in dietary SM (P<.001). Participants with high weight bias internalization had the highest rates of weight SM (P=.03). Conclusions: Participants in BWL programs have low adherence to the recommendation to sustain daily SM during WLM, particularly for SM of diet and weight. Weight-related information avoidance and weight bias internalization may be relevant indicators for SM engagement. Interventions may benefit from innovative strategies that target participants at key moments of risk for disengagement. UR - https://mhealth.jmir.org/2023/1/e45057 UR - http://dx.doi.org/10.2196/45057 UR - http://www.ncbi.nlm.nih.gov/pubmed/37463017 ID - info:doi/10.2196/45057 ER - TY - JOUR AU - Chen, Kay-Yut AU - Lang, Yan AU - Zhou, Yuan AU - Kosmari, Ludmila AU - Daniel, Kathryn AU - Gurses, Ayse AU - Xiao, Yan PY - 2023/7/13 TI - Assessing Interventions on Crowdsourcing Platforms to Nudge Patients for Engagement Behaviors in Primary Care Settings: Randomized Controlled Trial JO - J Med Internet Res SP - e41431 VL - 25 KW - Amazon Mechanical Turk KW - behavioral interventions KW - crowdsourcing KW - medication safety KW - Mturk KW - patient engagement KW - primary care N2 - Background: Engaging patients in health behaviors is critical for better outcomes, yet many patient partnership behaviors are not widely adopted. Behavioral economics?based interventions offer potential solutions, but it is challenging to assess the time and cost needed for different options. Crowdsourcing platforms can efficiently and rapidly assess the efficacy of such interventions, but it is unclear if web-based participants respond to simulated incentives in the same way as they would to actual incentives. Objective: The goals of this study were (1) to assess the feasibility of using crowdsourced surveys to evaluate behavioral economics interventions for patient partnerships by examining whether web-based participants responded to simulated incentives in the same way they would have responded to actual incentives, and (2) to assess the impact of 2 behavioral economics?based intervention designs, psychological rewards and loss of framing, on simulated medication reconciliation behaviors in a simulated primary care setting. Methods: We conducted a randomized controlled trial using a between-subject design on a crowdsourcing platform (Amazon Mechanical Turk) to evaluate the effectiveness of behavioral interventions designed to improve medication adherence in primary care visits. The study included a control group that represented the participants? baseline behavior and 3 simulated interventions, namely monetary compensation, a status effect as a psychological reward, and a loss frame as a modification of the status effect. Participants? willingness to bring medicines to a primary care visit was measured on a 5-point Likert scale. A reverse-coding question was included to ensure response intentionality. Results: A total of 569 study participants were recruited. There were 132 in the baseline group, 187 in the monetary compensation group, 149 in the psychological reward group, and 101 in the loss frame group. All 3 nudge interventions increased participants? willingness to bring medicines significantly when compared to the baseline scenario. The monetary compensation intervention caused an increase of 17.51% (P<.001), psychological rewards on status increased willingness by 11.85% (P<.001), and a loss frame on psychological rewards increased willingness by 24.35% (P<.001). Responses to the reverse-coding question were consistent with the willingness questions. Conclusions: In primary care, bringing medications to office visits is a frequently advocated patient partnership behavior that is nonetheless not widely adopted. Crowdsourcing platforms such as Amazon Mechanical Turk support efforts to efficiently and rapidly reach large groups of individuals to assess the efficacy of behavioral interventions. We found that crowdsourced survey-based experiments with simulated incentives can produce valid simulated behavioral responses. The use of psychological status design, particularly with a loss framing approach, can effectively enhance patient engagement in primary care. These results support the use of crowdsourcing platforms to augment and complement traditional approaches to learning about behavioral economics for patient engagement. UR - https://www.jmir.org/2023/1/e41431 UR - http://dx.doi.org/10.2196/41431 UR - http://www.ncbi.nlm.nih.gov/pubmed/37440308 ID - info:doi/10.2196/41431 ER - TY - JOUR AU - Presseller, K. Emily AU - Lampe, W. Elizabeth AU - Zhang, Fengqing AU - Gable, A. Philip AU - Guetterman, C. Timothy AU - Forman, M. Evan AU - Juarascio, S. Adrienne PY - 2023/7/6 TI - Using Wearable Passive Sensing to Predict Binge Eating in Response to Negative Affect Among Individuals With Transdiagnostic Binge Eating: Protocol for an Observational Study JO - JMIR Res Protoc SP - e47098 VL - 12 KW - affect KW - binge eating KW - heart rate KW - heart rate variability KW - electrodermal activity KW - ecological momentary assessment KW - wearable sensors KW - ecological momentary intervention N2 - Background: Binge eating (BE), characterized by eating a large amount of food accompanied by a sense of loss of control over eating, is a public health crisis. Negative affect is a well-established antecedent for BE. The affect regulation model of BE posits that elevated negative affect increases momentary risk for BE, as engaging in BE alleviates negative affect and reinforces the behavior. The eating disorder field?s capacity to identify moments of elevated negative affect, and thus BE risk, has exclusively relied on ecological momentary assessment (EMA). EMA involves the completion of surveys in real time on one?s smartphone to report behavioral, cognitive, and emotional symptoms throughout the day. Although EMA provides ecologically valid information, EMA surveys are often delivered only 5-6 times per day, involve self-report of affect intensity only, and are unable to assess affect-related physiological arousal. Wearable, psychophysiological sensors that measure markers of affect arousal including heart rate, heart rate variability, and electrodermal activity may augment EMA surveys to improve accurate real-time prediction of BE. These sensors can objectively and continuously measure biomarkers of nervous system arousal that coincide with affect, thus allowing them to measure affective trajectories on a continuous timescale, detect changes in negative affect before the individual is consciously aware of them, and reduce user burden to improve data completeness. However, it is unknown whether sensor features can distinguish between positive and negative affect states, given that physiological arousal may occur during both negative and positive affect states. Objective: The aims of this study are (1) to test the hypothesis that sensor features will distinguish positive and negative affect states in individuals with BE with >60% accuracy and (2) test the hypothesis that a machine learning algorithm using sensor data and EMA-reported negative affect to predict the occurrence of BE will predict BE with greater accuracy than an algorithm using EMA-reported negative affect alone. Methods: This study will recruit 30 individuals with BE who will wear Fitbit Sense 2 wristbands to passively measure heart rate and electrodermal activity and report affect and BE on EMA surveys for 4 weeks. Machine learning algorithms will be developed using sensor data to distinguish instances of high positive and high negative affect (aim 1) and to predict engagement in BE (aim 2). Results: This project will be funded from November 2022 to October 2024. Recruitment efforts will be conducted from January 2023 through March 2024. Data collection is anticipated to be completed in May 2024. Conclusions: This study is anticipated to provide new insight into the relationship between negative affect and BE by integrating wearable sensor data to measure affective arousal. The findings from this study may set the stage for future development of more effective digital ecological momentary interventions for BE. International Registered Report Identifier (IRRID): DERR1-10.2196/47098 UR - https://www.researchprotocols.org/2023/1/e47098 UR - http://dx.doi.org/10.2196/47098 UR - http://www.ncbi.nlm.nih.gov/pubmed/37410522 ID - info:doi/10.2196/47098 ER - TY - JOUR AU - Munns, Alice AU - Wiffen, Laura AU - Brown, Thomas AU - Fasulo, Alessandra AU - Chauhan, Milan AU - D'Cruz, Leon AU - Kaklamanou, Daphne AU - Chauhan, J. Anoop PY - 2023/7/6 TI - Capability, Opportunity, and Motivation Model for Behavior Change in People With Asthma: Protocol for a Cross-Sectional Study JO - JMIR Res Protoc SP - e44710 VL - 12 KW - adherence KW - asthma KW - behavioral barriers KW - psychological barriers KW - capability, opportunity, and motivation model of behavior change KW - COM-B KW - medication KW - theoretical domains framework N2 - Background: Asthma is a common lung condition that cannot be cured, but it can usually be effectively managed using available treatments. Despite this, it is widely acknowledged that 70% of patients do not adhere to their asthma treatment. Personalizing treatment by providing the most appropriate interventions based on the patient?s psychological or behavioral needs produces successful behavior change. However, health care providers have limited available resources to deliver a patient-centered approach for their psychological or behavioral needs, resulting in a current one-size-fits-all strategy due to the nonfeasible nature of existing surveys. The solution would be to provide health care professionals with a clinically feasible questionnaire that identifies the patient?s personal psychological and behavioral factors related to adherence. Objective: We aim to apply the capability, opportunity, and motivation model of behavior change (COM-B) questionnaire to detect a patient?s perceived psychological and behavioral barriers to adherence. Additionally, we aim to explore the key psychological and behavioral barriers indicated by the COM-B questionnaire and adherence to treatment in patients with confirmed asthma with heterogeneous severity. Exploratory objectives will include a focus on the associations between the COM-B questionnaire responses and asthma phenotype, including clinical, biological, psychosocial, and behavioral components. Methods: In a single visit, participants visiting Portsmouth Hospital?s asthma clinic with a diagnosis of asthma will be asked to complete a 20-minute questionnaire on an iPad about their psychological and behavioral barriers following the theoretical domains framework and capability, opportunity, and motivation model. Participants? data are routinely collected, including demographics, asthma characteristics, asthma control, asthma quality of life, and medication regime, which will be recorded on an electronic data capture form. Results: The study is already underway, and it is anticipated that the results will be available by early 2023. Conclusions: The COM-B asthma study will investigate an easily accessible theory-based tool (a questionnaire) for identifying psychological and behavioral barriers in patients with asthma who are not adhering to their treatment. This will provide useful information on the behavioral barriers to asthma adherence and whether or not a questionnaire can be used to identify these needs. The highlighted barriers will improve health care professionals? knowledge of this important subject, and participants will benefit from the study by removing their barriers. Overall, this will enable health care professionals to use effective individualized interventions to support improved medication adherence while also recognizing and meeting the psychological needs of patients with asthma. Trial Registration: ClinicalTrials.gov NCT05643924; https://clinicaltrials.gov/ct2/show/NCT05643924 International Registered Report Identifier (IRRID): DERR1-10.2196/44710 UR - https://www.researchprotocols.org/2023/1/e44710 UR - http://dx.doi.org/10.2196/44710 UR - http://www.ncbi.nlm.nih.gov/pubmed/37410518 ID - info:doi/10.2196/44710 ER - TY - JOUR AU - Collier, Futterman Ann AU - Hagemann, Shelby AU - Trinidad, Brown Susan AU - Vigil-Hayes, Morgan PY - 2023/6/30 TI - Human-to-Computer Interactivity Features Incorporated Into Behavioral Health mHealth Apps: Systematic Search JO - JMIR Form Res SP - e44926 VL - 7 KW - app KW - behavioral app KW - behavioral health KW - consumers KW - engagement KW - health application KW - interactivity KW - mHealth KW - stickiness KW - support KW - therapeutic KW - user engagement KW - users N2 - Background: While there are thousands of behavioral health apps available to consumers, users often quickly discontinue their use, which limits their therapeutic value. By varying the types and number of ways that users can interact with behavioral health mobile health apps, developers may be able to support greater therapeutic engagement and increase app stickiness. Objective: The main objective of this analysis was to systematically characterize the types of user interactions that are available in behavioral health apps and then examine if greater interactivity was associated with greater user satisfaction, as measured by app metrics. Methods: Using a modified PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) methodology, we searched several different app clearinghouse websites and identified 76 behavioral health apps that included some type of interactivity. We then filtered the results to ensure we were examining behavioral health apps and further refined our search to include apps that identified one or more of the following terms: peer or therapist forum, discussion, feedback, professional, licensed, buddy, friend, artificial intelligence, chatbot, counselor, therapist, provider, mentor, bot, coach, message, comment, chat room, community, games, care team, connect, share, and support in the app descriptions. In the final group of 34 apps, we examined the presence of 6 types of human-machine interactivities: human-to-human with peers, human-to-human with providers, human-to?artificial intelligence, human-to-algorithms, human-to-data, and novel interactive smartphone modalities. We also downloaded information on app user ratings and visibility, as well as reviewed other key app features. Results: We found that on average, the 34 apps reviewed included 2.53 (SD 1.05; range 1-5) features of interactivity. The most common types of interactivities were human-to-data (n=34, 100%), followed by human-to-algorithm (n=15, 44.2%). The least common type of interactivity was human?artificial intelligence (n=7, 20.5%). There were no significant associations between the total number of app interactivity features and user ratings or app visibility. We found that a full range of therapeutic interactivity features were not used in behavioral health apps. Conclusions: Ideally, app developers would do well to include more interactivity features in behavioral health apps in order to fully use the capabilities of smartphone technologies and increase app stickiness. Theoretically, increased user engagement would occur by using multiple types of user interactivity, thereby maximizing the benefits that a person would receive when using a mobile health app. UR - https://formative.jmir.org/2023/1/e44926 UR - http://dx.doi.org/10.2196/44926 UR - http://www.ncbi.nlm.nih.gov/pubmed/37389916 ID - info:doi/10.2196/44926 ER - TY - JOUR AU - Kekkonen, Markku AU - Korkiakangas, Eveliina AU - Laitinen, Jaana AU - Oinas-Kukkonen, Harri PY - 2023/6/26 TI - Factors Reducing the Use of a Persuasive mHealth App and How to Mitigate Them: Thematic Analysis JO - JMIR Hum Factors SP - e40579 VL - 10 KW - mobile phone KW - mobile health KW - mHealth KW - Persuasive Systems Design KW - behavior change KW - thematic analysis KW - microentrepreneurs KW - randomized controlled trial N2 - Background: Studies on which persuasive features may work for different users in health contexts are rare. The participants in this study were microentrepreneurs. We built a persuasive mobile app to help them to recover from work. Representatives of this target group tend to be very busy due to work, which was reflected in their use of the app during the randomized controlled trial intervention. Microentrepreneurs also often have dual roles; they are professionals in their line of work as well as entrepreneurs managing their own business, which may add to their workload. Objective: This study aimed to present users? views on the factors that hinder their use of the mobile health app that we developed and how these factors could be mitigated. Methods: We interviewed 59 users and conducted both data-driven and theory-driven analyses on the interviews. Results: Factors reducing app use could be divided into 3 categories: use context (problem domain?related issues, eg, the lack of time due to work), user context (user-related issues, eg, concurrent use of other apps), and technology context (technology-related issues, eg, bugs and usability). Due to the nature of the participants? entrepreneurship, which often interferes with personal life, it became clear that designs targeting similar target groups should avoid steep learning curves and should be easy (quick) to use. Conclusions: Personalized tunneling?guiding the user through a system via personalized solutions?could help similar target groups with similar issues better engage with and keep using health apps because of the easy learning curve. When developing health apps for interventions, background theories should not be interpreted too strictly. Applying theory in practice may require rethinking approaches for adaptation as technology has evolved rapidly and continues to evolve. Trial Registration: ClinicalTrials.gov NCT03648593; https://clinicaltrials.gov/ct2/show/NCT03648593 UR - https://humanfactors.jmir.org/2023/1/e40579 UR - http://dx.doi.org/10.2196/40579 UR - http://www.ncbi.nlm.nih.gov/pubmed/37358883 ID - info:doi/10.2196/40579 ER - TY - JOUR AU - Gordon, S. Judith AU - Armin, S. Julie AU - Giacobbi Jr, Peter AU - Hsu, Chiu-Hsieh AU - Marano, Kari AU - Sheffer, E. Christine PY - 2023/6/23 TI - Testing the Efficacy of a Scalable Telephone-Delivered Guided Imagery Tobacco Cessation Treatment: Protocol for a Randomized Clinical Trial JO - JMIR Res Protoc SP - e48898 VL - 12 KW - tobacco KW - smoking KW - treatment KW - integrative health KW - guided imagery KW - behavior change KW - telephone KW - mobile phone N2 - Background: Tobacco use continues to be a leading preventable cause of death and disease in the United States, accounting for >480,000 deaths each year. Although treatments for tobacco use are effective for many, there is substantial variability in outcomes, and these approaches are not effective for all individuals seeking to quit smoking cigarettes. New, effective therapeutic approaches are needed to meet the preferences of people who want to stop smoking. Guided imagery (GI) is a mind-body technique that involves the guided visualization of specific mental images, which is enhanced with other sensory modalities and emotions. Preliminary evidence provides initial support for the use of GI as a treatment for cigarette smoking. Meta-analyses have shown that standard treatment for cigarette smoking delivered over the telephone via quitlines is effective. A telephone-based intervention that uses GI might provide another effective treatment option and increase the reach and effectiveness of quitlines. Objective: This study aims to test the efficacy of Be Smoke Free, a telephone-delivered GI treatment for smoking cessation. Methods: This multisite randomized clinical trial (RCT) will compare a novel telephone-delivered GI tobacco cessation treatment with a standard evidence-based behavioral treatment. The study will be conducted over 5 years. In phase 1, we refined protocols and procedures for the New York State and West Virginia sites for use in the RCT. During phase 2, we will conduct an RCT with 1200 participants: 600 (50%) recruited via quitlines and 600 (50%) recruited via population-based methods. Participants will be randomly assigned to either the GI condition or the behavioral condition; both treatments will be delivered by trained study coaches located at the University of Arizona. Assessments will be conducted at baseline and 3 and 6 months after enrollment by University of Arizona research staff. The primary outcome will be self-reported 30-day point prevalence abstinence 6 months after enrollment. Secondary outcomes include biochemically verified 7-day point prevalence abstinence 6 months after enrollment. Results: Recruitment in West Virginia and New York began in October 2022. As of March 31, 2023, a total of 242 participants had been enrolled. Follow-up assessments began in November 2022. As of March 31, 2023, of the 118 eligible participants, 97 (82.2%) had completed the 3-month assessment, and 93% (26/28) of eligible participants had completed the 6-month assessment. Biochemical verification and qualitative interviews began in April 2023. Recruitment will continue through 2025 and follow-up assessments through 2026. Primary results are expected to be published in 2027. Conclusions: The Be Smoke Free study is a first-of-its-kind RCT that incorporates GI into telephone-based tobacco cessation treatment. If successful, Be Smoke Free will have substantial benefits for the long-term health of people who use tobacco across the United States. Trial Registration: ClinicalTrials.gov NCT05277831; https://clinicaltrials.gov/ct2/show/NCT05277831 International Registered Report Identifier (IRRID): PRR1-10.2196/48898 UR - https://www.researchprotocols.org/2023/1/e48898 UR - http://dx.doi.org/10.2196/48898 UR - http://www.ncbi.nlm.nih.gov/pubmed/37351932 ID - info:doi/10.2196/48898 ER - TY - JOUR AU - Bell, Lauren AU - Garnett, Claire AU - Bao, Yihan AU - Cheng, Zhaoxi AU - Qian, Tianchen AU - Perski, Olga AU - Potts, W. Henry W. AU - Williamson, Elizabeth PY - 2023/6/9 TI - How Notifications Affect Engagement With a Behavior Change App: Results From a Micro-Randomized Trial JO - JMIR Mhealth Uhealth SP - e38342 VL - 11 KW - mobile health KW - mHealth KW - digital health KW - behavior change KW - digital behavior change KW - engagement KW - micro-randomized trial KW - randomized trial KW - randomization KW - just-in-time adaptive intervention KW - adaptive intervention KW - push notification KW - notification KW - excessive alcohol consumption KW - smartphone app KW - alcohol KW - drinking KW - drinker KW - mobile phone N2 - Background: Drink Less is a behavior change app to help higher-risk drinkers in the United Kingdom reduce their alcohol consumption. The app includes a daily notification asking users to ?Please complete your drinks and mood diary,? yet we did not understand the causal effect of the notification on engagement nor how to improve this component of Drink Less. We developed a new bank of 30 new messages to increase users? reflective motivation to engage with Drink Less. This study aimed to determine how standard and new notifications affect engagement. Objective: Our objective was to estimate the causal effect of the notification on near-term engagement, to explore whether this effect changed over time, and to create an evidence base to further inform the optimization of the notification policy. Methods: We conducted a micro-randomized trial (MRT) with 2 additional parallel arms. Inclusion criteria were Drink Less users who consented to participate in the trial, self-reported a baseline Alcohol Use Disorders Identification Test score of ?8, resided in the United Kingdom, were aged ?18 years, and reported interest in drinking less alcohol. Our MRT randomized 350 new users to test whether receiving a notification, compared with receiving no notification, increased the probability of opening the app in the subsequent hour, over the first 30 days since downloading Drink Less. Each day at 8 PM, users were randomized with a 30% probability of receiving the standard message, a 30% probability of receiving a new message, or a 40% probability of receiving no message. We additionally explored time to disengagement, with the allocation of 60% of eligible users randomized to the MRT (n=350) and 40% of eligible users randomized in equal number to the 2 parallel arms, either receiving the no notification policy (n=98) or the standard notification policy (n=121). Ancillary analyses explored effect moderation by recent states of habituation and engagement. Results: Receiving a notification, compared with not receiving a notification, increased the probability of opening the app in the next hour by 3.5-fold (95% CI 2.91-4.25). Both types of messages were similarly effective. The effect of the notification did not change significantly over time. A user being in a state of already engaged lowered the new notification effect by 0.80 (95% CI 0.55-1.16), although not significantly. Across the 3 arms, time to disengagement was not significantly different. Conclusions: We found a strong near-term effect of engagement on the notification, but no overall difference in time to disengagement between users receiving the standard fixed notification, no notification at all, or the random sequence of notifications within the MRT. The strong near-term effect of the notification presents an opportunity to target notifications to increase ?in-the-moment? engagement. Further optimization is required to improve the long-term engagement. International Registered Report Identifier (IRRID): RR2-10.2196/18690 UR - https://mhealth.jmir.org/2023/1/e38342 UR - http://dx.doi.org/10.2196/38342 UR - http://www.ncbi.nlm.nih.gov/pubmed/37294612 ID - info:doi/10.2196/38342 ER - TY - JOUR AU - Norman-Nott, Nell AU - Hesam-Shariati, Negin AU - Wilks, R. Chelsey AU - Schroeder, Jessica AU - Suh, Jina AU - Briggs, E. Nancy AU - McAuley, H. James AU - Quidé, Yann AU - Gustin, M. Sylvia PY - 2023/6/7 TI - Internet-Delivered Dialectical Behavioral Therapy Skills Training for Chronic Pain: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e41890 VL - 12 KW - internet-delivered KW - dialectical behavioral therapy KW - chronic pain KW - emotion dysregulation KW - emotion-centric intervention KW - mobile phone N2 - Background: Emotion dysregulation is key to the development and maintenance of chronic pain, feeding into a cycle of worsening pain and disability. Dialectical behavioral therapy (DBT), an evidence-based treatment for complex transdiagnostic conditions presenting with high emotion dysregulation, may be beneficial to manage and mitigate the emotional and sensory aspects of chronic pain. Increasingly, DBT skills training as a key component of standard DBT is being delivered as a stand-alone intervention without concurrent therapy to help develop skills for effective emotion regulation. A previous repeated-measure single-case trial investigating a novel technologically driven DBT skills training, internet-delivered DBT skills training for chronic pain (iDBT-Pain), revealed promising findings to improve both emotion dysregulation and pain intensity. Objective: This randomized controlled trial aims to examine the efficacy of iDBT-Pain in comparison with treatment as usual to reduce emotion dysregulation (primary outcome) for individuals with chronic pain after 9 weeks and at the 21-week follow-up. The secondary outcomes include pain intensity, pain interference, anxiety symptoms, depressive symptoms, perceived stress, posttraumatic stress, harm avoidance, social cognition, sleep quality, life satisfaction, and well-being. The trial also examines the acceptability of the iDBT-Pain intervention for future development and testing. Methods: A total of 48 people with chronic pain will be randomly assigned to 1 of 2 conditions: treatment and treatment as usual. Participants in the treatment condition will receive iDBT-Pain, consisting of 6 live web-based group sessions led by a DBT skills trainer and supervised by a registered psychologist and the iDBT-Pain app. Participants in the treatment-as-usual condition will not receive iDBT-Pain but will still access their usual medication and health interventions. We predict that iDBT-Pain will improve the primary outcome of emotion dysregulation and the secondary outcomes of pain intensity, pain interference, anxiety symptoms, depressive symptoms, perceived stress, harm avoidance, social cognition, sleep quality, life satisfaction, and well-being. A linear mixed model with random effects of individuals will be conducted to investigate the differences between the baseline, 9-week (primary end point), and 21-week (follow-up) assessments as a function of experimental condition. Results: Recruitment started in February 2023, and the clinical trial started in March 2023. Data collection for the final assessment is planned to be completed by July 2024. Conclusions: If our hypothesis is confirmed, our findings will contribute to the evidence for the efficacy and acceptability of a viable intervention that may be used by health care professionals for people with chronic pain. The results will add to the chronic pain literature to inform about the potential benefits of DBT skills training for chronic pain and will contribute evidence about technologically driven interventions. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12622000113752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383208&isReview=true International Registered Report Identifier (IRRID): PRR1-10.2196/41890 UR - https://www.researchprotocols.org/2023/1/e41890 UR - http://dx.doi.org/10.2196/41890 UR - http://www.ncbi.nlm.nih.gov/pubmed/37285187 ID - info:doi/10.2196/41890 ER - TY - JOUR AU - Jackson, M. Hayley AU - Calear, L. Alison AU - Batterham, J. Philip AU - Ohan, L. Jeneva AU - Farmer, M. Glenda AU - Farrer, M. Louise PY - 2023/5/31 TI - Skill Enactment and Knowledge Acquisition in Digital Cognitive Behavioral Therapy for Depression and Anxiety: Systematic Review of Randomized Controlled Trials JO - J Med Internet Res SP - e44673 VL - 25 KW - cognitive behavioral therapy KW - technology KW - engagement KW - skill enactment KW - knowledge acquisition KW - depression KW - anxiety KW - adults KW - young people KW - systematic review KW - mobile phone N2 - Background: Digital cognitive behavioral therapy (CBT) interventions can effectively prevent and treat depression and anxiety, but engagement with these programs is often low. Although extensive research has evaluated program use as a proxy for engagement, the extent to which users acquire knowledge and enact skills from these programs has been largely overlooked. Objective: This study aimed to investigate how skill enactment and knowledge acquisition have been measured, evaluate postintervention changes in skill enactment and knowledge acquisition, examine whether mental health outcomes are associated with skill enactment or knowledge acquisition, and evaluate predictors of skill enactment and knowledge acquisition. Methods: PubMed, PsycINFO, and Cochrane CENTRAL were searched for randomized controlled trials (RCTs) published between January 2000 and July 2022. We included RCTs comparing digital CBT with any comparison group in adolescents or adults (aged ?12 years) for anxiety or depression. Eligible studies reported quantitative measures of skill enactment or knowledge acquisition. The methodological quality of the studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for RCTs. Narrative synthesis was used to address the review questions. Results: In total, 43 papers were included, of which 29 (67%) reported a skill enactment measure and 15 (35%) reported a knowledge acquisition measure. Skill enactment was typically operationalized as the frequency of enacting skills using the completion of in-program activities (ie, formal skill enactment; 13/29, 45%) and intervention-specific (9/29, 31%) or standardized (8/29, 28%) questionnaires. Knowledge measures included tests of CBT knowledge (6/15, 40%) or mental health literacy (5/15, 33%) and self-report questionnaires (6/15, 40%). In total, 17 studies evaluated postintervention changes in skill enactment or knowledge acquisition, and findings were mostly significant for skill enactment (6/8, 75% of the studies), CBT knowledge (6/6, 100%), and mental health literacy (4/5, 80%). Of the 12 studies that evaluated the association between skill enactment and postintervention mental health outcomes, most reported ?1 significant positive finding on standardized questionnaires (4/4, 100%), formal skill enactment indicators (5/7, 71%), or intervention-specific questionnaires (1/1, 100%). None of the 4 studies that evaluated the association between knowledge acquisition and primary mental health outcomes reported significant results. A total of 13 studies investigated predictors of skill enactment; only type of guidance and improvements in psychological variables were associated with increased skill enactment in ?2 analyses. Predictors of knowledge acquisition were evaluated in 2 studies. Conclusions: Digital CBT for depression and anxiety can improve skill enactment and knowledge acquisition. However, only skill enactment appears to be associated with mental health outcomes, which may depend on the type of measure examined. Additional research is needed to understand what types and levels of skill enactment and knowledge acquisition are most relevant for outcomes and identify predictors of these constructs. Trial Registration: PROSPERO CRD42021275270; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=275270 UR - https://www.jmir.org/2023/1/e44673 UR - http://dx.doi.org/10.2196/44673 UR - http://www.ncbi.nlm.nih.gov/pubmed/37256673 ID - info:doi/10.2196/44673 ER - TY - JOUR AU - Alber, Sophie Carolin AU - Krämer, Violetta Lena AU - Rosar, Marie Sophia AU - Mueller-Weinitschke, Claudia PY - 2023/5/25 TI - Internet-Based Behavioral Activation for Depression: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e41643 VL - 25 KW - behavioral activation KW - depression KW - systematic review KW - meta-analysis KW - internet- and mobile-based intervention N2 - Background: Behavioral activation is an effective treatment for reducing depression. As depressive disorders affect many people worldwide, internet-based behavioral activation (iBA) could provide enhanced treatment access. Objective: This study aimed to investigate whether iBA is effective in reducing depressive symptoms and to assess the impact on secondary outcomes. Methods: We systematically searched MEDLINE, PsycINFO, PSYNDEX, and CENTRAL up to December 2021 for eligible randomized controlled trials. In addition, a reference search was conducted. Title and abstract screening, as well as a full-text screening, was conducted by 2 independent reviewers. Randomized controlled trials that investigated the effectiveness of iBA for depression as a treatment or main component were included. Randomized controlled trials had to report depressive symptoms, with a quantitative outcome measure and assess an adult population with depressive symptoms above cutoff. Two independent reviewers performed the data extraction and risk of bias assessment. Data were pooled in random-effects meta-analyses. The primary outcome was self-reported depressive symptoms posttreatment. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Results: A total of 12 randomized controlled trials, with 3274 participants (88% female, 43.61 years) were included. iBA was more effective in reducing depressive symptom severity posttreatment than inactive control groups (standardized mean difference ?0.49; 95% CI ?0.63 to ?0.34; P<.001). The overall level of heterogeneity was moderate to substantial (I2=53%). No significant effect of iBA on depressive symptoms could be found at 6-month follow-up. Participants assigned to iBA also experienced a significant reduction of anxiety and a significant increase in quality of life and activation compared to the inactive control groups. The results remained robust in multiple sensitivity analyses. The risk of bias assessment revealed at least some concerns for all studies, and there was evidence of slight publication bias. Conclusions: This systematic review and meta-analysis implies that iBA is effective in reducing depressive symptoms. It represents a promising treatment option, providing treatment access where no treatment is available yet. Trial Registration: International Prospective Register of Systematic Reviews CRD42021236822; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=236822 UR - https://www.jmir.org/2023/1/e41643 UR - http://dx.doi.org/10.2196/41643 UR - http://www.ncbi.nlm.nih.gov/pubmed/37227760 ID - info:doi/10.2196/41643 ER - TY - JOUR AU - Giovanelli, Alison AU - Rowe, Jonathan AU - Taylor, Madelynn AU - Berna, Mark AU - Tebb, P. Kathleen AU - Penilla, Carlos AU - Pugatch, Marianne AU - Lester, James AU - Ozer, M. Elizabeth PY - 2023/5/24 TI - Supporting Adolescent Engagement with Artificial Intelligence?Driven Digital Health Behavior Change Interventions JO - J Med Internet Res SP - e40306 VL - 25 KW - digital health behavior change KW - adolescent KW - adolescence KW - behavior change KW - BCT KW - behavioral intervention KW - artificial intelligence KW - machine learning KW - model KW - AI ethics KW - trace log data KW - ethics KW - ethical KW - youth KW - risky behavior KW - engagement KW - privacy KW - security KW - optimization KW - operationalization UR - https://www.jmir.org/2023/1/e40306 UR - http://dx.doi.org/10.2196/40306 UR - http://www.ncbi.nlm.nih.gov/pubmed/37223987 ID - info:doi/10.2196/40306 ER - TY - JOUR AU - Portz, Dickman Jennifer AU - Schmid, Arlene AU - Fruhauf, Christine AU - Fox, Aimee AU - Van Puymbroeck, Marieke AU - Sharp, Julia AU - Leach, Heather PY - 2023/5/24 TI - Acceptability of Online Yoga Among Individuals With Chronic Conditions and Their Caregivers: Qualitative Study JO - JMIR Form Res SP - e39158 VL - 7 KW - yoga KW - meditative movement KW - online KW - chronic conditions KW - self-management KW - caregiver KW - dyads KW - meditation KW - participation KW - perspective KW - intervention N2 - Background: The online delivery of yoga interventions rapidly expanded during the COVID-19 pandemic, and preliminary studies indicate that online yoga is feasible across multiple chronic conditions. However, few yoga studies provide synchronous online yoga sessions and rarely target the caregiving dyad. Online chronic disease management interventions have been evaluated across conditions, life spans, and diverse samples. However, the perceived acceptability of online yoga, including self-reported satisfaction and online delivery preferences, is underexplored among individuals with chronic conditions and their caregivers. Understanding user preferences is essential for successful and safe online yoga implementation. Objective: We aimed to qualitatively examine the perceived acceptability of online yoga among individuals with chronic conditions and their caregivers who participated in an online dyadic intervention that merged yoga and self-management education to develop skills (MY-Skills) to manage persistent pain. Methods: We conducted a qualitative study among 9 dyads (>18 years of age; individuals experiencing persistent moderate pain) who participated in MY-Skills online during the COVID-19 pandemic. The intervention consisted of 16 online, synchronous yoga sessions over 8 weeks for both dyad members. After the completion of the intervention, participants (N=18) participated in semistructured telephone interviews for around 20 minutes, discussing their preferences, challenges, and recommendations for improved online delivery. Interviews were analyzed by using a rapid analytic approach. Results: MY-Skills participants were, on average, aged 62.7 (SD 19) years; were primarily women; were primarily White; and had a mean of 5.5 (SD 3) chronic conditions. Both participants and caregivers reported moderate pain severity scores (mean 6.02, SD 1.3) on the Brief Pain Inventory. The following three themes were identified related to online delivery: (1) participants indicated a preference for the intervention to be in person rather than online because they were distracted in the home setting, because they felt that in-person yoga would be more engaging, because the yoga therapist could physically correct positions, and because of safety concerns (eg, fear of falling); (2) participants indicated good acceptability of online MY-Skills delivery due to convenience, access, and comfort with being in their home; and (3) recommendations for improving online delivery highlighted a need for additional and accessible technical support. Conclusions: Both individuals with chronic conditions and their caregivers find online yoga to be an acceptable intervention. Participants who preferred in-person yoga did so due to distractions in the home and group dynamics. Some participants preferred in-person corrections to ensure correct positioning, while others felt safe with verbal modifications in their homes. Convenience and access were the primary reasons for preferring online delivery. To improve online delivery, future yoga studies should include specific activities for fostering group engagement, enhancing safety protocols, and increasing technical support. Trial Registration: ClinicalTrials.gov NCT03440320; https://clinicaltrials.gov/ct2/show/NCT03440320 UR - https://formative.jmir.org/2023/1/e39158 UR - http://dx.doi.org/10.2196/39158 UR - http://www.ncbi.nlm.nih.gov/pubmed/37223971 ID - info:doi/10.2196/39158 ER - TY - JOUR AU - Seon, Quinta AU - Mady, Noor AU - Yang, Michelle AU - Karia, Maharshee AU - Lashley, Myrna AU - Sescu, Claudia AU - Lalonde, Maud AU - Puskas, Stephen AU - Outerbridge, Joy AU - Parent-Racine, Echo AU - Pagiatakis, Catherine AU - Gomez-Cardona, Liliana AU - Jiang, Di AU - Bouchard, Stéphane AU - Linnaranta, Outi PY - 2023/5/24 TI - A Virtual Reality?Assisted Cognitive Behavioral Therapy for and With Inuit in Québec: Protocol for a Proof-of-Concept Randomized Controlled Trial JO - JMIR Res Protoc SP - e40236 VL - 12 KW - Inuit health KW - randomized controlled trial KW - emotion regulation KW - virtual reality KW - cognitive behavioral therapy KW - co-design KW - biofeedback KW - cultural adaptation KW - Indigenous N2 - Background: Emotion regulation is an ability related to psychological well-being; when dysregulated, individuals may have psychiatric symptoms and maladapted physiological responses. Virtual reality?assisted cognitive behavioral therapy (VR-CBT) is an effective psychotherapy to target and strengthen emotion regulation; however, it currently lacks cultural sensitivity and can be improved by adapting it to the cultural context of service users. During previous participatory research, we co-designed a culturally adapted cognitive behavioral therapy (CBT) manual and 2 virtual reality (VR) environments to function as a complement to therapy (VR-CBT) for Inuit who would like to access psychotherapy. Emotion regulation skill building will occur in virtual environments that have interactive components such as heart rate biofeedback. Objective: We describe a protocol for a proof-of-concept 2-arm randomized controlled trial (RCT) with Inuit (n=40) in Québec. The primary aims of this research are to investigate the feasibility, benefits, and challenges of the culturally adapted VR-CBT intervention versus an established VR self-management that is available commercially. We will also investigate self-rated mental well-being and objective psychophysiological measures. Finally, we will use proof-of-concept data to identify suitable primary outcome measures, conduct power calculations in a larger trial for efficacy, and collect information about preferences for on-site or at-home treatment. Methods: Trial participants will be randomly assigned to an active condition or active control condition in a 1:1 ratio. Inuit aged 14 to 60 years will receive a culturally adapted and therapist-guided VR-CBT with biofeedback or a VR relaxation program with nonpersonalized guided components over a 10-week period. We will collect pre- and posttreatment measures of emotion regulation and biweekly assessments over the treatment and at 3-month follow-up. The primary outcome will be measured by the Difficulties in Emotion Regulation Scale (DERS-16) and a novel psychophysiological reactivity paradigm. Secondary measures include psychological symptoms and well-being via rating scales (eg, anxiety or depressive symptoms). Results: As this is the prospective registration of an RCT protocol, we do not yet report any results from the trial. Funding was confirmed in January 2020, and recruitment is expected to start in March 2023 and is set to finish in August 2025. The expected results are to be published in spring 2026. Conclusions: The proposed study responds to the community?s desire for accessible and appropriate resources for psychological well-being, as it was developed in active collaboration with the Inuit community in Québec. We will test feasibility and acceptance by comparing a culturally adapted, on-site psychotherapy with a commercial self-management program while incorporating novel technology and measurement in the area of Indigenous health. We also aim to fulfill the needs for RCT evidence of culturally adapted psychotherapies that are lacking in Canada. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 21831510; https://www.isrctn.com/ISRCTN21831510 International Registered Report Identifier (IRRID): PRR1-10.2196/40236 UR - https://www.researchprotocols.org/2023/1/e40236 UR - http://dx.doi.org/10.2196/40236 UR - http://www.ncbi.nlm.nih.gov/pubmed/37223973 ID - info:doi/10.2196/40236 ER - TY - JOUR AU - Veldheer, Susan AU - Whitehead-Zimmers, Maxfield AU - Bordner, Candace AU - Watt, Benjamin AU - Conroy, E. David AU - Schmitz, H. Kathryn AU - Sciamanna, Christopher PY - 2023/5/2 TI - Participant Preferences for the Development of a Digitally Delivered Gardening Intervention to Improve Diet, Physical Activity, and Cardiovascular Health: Cross-sectional Study JO - JMIR Form Res SP - e41498 VL - 7 KW - intervention development KW - cardiovascular health KW - gardening KW - diet KW - physical activity KW - behavior change wheel N2 - Background: Low dietary intake of fruits and vegetables and physical inactivity are 2 modifiable risk factors for cardiovascular disease. Fruit and vegetable gardening can provide access to fresh produce, and many gardening activities are considered moderate physical activity. This makes gardening interventions a potential strategy for cardiovascular disease risk reduction. Previously developed gardening interventions have relied on in-person delivery models, which limit scalability and reach. Objective: The purpose of this study was to ascertain participant insight on intervention components and topics of interest to inform a digitally delivered, gardening-focused, multiple health behavior change intervention. Methods: A web-based survey was delivered via Amazon Mechanical Turk (MTurk), including quantitative and open-ended questions. Eligible participants were aged ?20 years, could read and write in English, were US residents, and had at least a 98% MTurk task approval rating. A multilevel screening process was used to identify and exclude respondents with response inattention, poor language fluency, or suspected automated web robots (bots). Participants were asked about their interest in gardening programming, their preferences for intervention delivery modalities (1-hour expert lectures, a series of brief <5-minute videos, or in-person meetings), and what information is needed to teach new gardeners. Comparisons were made between never gardeners (NG) and ever gardeners (EG) in order to examine differences in perceptions based on prior experience. Quantitative data were summarized, and differences between groups were tested using chi-square tests. Qualitative data were coded and organized into intervention functions based on the Behavior Change Wheel. Results: A total of 465 participants were included (n=212, 45.6% NG and n=253, 54.4% EG). There was a high level of program interest overall (n=355, 76.3%), though interest was higher in EG (142/212, 67% NG; 213/253, 84.2% EG; P<.001). The majority of participants (n=282, 60.7%) preferred a series of brief <5-minute videos (136/212, 64.2% NG; 146/253, 57.7% EG; P=.16) over 1-hour lectures (29/212, 13.7% NG; 50/253, 19.8% EG; P=.08) or in-person delivery modes (47/212, 22.2% NG; 57/253, 22.5% EG; P=.93). Intervention functions identified were education and training (performing fundamental gardening and cooking activities), environmental restructuring (eg, social support), enablement (provision of tools or seeds), persuasion (offering encouragement and highlighting the benefits of gardening), and modeling (using content experts and participant testimonials). Content areas identified included the full lifecycle of gardening activities, from the fundamentals of preparing a garden site, planting and maintenance to harvesting and cooking. Conclusions: In a sample of potential web-based learners, participants were interested in a digitally delivered gardening program. They preferred brief videos for content delivery and suggested content topics that encompassed how to garden from planting to harvesting and cooking. The next step in this line of work is to identify target behavior change techniques and pilot test the intervention to assess participant acceptability and preliminary efficacy. UR - https://formative.jmir.org/2023/1/e41498 UR - http://dx.doi.org/10.2196/41498 UR - http://www.ncbi.nlm.nih.gov/pubmed/37129952 ID - info:doi/10.2196/41498 ER - TY - JOUR AU - Melisse, Bernou AU - Berg, den Elske van AU - Jonge, de Margo AU - Blankers, Matthijs AU - Furth, van Eric AU - Dekker, Jack AU - Beurs, de Edwin PY - 2023/5/1 TI - Efficacy of Web-Based, Guided Self-help Cognitive Behavioral Therapy?Enhanced for Binge Eating Disorder: Randomized Controlled Trial JO - J Med Internet Res SP - e40472 VL - 25 KW - randomized controlled trial KW - RCT KW - binge eating disorder KW - BED KW - guided self-help KW - cognitive behavioral therapy?enhanced KW - CBT-E N2 - Background: Owing to the gap between treatment supply and demand, there are long waiting periods for patients with binge eating disorder, and there is an urgent need to increase their access to specialized treatment. Guided self-help cognitive behavioral therapy?enhanced (CBT-E) may have great advantages for patients if its efficacy can be established. Objective: The aim of this study was to examine the efficacy of guided self-help CBT-E compared with that of a delayed-treatment control condition. Methods: A single-blind 2-arm randomized controlled trial was designed to evaluate guided self-help CBT-E according to an intention-to-treat analysis. A total of 180 patients were randomly assigned to guided self-help CBT-E (n=90, 50%) or the delayed-treatment control condition (n=90, 50%) for which guided self-help CBT-E was provided after the initial 12-week delay. The primary outcome was reduction in binges. The secondary outcome was full recovery at the end of treatment, as measured using the Eating Disorder Examination during the last 4 weeks of treatment. A linear mixed model analysis was performed to compare treatment outcomes at the end of treatment. A second linear mixed model analysis was performed to measure between- and within-group effects for up to 24 weeks of follow-up. The Eating Disorder Examination?Questionnaire and clinical impairment assessment were conducted before and after treatment and during follow-up. In addition, dropout rates were assessed in both conditions. Results: During the last 4 weeks of treatment, objective binges reduced from an average of 19 (SD 16) to 3 (SD 5) binges, and 40% (36/90) showed full recovery in the guided self-help CBT-E group. Between-group effect size (Cohen d) was 1.0 for objective binges. At follow-up, after both groups received treatment, there was no longer a difference between the groups. Of the 180 participants, 142 (78.9%) completed treatment. The overall treatment dropout appeared to be associated with gender, level of education, and number of objective binges at baseline but not with treatment condition. Conclusions: This is the first study to investigate the efficacy of guided self-help CBT-E. Guided self-help CBT-E appeared to be an efficacious treatment. This study?s findings underscore the international guidelines recommending this type of treatment for binge eating disorder. Trial Registration: Netherlands Trial Registry (NTR) NL7994; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7994 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-020-02604-1 UR - https://www.jmir.org/2023/1/e40472 UR - http://dx.doi.org/10.2196/40472 UR - http://www.ncbi.nlm.nih.gov/pubmed/37126386 ID - info:doi/10.2196/40472 ER - TY - JOUR AU - Alshagrawi, Salah AU - Abidi, Taha Syed PY - 2023/4/27 TI - Efficacy of an mHealth Behavior Change Intervention for Promoting Physical Activity in the Workplace: Randomized Controlled Trial JO - J Med Internet Res SP - e44108 VL - 25 KW - text messaging KW - mobile phones KW - physical activity KW - eHealth KW - pedometer KW - smartphone KW - activity tracker KW - accelerometer KW - behavioral KW - workplace KW - risk factor KW - noncommunicable disease KW - BMI KW - wellness N2 - Background: Insufficient physical activity (PA) is a well-established risk factor for several noncommunicable diseases such as cardiovascular diseases, cancer, diabetes, depression, and dementia. The World Health Organization (WHO) advises that individuals engage in 150 minutes of moderate PA per week or 75 minutes of intense PA per week. According to the WHO?s latest report, 23% of adults fail to meet the minimum recommended level of PA. The percentage was even higher in a recent global study that showed 27% of adults were insufficiently active and reported a 5% increase in the prevalence trend of insufficient PA between 2001 and 2016. The study also showed the rate of insufficient PA among countries varied significantly. For instance, it was estimated that 40% were insufficiently active in the United States, and the percentage was even higher in Saudi Arabia (more than 50%). Governments are actively developing policies and methods to successfully establish a PA-inducing environment that encourages a healthy lifestyle in order to address the global steady decline in PA. Objective: The purpose of this study was to determine the effectiveness of mobile health (mHealth) interventions, particularly SMS text messaging interventions, to improve PA and decrease BMI in healthy adults in the workplace. Methods: In this parallel, 2-arm randomized controlled trial, healthy adults (N=327) were randomized to receive an mHealth intervention (tailored text messages combined with self-monitoring (intervention; n=166) or no intervention (control; n=161). Adults who were fully employed in an academic institution and had limited PA during working hours were recruited for the study. Outcomes, such as PA and BMI, were assessed at baseline and 3 months later. Results: Results showed significant improvement in PA levels (weekly step counts) in the intervention group (?=1097, 95% CI 922-1272, P<.001). There was also a significant reduction in BMI (?=0.60, 95% CI 0.50-0.69, P<.001). Conclusions: Combining tailored text messages and self-monitoring interventions to improve PA and lower BMI was significantly effective and has the potential to leverage current methods to improve wellness among the public. UR - https://www.jmir.org/2023/1/e44108 UR - http://dx.doi.org/10.2196/44108 UR - http://www.ncbi.nlm.nih.gov/pubmed/37103981 ID - info:doi/10.2196/44108 ER - TY - JOUR AU - Lin, Haoxiang AU - Wang, Ying AU - Xing, Yanling AU - Han, Yinglian AU - Zhang, Chengqian AU - Luo, Ting AU - Chang, Chun PY - 2023/4/26 TI - A Personalized Mobile Cessation Intervention to Promote Smokers From the Preparation Stage to the Action Stage: Double-blind Randomized Controlled Trial JO - J Med Internet Res SP - e41911 VL - 25 KW - smoking cessation KW - mobile health KW - health education KW - smoking KW - behavior intervention KW - behavior change KW - support KW - text message KW - personalized KW - smoking abstinence KW - health behavior KW - health promotion N2 - Background: Most mobile cessation studies have found that such interventions have a higher quitting rate than interventions providing minimal smoking cessation support. However, why such interventions are effective has been almost unstudied by researchers. Objective: This paper describes the principles of the personalized mobile cessation intervention-based WeChat app and used generalized estimated equations to assess why a personalized mobile cessation intervention was more likely to promote smokers from the preparation stage to the action stage than a nonpersonalized intervention. Methods: This is a 2-arm, double-blind, randomized controlled trial in five cities in China. The intervention group received a personalized mobile cessation intervention. The control group received a nonpersonalized SMS text message smoking cessation intervention. All information was sent by the WeChat app. The outcomes were the change in protection motivation theory construct scores and the change in transtheoretical model stages. Results: A total of 722 participants were randomly assigned to the intervention or control group. Compared with those who received the nonpersonalized SMS text message intervention, smokers who received the personalized intervention presented lower intrinsic rewards, extrinsic rewards, and response costs. Intrinsic rewards were determinants of stage change, thus explaining why the intervention group was more likely to promote smokers from the preparation stage to the action stage (odds ratio 2.65, 95% CI 1.41-4.98). Conclusions: This study identified the psychological determinants at different stages to facilitate smokers moving forward to the next stage of quitting behavior and provides a framework to explore why a smoking cessation intervention is effective. Trial Registration: Chinese Clinical Trial Registry ChiCTR2100041942; https://tinyurl.com/2hhx4m7f UR - https://www.jmir.org/2023/1/e41911 UR - http://dx.doi.org/10.2196/41911 UR - http://www.ncbi.nlm.nih.gov/pubmed/37099360 ID - info:doi/10.2196/41911 ER - TY - JOUR AU - Sevic, Aleksandra AU - Hashemi, S. Neda AU - Thørrisen, Magnus Mikkel AU - Strømstad, Kine AU - Skarpaas, Skeie Lisebet AU - Storm, Marianne AU - Brønnick, Kallesten Kolbjørn PY - 2023/4/20 TI - Effectiveness of eHealth Interventions Targeting Employee Health Behaviors: Systematic Review JO - J Med Internet Res SP - e38307 VL - 25 KW - eHealth KW - employees KW - workplace KW - health behaviors KW - sickness absence KW - behavior change techniques KW - systematic review KW - mobile phone N2 - Background: The number of people with noncommunicable diseases is increasing. Noncommunicable diseases are the major cause of disability and premature mortality worldwide, associated with negative workplace outcomes such as sickness absence and reduced work productivity. There is a need to identify scalable interventions and their active components to relieve disease and treatment burden and facilitate work participation. eHealth interventions have shown potential in clinical and general populations to increase well-being and physical activity and could be well suited for workplace settings. Objective: We aimed to provide an overview of the effectiveness of eHealth interventions at the workplace targeting employee health behaviors and map behavior change techniques (BCTs) used in these interventions. Methods: A systematic literature search was performed in PubMed, Embase, PsycINFO, Cochrane CENTRAL, and CINAHL in September 2020 and updated in September 2021. Extracted data included participant characteristics, setting, eHealth intervention type, mode of delivery, reported outcomes, effect sizes, and attrition rates. Quality and risk of bias of the included studies were assessed using the Cochrane Collaboration risk-of-bias 2 tool. BCTs were mapped in accordance with the BCT Taxonomy v1. The review was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Results: In total, 17 randomized controlled trials met the inclusion criteria. The measured outcomes, treatment and follow-up periods, content of eHealth interventions, and workplace contexts had high heterogeneity. Of the 17 studies, 4 (24%) reported unequivocally significant findings for all primary outcomes, with effect sizes ranging from small to large. Furthermore, 53% (9/17) of the studies reported mixed results, and 24% (4/17) reported nonsignificant results. The most frequently targeted behavior was physical activity (15/17, 88% of the studies); the least frequently targeted behavior was smoking (2/17, 12% of the studies). Attrition varied greatly across the studies (0%-37%). Risk of bias was high in 65% (11/17) of the studies, with some concerns in the remaining 35% (6/17). Interventions used various BCTs, and the most frequently used were feedback and monitoring (14/17, 82%), goals and planning (10/17, 59%), antecedents (10/17, 59%), and social support (7/17, 41%). Conclusions: This review suggests that, although eHealth interventions may have potential, there are still unanswered questions regarding their effectiveness and what drives the mechanism behind these effects. Low methodological quality, high heterogeneity and complexity, the characteristics of the included samples, and often high attrition rates challenge the investigation of the effectiveness and the making of sound inferences about the effect sizes and significance of the results. To address this, new studies and methods are needed. A megastudy design in which different interventions are evaluated in the same population over the same period on the same outcomes may solve some of the challenges. Trial Registration: PROSPERO CRD42020202777; https://www-crd-york-ac-uk/prospero/display_record.php?RecordID=202777 UR - https://www.jmir.org/2023/1/e38307 UR - http://dx.doi.org/10.2196/38307 UR - http://www.ncbi.nlm.nih.gov/pubmed/37079369 ID - info:doi/10.2196/38307 ER - TY - JOUR AU - Musgrave, Loretta AU - Cheney, Kate AU - Dorney, Edwina AU - Homer, E. Caroline S. AU - Gordon, Adrienne PY - 2023/4/19 TI - Addressing Preconception Behavior Change Through Mobile Phone Apps: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e41900 VL - 25 KW - apps KW - mobile KW - preconception KW - prenatal care KW - perinatal KW - reproductive health KW - reproductive age KW - maternal KW - interconception KW - behavior change KW - mobile phone N2 - Background: Positive health behavior changes before pregnancy can optimize perinatal outcomes for mothers, babies, and future generations. Women are often motivated to positively change their behavior in preparation for pregnancy to enhance their health and well-being. Mobile phone apps may provide an opportunity to deliver public health interventions during the preconception period. Objective: This review aimed to synthesize the evidence of the effectiveness of mobile phone apps in promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods), which may improve future outcomes for mothers and babies. Methods: Five databases were searched in February 2022 for studies exploring mobile phone apps as a prepregnancy intervention to promote positive behavior change. The identified studies were retrieved and exported to EndNote (Thomson Reuters). Using Covidence (Veritas Health Innovation), a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study flow diagram was generated to map the number of records identified, included, and excluded. Three independent reviewers assessed the risk of bias and conducted data extraction using the Review Manager software (version 5.4, The Cochrane Collaboration), and the data were then pooled using a random-effects model. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess the certainty of the evidence. Results: Of the 2973 publications identified, 7 (0.24%) were included. The total number of participants across the 7 trials was 3161. Of the 7 studies, 4 (57%) included participants in the interconception period, and 3 (43%) included women in the preconception period. Of the 7 studies, 5 (71%) studies focused on weight reduction, assessing the outcomes of reductions in adiposity and weight. Of the 7 studies, nutrition and dietary outcomes were evaluated in 2 (29%) studies, blood pressure outcomes were compared in 4 (57%) studies, and biochemical and marker outcomes associated with managing disease symptoms were included in 4 (57%) studies. Analysis showed that there were no statistically significant differences in energy intake; weight loss; body fat; and biomarkers such as glycated hemoglobin, total cholesterol, fasting lipid profiles, or blood pressure when compared with standard care. Conclusions: Owing to the limited number of studies and low certainty of the evidence, no firm conclusions can be drawn on the effects of mobile phone app interventions on promoting positive behavior changes in women of reproductive age before they are pregnant (preconception and interconception periods). Trial Registration: PROSPERO CRD42017065903; https://tinyurl.com/2p9dwk4a International Registered Report Identifier (IRRID): RR2-10.1186/s13643-019-0996-6 UR - https://www.jmir.org/2023/1/e41900 UR - http://dx.doi.org/10.2196/41900 UR - http://www.ncbi.nlm.nih.gov/pubmed/37074767 ID - info:doi/10.2196/41900 ER - TY - JOUR AU - Chew, Jocelyn Han Shi AU - Rajasegaran, Nicole Nagadarshini AU - Chin, Han Yip AU - Chew, Nicholas W. S. AU - Kim, Mi Kyung PY - 2023/4/18 TI - Effectiveness of Combined Health Coaching and Self-Monitoring Apps on Weight-Related Outcomes in People With Overweight and Obesity: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e42432 VL - 25 KW - apps KW - BMI KW - cardiometabolic KW - database KW - diet behaviour KW - health coaching KW - monitoring KW - obesity KW - physical activity KW - waist circumference KW - weight loss KW - weight N2 - Background: Self-monitoring smartphone apps and health coaching have both individually been shown to improve weight-related outcomes, but their combined effects remain unclear. Objective: This study aims to examine the effectiveness of combining self-monitoring apps with health coaching on anthropometric, cardiometabolic, and lifestyle outcomes in people with overweight and obesity. Methods: Relevant articles published from inception till June 9, 2022, were searched through 8 databases (Embase, CINAHL, PubMed, PsycINFO, Scopus, The Cochrane Library, and Web of Science). Effect sizes were pooled using random-effects models. Behavioral strategies used were coded using the behavior change techniques taxonomy V1. Results: A total of 14 articles were included, representing 2478 participants with a mean age of 39.1 years and a BMI of 31.8 kg/m2. Using combined intervention significantly improved weight loss by 2.15 kg (95% CI ?3.17 kg to ?1.12 kg; P<.001; I2=60.3%), waist circumference by 2.48 cm (95% CI ?3.51 cm to ?1.44 cm; P<.001; I2=29%), triglyceride by 0.22 mg/dL (95% CI ?0.33 mg/dL to 0.11 mg/dL; P=.008; I2=0%), glycated hemoglobin by 0.12% (95% CI ?0.21 to ?0.02; P=.03; I2=0%), and total calorie consumption per day by 128.30 kcal (95% CI ?182.67 kcal to ?73.94 kcal; P=.003; I2=0%) kcal, but not BMI, blood pressure, body fat percentage, cholesterol, and physical activity. Combined interventional effectiveness was superior to receiving usual care and apps for waist circumference but only superior to usual care for weight loss. Conclusions: Combined intervention could improve weight-related outcomes, but more research is needed to examine its added benefits to using an app. Trial Registration: PROSPERO CRD42022345133; https://tinyurl.com/2zxfdpay UR - https://www.jmir.org/2023/1/e42432 UR - http://dx.doi.org/10.2196/42432 UR - http://www.ncbi.nlm.nih.gov/pubmed/37071452 ID - info:doi/10.2196/42432 ER - TY - JOUR AU - Peynenburg, Vanessa AU - Sapkota, P. Ram AU - Lozinski, Tristen AU - Sundström, Christopher AU - Wilhelms, Andrew AU - Titov, Nickolai AU - Dear, Blake AU - Hadjistavropoulos, Heather PY - 2023/4/18 TI - The Impacts of a Psychoeducational Alcohol Resource During Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety: Observational Study JO - JMIR Ment Health SP - e44722 VL - 10 KW - internet-delivered cognitive behavioral therapy KW - transdiagnostic KW - depression KW - anxiety KW - alcohol KW - drinking N2 - Background: Problematic alcohol use is common among clients seeking transdiagnostic internet-delivered cognitive behavioral therapy (ICBT) for depression or anxiety but is not often addressed in these treatment programs. The benefits of offering clients a psychoeducational resource focused on alcohol use during ICBT for depression or anxiety are unknown. Objective: This observational study aimed to elucidate the impacts of addressing comorbid alcohol use in ICBT for depression and anxiety. Methods: All patients (N=1333) who started an 8-week transdiagnostic ICBT course for depression and anxiety received access to a resource containing information, worksheets, and strategies for reducing alcohol use, including psychoeducation, reasons for change, identifying risk situations, goal setting, replacing drinking with positive activities, and information on relapse prevention. We assessed clients? use and perceptions of the resource; client characteristics associated with reviewing the resource; and whether reviewing the resource was associated with decreases in clients? alcohol use, depression, and anxiety at posttreatment and 3-month follow-up among clients dichotomized into low-risk and hazardous drinking categories based on pretreatment Alcohol Use Disorders Identification Test (AUDIT) scores. Results: During the 8-week course, 10.8% (144/1333) of clients reviewed the resource, and those who reviewed the resource provided positive feedback (eg, 127/144, 88.2% of resource reviewers found it worth their time). Furthermore, 18.15% (242/1333) of clients exhibited hazardous drinking, with 14.9% (36/242) of these clients reviewing the resources. Compared with nonreviewers, resource reviewers were typically older (P=.004) and separated, divorced, or widowed (P<.001). Reviewers also consumed more weekly drinks (P<.001), scored higher on the AUDIT (P<.001), and were more likely to exhibit hazardous drinking (P<.001). Regardless of their drinking level (ie, low risk vs hazardous), all clients showed a reduction in AUDIT-Consumption scores (P=.004), depression (P<.001), and anxiety (P<.001) over time; in contrast, there was no change in clients? drinks per week over time (P=.81). Reviewing alcohol resources did not predict changes in AUDIT-Consumption scores or drinks per week. Conclusions: Overall, ICBT appeared to be associated with a reduction in alcohol consumption scores, but this reduction was not greater among alcohol resource reviewers. Although there was some evidence that the resource was more likely to be used by clients with greater alcohol-related difficulties, the results suggest that further attention should be given to ensuring that those who could benefit from the resource review it to adequately assess the benefits of the resource. UR - https://mental.jmir.org/2023/1/e44722 UR - http://dx.doi.org/10.2196/44722 UR - http://www.ncbi.nlm.nih.gov/pubmed/37071454 ID - info:doi/10.2196/44722 ER - TY - JOUR AU - Sweeney, M. Allison AU - Wilson, K. Dawn AU - Resnicow, Kenneth AU - Van Horn, Lee M. AU - Kitzman, Heather PY - 2023/4/12 TI - Engagement With Tailored Physical Activity Content: Secondary Findings From the Families Improving Together for Weight Loss Randomized Controlled Trial JO - J Med Internet Res SP - e42581 VL - 25 KW - tailoring KW - eHealth KW - African Americans KW - physical activity KW - weight loss N2 - Background: Web-based tailored interventions offer rich opportunities for improved access to and personalization of behavioral interventions. However, despite the promise of this approach, the engagement and underrepresentation of minority groups remain major issues. Objective: This study evaluated whether engagement (log-in status and log-in duration) with different types of tailored behavioral content from the Families Improving Together for weight loss web-based intervention was associated with changes in moderate to vigorous physical activity (MVPA) among African American families with overweight or obesity. Methods: Parent-adolescent dyads were randomized to a web-based tailored intervention or web-based health education comparison program. The web-based intervention (N=119) was completed by parents and targeted 6 weight-related behaviors to support their adolescent children?s weight loss goals (session contents included energy balance, fast food, fruits and vegetables, physical activity [PA], sedentary behavior, and sweetened beverages). MVPA was measured using accelerometers at baseline and after the intervention. Results: Using a hierarchical approach, the log-in status and duration for each web-based session were used to evaluate the additive effects of engagement with different types of tailored behavioral content on MVPA after the web-based intervention. Among parents, logging in to the PA session was not associated with greater MVPA (B=?12.561, 95% CI ?18.759 to ?6.367), but MVPA increased with greater log-in duration for the PA (B=0.008, 95% CI 0.004-0.012) and sedentary behavior (B= 0.008, 95% CI 0.004-0.012) sessions. These results suggest that parents who logged in to the PA session had lower MVPA, but MVPA increased with greater log-in duration for the PA and sedentary behavior sessions. These associations remained even after accounting for engagement with other content sessions. However, these engagement effects did not translate to the adolescents. Conclusions: The results of this study highlight the need to disentangle the impact of engagement with different tailored content to improve the efficacy of tailored web-based interventions, especially for promoting PA in African American families. Trial Registration: ClinicalTrials.gov NCT01796067; https://clinicaltrials.gov/ct2/show/NCT01796067 UR - https://www.jmir.org/2023/1/e42581 UR - http://dx.doi.org/10.2196/42581 UR - http://www.ncbi.nlm.nih.gov/pubmed/37043271 ID - info:doi/10.2196/42581 ER - TY - JOUR AU - Bittel, M. Kelsey AU - O'Briant, Y. Kate AU - Ragaglia, M. Rena AU - Buseth, Lake AU - Murtha, Courtney AU - Yu, Jessica AU - Stanely, M. Jennifer AU - Hudgins, L. Brynn AU - Hevel, J. Derek AU - Maher, P. Jaclyn PY - 2023/4/7 TI - Associations Between Social Cognitive Determinants and Movement-Related Behaviors in Studies Using Ecological Momentary Assessment Methods: Systematic Review JO - JMIR Mhealth Uhealth SP - e44104 VL - 11 KW - motivation KW - psychosocial KW - physical activity KW - sedentary behavior KW - ambulatory assessment KW - mobile phone N2 - Background: The social cognitive framework is a long-standing framework within physical activity promotion literature to explain and predict movement-related behaviors. However, applications of the social cognitive framework to explain and predict movement-related behaviors have typically examined the relationships between determinants and behavior across macrotimescales (eg, weeks and months). There is more recent evidence suggesting that movement-related behaviors and their social cognitive determinants (eg, self-efficacy and intentions) change across microtimescales (eg, hours and days). Therefore, efforts have been devoted to examining the relationship between social cognitive determinants and movement-related behaviors across microtimescales. Ecological momentary assessment (EMA) is a growing methodology that can capture movement-related behaviors and social cognitive determinants as they change across microtimescales. Objective: The objective of this systematic review was to summarize evidence from EMA studies examining associations between social cognitive determinants and movement-related behaviors (ie, physical activity and sedentary behavior). Methods: Studies were included if they quantitatively tested such an association at the momentary or day level and excluded if they were an active intervention. Using keyword searches, articles were identified across the PubMed, SPORTDiscus, and PsycINFO databases. Articles were first assessed through abstract and title screening followed by full-text review. Each article was screened independently by 2 reviewers. For eligible articles, data regarding study design, associations between social cognitive determinants and movement-related behaviors, and study quality (ie, Methodological Quality Questionnaire and Checklist for Reporting Ecological Momentary Assessment Studies) were extracted. At least 4 articles were required to draw a conclusion regarding the overall associations between a social cognitive determinant and movement-related behavior. For the social cognitive determinants in which a conclusion regarding an overall association could be drawn, 60% of the articles needed to document a similar association (ie, positive, negative, or null) to conclude that the association existed in a particular direction. Results: A total of 24 articles including 1891 participants were eligible for the review. At the day level, intentions and self-efficacy were positively associated with physical activity. No other associations could be determined because of conflicting findings or the small number of studies investigating associations. Conclusions: Future research would benefit from validating EMA assessments of social cognitive determinants and systematically investigating associations across different operationalizations of key constructs. Despite the only recent emergence of EMA to understand social cognitive determinants of movement-related behaviors, the findings indicate that daily intentions and self-efficacy play an important role in regulating physical activity in everyday life. Trial Registration: PROSPERO CRD42022328500; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=328500 UR - https://mhealth.jmir.org/2023/1/e44104 UR - http://dx.doi.org/10.2196/44104 UR - http://www.ncbi.nlm.nih.gov/pubmed/37027185 ID - info:doi/10.2196/44104 ER - TY - JOUR AU - Tessier, Anne-Julie AU - Moyen, Audrey AU - Lawson, Claire AU - Rappaport, Ilysse Aviva AU - Yousif, Hiba AU - Fleurent-Grégoire, Chloé AU - Lalonde-Bester, Sophie AU - Brazeau, Anne-Sophie AU - Chevalier, Stéphanie PY - 2023/3/30 TI - Lifestyle Behavior Changes and Associated Risk Factors During the COVID-19 Pandemic: Results from the Canadian COVIDiet Online Cohort Study JO - JMIR Public Health Surveill SP - e43786 VL - 9 KW - healthy lifestyle KW - behaviors KW - pandemic KW - COVID-19 KW - public health KW - body image KW - gender KW - stress KW - risk factor KW - physical activity KW - mental well-being KW - depression N2 - Background: The COVID-19 pandemic and related lockdowns have impacted lifestyle behaviors, including eating habits and physical activity; yet, few studies have identified the emerging patterns of such changes and associated risk factors. Objective: This study aims to identify the patterns of weight and lifestyle behavior changes, and the potential risk factors, resulting from the pandemic in Canadian adults. Methods: Analyses were conducted on 1609 adults (18-89 years old; n=1450, 90.1%, women; n=1316, 81.8%, White) of the Canadian COVIDiet study baseline data (May-December 2020). Self-reported current and prepandemic weight, physical activity, smoking status, perceived eating habits, alcohol intake, and sleep quality were collected through online questionnaires. Based on these 6 indicator variables, latent class analysis (LCA) was used to identify lifestyle behavior change patterns. Associations with potential risk factors, including age, gender, ethnicity, education, income, chronic diseases, body image perception, and changes in the stress level, living situation, and work arrangement, were examined with logistic regressions. Results: Participants? mean BMI was 26.1 (SD 6.3) kg/m2. Of the 1609 participants, 980 (60.9%) had a bachelor?s degree or above. Since the pandemic, 563 (35%) had decreased income and 788 (49%) changed their work arrangement. Most participants reported unchanged weight, sleep quality, physical activity level, and smoking and alcohol consumption, yet 708 (44%) reported a perceived decrease in eating habit quality. From LCA, 2 classes of lifestyle behavior change emerged: healthy and less healthy (probability: 0.605 and 0.395, respectively; Bayesian information criterion [BIC]=15574, entropy=4.8). The healthy lifestyle behavior change group more frequently reported unchanged weight, sleep quality, smoking and alcohol intake, unchanged/improved eating habits, and increased physical activity. The less healthy lifestyle behavior change group reported significant weight gain, deteriorated eating habits and sleep quality, unchanged/increased alcohol intake and smoking, and decreased physical activity. Among risk factors, body image dissatisfaction (odds ratio [OR] 8.8, 95% CI 5.3-14.7), depression (OR 1.8, 95% CI 1.3-2.5), increased stress level (OR 3.4, 95% CI 2.0-5.8), and gender minority identity (OR 5.5, 95% CI 1.3-22.3) were associated with adopting less healthy behaviors in adjusted models. Conclusions: The COVID-19 pandemic has appeared to have influenced lifestyle behaviors unfavorably in some but favorably in others. Body image perception, change in stress level, and gender identity are factors associated with behavior change patterns; whether these will sustain over time remains to be studied. Findings provide insights into developing strategies for supporting adults with poorer mental well-being in the postpandemic context and promoting healthful behaviors during future disease outbreaks. Trial Registration: ClinicalTrials.gov NCT04407533; https://clinicaltrials.gov/ct2/show/NCT04407533 UR - https://publichealth.jmir.org/2023/1/e43786 UR - http://dx.doi.org/10.2196/43786 UR - http://www.ncbi.nlm.nih.gov/pubmed/36848226 ID - info:doi/10.2196/43786 ER - TY - JOUR AU - Yu, Tianzhuo AU - Xu, Haiyan AU - Sui, Xin AU - Zhang, Xin AU - Pang, Yue AU - Yu, Tianyue AU - Lian, Xiaoqian AU - Zeng, Ting AU - Wu, Yuejin AU - Leng, Xin AU - Li, Feng PY - 2023/3/29 TI - Effectiveness of eHealth Interventions on Moderate-to-Vigorous Intensity Physical Activity Among Patients in Cardiac Rehabilitation: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e42845 VL - 25 KW - cardiac rehabilitation KW - cardiorespiratory fitness KW - cardiovascular diseases KW - exercise KW - physical activity KW - heart disease risk factors KW - meta-analysis KW - systematic review KW - eHealth KW - telemedicine N2 - Background: Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of a cardiac rehabilitation program. However, many patients with cardiovascular diseases are failing to meet cardiac rehabilitation guidelines that recommend moderate-to-vigorous intensity physical activity. Objective: The major objective of this study was to review the evidence of the effectiveness of eHealth interventions in increasing moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. The secondary objective was to examine the effectiveness of eHealth interventions in improving cardiovascular-related outcomes, that is, cardiorespiratory fitness, waist circumference, and systolic blood pressure. Methods: A comprehensive search strategy was developed, and a systematic search of 4 electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) was conducted for papers published from the start of the creation of the database until November 27, 2022. Experimental studies reporting on eHealth interventions designed to increase moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation were included. Multiple unblinded reviewers determined the study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and the Cochrane Effective Practice and Organization of Care group methods for nonrandomized controlled trials. A random-effect model was used to provide the summary measures of effect (ie, standardized mean difference and 95% CI). All statistical analyses were performed using Stata 17. Results: We screened 3636 studies, but only 29 studies were included in the final review, of which 18 were included in the meta-analysis. The meta-analysis demonstrated that eHealth interventions improved moderate-to-vigorous intensity physical activity (standardized mean difference=0.18, 95% CI 0.07-0.28; P=.001) and vigorous-intensity physical activity (standardized mean difference=0.2, 95% CI 0.00-0.39; P=.048) but did not improve moderate-intensity physical activity (standardized mean difference=0.19, 95% CI ?0.12 to 0.51; P=.23). No changes were observed in the cardiovascular-related outcomes. Post hoc subgroup analyses identified that wearable-based, web-based, and communication-based eHealth intervention delivery methods were effective. Conclusions: eHealth interventions are effective at increasing minutes per week of moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. There was no difference in the effectiveness of the major eHealth intervention delivery methods, thereby providing evidence that in the future, health care professionals and researchers can personalize convenient and affordable interventions tailored to patient characteristics and needs to eliminate the inconvenience of visiting center-based cardiac rehabilitation programs during the COVID-19 pandemic and to provide better support for home-based maintenance of cardiac rehabilitation. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021278029; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278029 UR - https://www.jmir.org/2023/1/e42845 UR - http://dx.doi.org/10.2196/42845 UR - http://www.ncbi.nlm.nih.gov/pubmed/36989017 ID - info:doi/10.2196/42845 ER - TY - JOUR AU - Ray, E. Anne AU - Mun, Eun-Young AU - Lewis, A. Melissa AU - Litt, M. Dana AU - Stapleton, L. Jerod AU - Tan, Lin AU - Buller, B. David AU - Zhou, Zhengyang AU - Bush, M. Heather AU - Himelhoch, Seth PY - 2023/3/20 TI - Cross-Tailoring Integrative Alcohol and Risky Sexual Behavior Feedback for College Students: Protocol for a Hybrid Type 1 Effectiveness-Implementation Trial JO - JMIR Res Protoc SP - e43986 VL - 12 KW - alcohol-related risky sexual behavior KW - college students KW - cross-tailored dynamic feedback KW - effectiveness-implementation hybrid designs KW - personalized feedback intervention KW - underage drinking N2 - Background: Underage drinking and related risky sexual behavior (RSB) are major public health concerns on United States college campuses. Although technology-delivered personalized feedback interventions (PFIs) are considered a best practice for individual-level campus alcohol prevention, there is room for improving the effectiveness of this approach with regard to alcohol-related RSB. Objective: The aims of this study are to (1) evaluate the impact of a brief PFI that integrates content on alcohol use and RSB and is adapted to include a novel cross-tailored dynamic feedback (CDF) component for at-risk first-year college students and (2) identify implementation factors critical to the CDF?s success to facilitate future scale-up in campus settings. Methods: This study uses a hybrid type 1 effectiveness-implementation design and will be conducted in 3 phases. Phase 1 is a stakeholder-engaged PFI+CDF adaptation guided by focus groups and usability testing. In phase 2, 600 first-year college students who drink and are sexually active will be recruited from 2 sites (n=300 per site) to participate in a 4-group randomized controlled trial to examine the effectiveness of PFI+CDF in reducing alcohol-related RSB. Eligible participants will complete a baseline survey during the first week of the semester and follow-up surveys at 1, 2, 3, 6, and 13 months post baseline. Phase 3 is a qualitative evaluation with stakeholders to better understand relevant implementation factors. Results: Recruitment and enrollment for phase 1 began in January 2022. Recruitment for phases 2 and 3 is planned for the summer of 2023 and 2024, respectively. Upon collection of data, the effectiveness of PFI+CDF will be examined, and factors critical to implementation will be evaluated. Conclusions: This hybrid type 1 trial is designed to impact the field by testing an innovative adaptation that extends evidence-based alcohol programs to reduce alcohol-related RSB and provides insights related to implementation to bridge the gap between research and practice at the university level. Trial Registration: ClinicalTrials.gov NCT05011903; https://clinicaltrials.gov/ct2/show/NCT05011903 International Registered Report Identifier (IRRID): DERR1-10.2196/43986 UR - https://www.researchprotocols.org/2023/1/e43986 UR - http://dx.doi.org/10.2196/43986 UR - http://www.ncbi.nlm.nih.gov/pubmed/36716301 ID - info:doi/10.2196/43986 ER - TY - JOUR AU - Shiyab, Wa'ed AU - Halcomb, Elizabeth AU - Rolls, Kaye AU - Ferguson, Caleb PY - 2023/3/16 TI - The Impact of Social Media Interventions on Weight Reduction and Physical Activity Improvement Among Healthy Adults: Systematic Review JO - J Med Internet Res SP - e38429 VL - 25 KW - social media KW - physical activity KW - overweight KW - lifestyle risk factors N2 - Background: A sedentary lifestyle and being overweight or obese are well-established cardiovascular risk factors and contribute substantially to the global burden of disease. Changing such behavior is complex and requires support. Social media interventions show promise in supporting health behavior change, but their impact is unclear. Moreover, previous reviews have reported contradictory evidence regarding the relationship between engagement with social media interventions and the efficacy of these interventions. Objective: This review aimed to critically synthesize available evidence regarding the impact of social media interventions on physical activity and weight among healthy adults. In addition, this review examined the effect of engagement with social media interventions on their efficacy. Methods: CINAHL and MEDLINE were searched for relevant randomized trials that were conducted to investigate the impact of social media interventions on weight and physical activity and were published between 2011 and 2021 in the English language. Studies were included if the intervention used social media tools that provided explicit interactions between the participants. Studies were excluded if the intervention was passively delivered through an app website or if the participants had a known chronic disease. Eligible studies were appraised for quality and synthesized using narrative synthesis. Results: A total of 17 papers reporting 16 studies from 4 countries, with 7372 participants, were identified. Overall, 56% (9/16) of studies explored the effect of social media interventions on physical activity; 38% (6/16) of studies investigated weight reduction; and 6% (1/16) of studies assessed the effect on both physical activity and weight reduction. Evidence of the effects of social media interventions on physical activity and weight loss was mixed across the included studies. There were no standard metrics for measuring engagement with social media, and the relationship between participant engagement with the intervention and subsequent behavior change was also mixed. Although 35% (6/16) of studies reported that engagement was not a predictor of behavior change, engagement with social media interventions was found to be related to behavior change in 29% (5/16) of studies. Conclusions: Despite the promise of social media interventions, evidence regarding their effectiveness is mixed. Further robust studies are needed to elucidate the components of social media interventions that lead to successful behavior change. Furthermore, the effect of engagement with social media interventions on behavior change needs to be clearly understood. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42022311430; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=311430 UR - https://www.jmir.org/2023/1/e38429 UR - http://dx.doi.org/10.2196/38429 UR - http://www.ncbi.nlm.nih.gov/pubmed/36927627 ID - info:doi/10.2196/38429 ER - TY - JOUR AU - Davanzo, Antonella AU - d´Huart, Delfine AU - Seker, Süheyla AU - Moessner, Markus AU - Zimmermann, Ronan AU - Schmeck, Klaus AU - Behn, Alex PY - 2023/3/15 TI - Study Features and Response Compliance in Ecological Momentary Assessment Research in Borderline Personality Disorder: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e44853 VL - 25 KW - borderline personality disorder KW - ecological momentary assessment KW - compliance KW - study design features KW - e?mental health KW - mobile phone N2 - Background: Borderline personality disorder (BPD) is characterized by frequent and intense moment-to-moment changes in affect, behavior, identity, and interpersonal relationships, which typically result in significant and negative deterioration of the person?s overall functioning and well-being. Measuring and characterizing the rapidly changing patterns of instability in BPD dysfunction as they occur in a person?s daily life can be challenging. Ecological momentary assessment (EMA) is a method that can capture highly dynamic processes in psychopathology research and, thus, is well suited to study intense variability patterns across areas of dysfunction in BPD. EMA studies are characterized by frequent repeated assessments that are delivered to participants in real-life, real-time settings using handheld devices capable of registering responses to short self-report questions in daily life. Compliance in EMA research is defined as the proportion of prompts answered by the participant, considering all planned prompts sent. Low compliance with prompt schedules can compromise the relative advantages of using this method. Despite the growing EMA literature on BPD in recent years, findings regarding study design features that affect compliance with EMA protocols have not been compiled, aggregated, and estimated. Objective: This systematic meta-analytic review aimed to investigate the relationship between study design features and participant compliance in EMA research of BPD. Methods: A systematic review was conducted on November 12, 2021, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analyses of Observational Studies in Epidemiology) guidelines to search for articles featuring EMA studies of BPD that reported compliance rates and included sufficient data to extract relevant design features. For studies with complete data, random-effect models were used to estimate the overall compliance rate and explore its association with design features. Results: In total, 28 peer-reviewed EMA studies comprising 2052 participants were included in the study. Design features (sampling strategy, average prompting frequency, number of items, response window, sampling device, financial incentive, and dropout rate) showed a large variability across studies, and many studies did not report design features. The meta-analytic synthesis was restricted to 64% (18/28) of articles and revealed a pooled compliance rate of 79% across studies. We did not find any significant relationship between design features and compliance rates. Conclusions: Our results show wide variability in the design and reporting of EMA studies assessing BPD. Compliance rates appear to be stable across varying setups, and it is likely that standard design features are not directly responsible for improving or diminishing compliance. We discuss possible nonspecific factors of study design that may have an impact on compliance. Given the promise of EMA research in BPD, we also discuss the importance of unifying standards for EMA reporting so that data stemming from this rich literature can be aggregated and interpreted jointly. UR - https://www.jmir.org/2023/1/e44853 UR - http://dx.doi.org/10.2196/44853 UR - http://www.ncbi.nlm.nih.gov/pubmed/36920466 ID - info:doi/10.2196/44853 ER - TY - JOUR AU - Voorheis, Paula AU - Bhuiya, R. Aunima AU - Kuluski, Kerry AU - Pham, Quynh AU - Petch, Jeremy PY - 2023/3/15 TI - Making Sense of Theories, Models, and Frameworks in Digital Health Behavior Change Design: Qualitative Descriptive Study JO - J Med Internet Res SP - e45095 VL - 25 KW - behavioral science KW - behavior change KW - health behavior KW - digital health KW - mobile health KW - theories KW - models KW - frameworks N2 - Background: Digital health interventions are increasingly being designed to support health behaviors. Although digital health interventions informed by behavioral science theories, models, and frameworks (TMFs) are more likely to be effective than those designed without them, design teams often struggle to use these evidence-informed tools. Until now, little work has been done to clarify the ways in which behavioral science TMFs can add value to digital health design. Objective: The aim of this study was to better understand how digital health design leaders select and use TMFs in design practice. The questions that were addressed included how do design leaders perceive the value of TMFs in digital health design, what considerations do design leaders make when selecting and applying TMFs, and what do design leaders think is needed in the future to advance the utility of TMFs in digital health design? Methods: This study used a qualitative description design to understand the experiences and perspectives of digital health design leaders. The participants were identified through purposive and snowball sampling. Semistructured interviews were conducted via Zoom software. Interviews were audio-recorded and transcribed using Otter.ai software. Furthermore, 3 researchers coded a sample of interview transcripts and confirmed the coding strategy. One researcher completed the qualitative analysis using a codebook thematic analysis approach. Results: Design leaders had mixed opinions on the value of behavioral science TMFs in digital health design. Leaders suggested that TMFs added the most value when viewed as a starting point rather than the final destination for evidence-informed design. Specifically, these tools added value when they acted as a gateway drug to behavioral science, supported health behavior conceptualization, were balanced with expert knowledge and user-centered design principles, were complementary to existing design methods, and supported both individual- and systems-level thinking. Design leaders also felt that there was a considerable nuance in selecting the most value-adding TMFs. Considerations should be made regarding their source, appropriateness, complexity, accessibility, adaptability, evidence base, purpose, influence, audience, fit with team expertise, fit with team culture, and fit with external pressures. Design leaders suggested multiple opportunities to advance the use of TMFs. These included improving TMF reporting, design, and accessibility, as well as improving design teams' capacity to use TMFs appropriately in practice. Conclusions: When designing a digital health behavior change intervention, using TMFs can help design teams to systematically integrate behavioral insights. The future of digital health behavior change design demands an easier way for designers to integrate evidence-based TMFs into practice. UR - https://www.jmir.org/2023/1/e45095 UR - http://dx.doi.org/10.2196/45095 UR - http://www.ncbi.nlm.nih.gov/pubmed/36920442 ID - info:doi/10.2196/45095 ER - TY - JOUR AU - Lorenzo-Luaces, Lorenzo AU - Dierckman, Clare AU - Adams, Sydney PY - 2023/3/13 TI - Attitudes and (Mis)information About Cognitive Behavioral Therapy on TikTok: An Analysis of Video Content JO - J Med Internet Res SP - e45571 VL - 25 KW - social media KW - cognitive behavioral therapy KW - misinformation KW - public health KW - mental health KW - TikTok KW - psychotherapy KW - content analysis KW - therapist KW - online health information UR - https://www.jmir.org/2023/1/e45571 UR - http://dx.doi.org/10.2196/45571 UR - http://www.ncbi.nlm.nih.gov/pubmed/36912883 ID - info:doi/10.2196/45571 ER - TY - JOUR AU - Ryan, Thomas Arthur AU - Brenner, Anne Lisa AU - Ulmer, S. Christi AU - Mackintosh, Margaret-Anne AU - Greene, J. Carolyn PY - 2023/3/6 TI - The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study JO - JMIR Form Res SP - e40104 VL - 7 KW - cognitive behavioral therapy for insomnia KW - CBT-I KW - insomnia KW - digital mental health intervention KW - digital MH intervention KW - internet-delivered KW - veterans KW - Path to Better Sleep N2 - Background: Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS). Objective: We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS. Methods: A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists? feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study. Results: The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course?s sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms. Conclusions: The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers. UR - https://formative.jmir.org/2023/1/e40104 UR - http://dx.doi.org/10.2196/40104 UR - http://www.ncbi.nlm.nih.gov/pubmed/36877553 ID - info:doi/10.2196/40104 ER - TY - JOUR AU - Fresán, Ujué AU - Bernard, Paquito AU - Fabregues, Sergi AU - Boronat, Anna AU - Araújo-Soares, Vera AU - König, M. Laura AU - Chevance, Guillaume PY - 2023/3/2 TI - A Smartphone Intervention to Promote a Sustainable Healthy Diet: Protocol for a Pilot Study JO - JMIR Res Protoc SP - e41443 VL - 12 KW - eating behavior change protocol KW - sustainable diet KW - dietary sustainability KW - eating behavior change KW - n-of-1 KW - nutritional education KW - eHealth KW - mobile health KW - mHealth KW - mobile phone N2 - Background: Changing current dietary patterns into sustainable healthy diets (ie, healthy diets with low environmental impact and socioeconomic fairness) is urgent. So far, few eating behavior change interventions have addressed all the dimensions of sustainable healthy diets at once and used cutting-edge methods from the field of digital health behavior change. Objective: The primary objectives of this pilot study were to assess the feasibility and effectiveness of an individual behavior change intervention toward the adoption of a more environmentally sustainable healthy diet as a whole and changes in specific relevant food groups, food waste, and obtaining food from fair sources. The secondary objectives included the identification of mechanisms of action that potentially mediate the effect of the intervention on behaviors, identification of potential spillover effects and covariations among different food outcomes, and identification of the role of socioeconomic status in behavior changes. Methods: We will run a series of ABA n-of-1 trials over a year, with the first A phase corresponding to a 2-week baseline evaluation, the B phase to a 22-week intervention, and the second A phase to a 24-week postintervention follow-up. We plan to enroll 21 participants from low, middle, and high socioeconomic statuses, with 7 from each socioeconomic group. The intervention will involve sending text messages and providing brief individualized web-based feedback sessions based on regular app-based assessments of eating behavior. The text messages will contain brief educational messages on human health and the environmental and socioeconomic effects of dietary choices; motivational messages to encourage the adoption of sustainable healthy diets by participants, providing tips to achieve their own behavioral goals; or links to recipes. Both quantitative and qualitative data will be collected. Quantitative data (eg, on eating behaviors and motivation) will be collected through self-reported questionnaires on several weekly bursts spread through the study. Qualitative data will be collected through 3 individual semistructured interviews before the intervention period, at the end of the intervention period, and at the end of the study. Analyses will be performed at both the individual and group levels depending on the outcome and objective. Results: The first participants were recruited in October 2022. The final results are expected by October 2023. Conclusions: The results of this pilot study will be useful for designing future larger interventions on individual behavior change for sustainable healthy diets. International Registered Report Identifier (IRRID): PRR1-10.2196/41443 UR - https://www.researchprotocols.org/2023/1/e41443 UR - http://dx.doi.org/10.2196/41443 UR - http://www.ncbi.nlm.nih.gov/pubmed/36862497 ID - info:doi/10.2196/41443 ER - TY - JOUR AU - Pathmendra, Pranujan AU - Raggatt, Michelle AU - Lim, SC Megan AU - Marino, L. Jennifer AU - Skinner, Rachel S. PY - 2023/2/28 TI - Exposure to Pornography and Adolescent Sexual Behavior: Systematic Review JO - J Med Internet Res SP - e43116 VL - 25 KW - adolescence KW - teenager KW - sexual debut KW - sexual behavior KW - risky behavior KW - pornography use KW - digital media N2 - Background: Formative experiences in adolescence lay the foundation for healthy and pleasurable romantic and sexual relationships. Exposure to pornography may affect these experiences. Objective: We aimed to synthesize evidence published in the past decade on the relationship between exposure to pornography and sexual behavior (earlier age of first sex [<16 years], condomless sex, past-year multiple partners [>1], lifetime multiple partners [>1], group sex, sexual aggression including forced sex, paid sex, teenage pregnancy, and history of sexually transmitted infection) in adolescents aged between 10 and 19 years. Methods: We identified 19 eligible studies by searching MEDLINE, PsycINFO, Cochrane, CINAHL, Embase, and Web of Science databases from January 2010 to November 2022. Results: Out of 8 studies that assessed earlier age of first sex, 5 studies, including 1 longitudinal study, found a statistically significant association with exposure to pornography. Given that most studies were cross-sectional or had substantial limitations, causal inference could not be made. Also, exposure to pornography was not measured consistently. The evidence was conflicting or insufficient to draw any conclusions regarding other outcomes. Conclusions: More quantitative research is needed to elucidate the association between pornography exposure and sexual behavior, and sex education should adopt evidence-based approaches to minimize the potential harms from pornography. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021227390; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227390 UR - https://www.jmir.org/2023/1/e43116 UR - http://dx.doi.org/10.2196/43116 UR - http://www.ncbi.nlm.nih.gov/pubmed/36853749 ID - info:doi/10.2196/43116 ER - TY - JOUR AU - Voss, Claire AU - Liu, Jianyi AU - Chang, Angela AU - Kosmas, A. Jacqueline AU - Biehl, Abigail AU - Flynn, L. Rebecca AU - Kruzan, P. Kaylee AU - Wildes, E. Jennifer AU - Graham, K. Andrea PY - 2023/2/28 TI - Weight Loss Expectations of Adults With Binge Eating: Cross-sectional Study With a Human-Centered Design Approach JO - JMIR Form Res SP - e40506 VL - 7 KW - binge eating KW - weight loss expectations KW - overvaluation of weight and shape KW - digital intervention KW - human-centered design KW - weight loss KW - user expectations KW - behavioral change KW - eating disorder KW - obesity KW - overweight N2 - Background: People tend to overestimate their expectations for weight loss relative to what is achievable in a typical evidence-based behavioral weight management program, which can impact treatment satisfaction and outcomes. We are engaged in formative research to design a digital intervention that addresses binge eating and weight management; thus, understanding expectations among this group can inform more engaging intervention designs to produce a digital intervention that can achieve greater clinical success. Studies examining weight loss expectations have primarily focused on people who have overweight or obesity. Only one study has investigated weight loss expectations among people with binge eating disorder, a population that frequently experiences elevated weight and shape concerns and often presents to treatment with the goal of losing weight. Objective: The aim of the study is to investigate differences in weight loss expectations among people with varying levels of binge eating to inform the design of a digital intervention for binge eating and weight management. Such an evaluation may be crucial for people presenting for a digital intervention, given that engagement and dropout are notable problems for digital behavior change interventions. We tested the hypotheses that (1) people who endorsed some or recurrent binge eating would expect to lose more weight than those who did not endorse binge eating and (2) people who endorsed a more severe versus a low or moderate overvaluation of weight and shape would have higher weight loss expectations. Methods: A total of 760 adults (n=504, 66% female; n=441, 58% non-Hispanic White) completed a web-based screening questionnaire. One-way ANOVAs were conducted to explore weight loss expectations for binge eating status as well as overvaluation of shape and weight. Results: Weight loss expectations significantly differed by binge eating status. Those who endorsed some and recurrent binge eating expected to lose more weight than those who endorsed no binge eating. Participants with severe overvaluation of weight or shape expected to lose the most weight compared to those with low or moderate levels of overvaluation of weight and shape. Conclusions: In the sample, people interested in a study to inform a digital intervention for binge eating and weight management overestimated their expectations for weight loss. Given that weight loss expectations can impact treatment completion and success, it may be important to assess and modify weight loss expectations among people with binge eating prior to enrolling in a digital intervention. Future work should design and test features that can modify these expectations relative to individuals? intended treatment goals to facilitate engagement and successful outcomes in a digital intervention. UR - https://formative.jmir.org/2023/1/e40506 UR - http://dx.doi.org/10.2196/40506 UR - http://www.ncbi.nlm.nih.gov/pubmed/36853750 ID - info:doi/10.2196/40506 ER - TY - JOUR AU - Huang, Yitong AU - Benford, Steve AU - Li, Benqian AU - Price, Dominic AU - Blake, Holly PY - 2023/2/27 TI - Feasibility and Acceptability of an Internet of Things?Enabled Sedentary Behavior Intervention: Mixed Methods Study JO - J Med Internet Res SP - e43502 VL - 25 KW - internet of things KW - health communication KW - pervasive media KW - ubiquitous computing KW - smart objects KW - wearable device KW - behavior change wheel KW - digital intervention KW - sedentary behavior KW - workplace intervention KW - employee well-being N2 - Background: Encouraging office workers to break up prolonged sedentary behavior (SB) at work with regular microbreaks can be beneficial yet challenging. The Internet of Things (IoT) offers great promise for delivering more subtle and hence acceptable behavior change interventions in the workplace. We previously developed an IoT-enabled SB intervention, called WorkMyWay, by applying a combination of theory-informed and human-centered design approaches. According to the Medical Research Council?s framework for developing and evaluating complex interventions such as WorkMyWay, process evaluation in the feasibility phase can help establish the viability of novel modes of delivery and identify facilitators and barriers to successful delivery. Objective: This study aims to evaluate the feasibility and acceptability of the WorkMyWay intervention and its technological delivery system. Methods: A mixed methods approach was adopted. A sample of 15 office workers were recruited to use WorkMyWay during work hours for 6 weeks. Questionnaires were administered before and after the intervention period to assess self-report occupational sitting and physical activity (OSPA) and psychosocial variables theoretically aligned with prolonged occupational SB (eg, intention, perceived behavioral control, prospective memory and retrospective memory of breaks, and automaticity of regular break behaviors). Behavioral and interactional data were obtained through the system database to determine adherence, quality of delivery, compliance, and objective OSPA. Semistructured interviews were conducted at the end of the study, and a thematic analysis was performed on interview transcripts. Results: All 15 participants completed the study (attrition=0%) and on average used the system for 25 tracking days (out of a possible 30 days; adherence=83%). Although no significant change was observed in either objective or self-report OSPA, postintervention improvements were significant in the automaticity of regular break behaviors (t14=2.606; P=.02), retrospective memory of breaks (t14=7.926; P<.001), and prospective memory of breaks (t14=?2.661; P=.02). The qualitative analysis identified 6 themes, which lent support to the high acceptability of WorkMyWay, though delivery was compromised by issues concerning Bluetooth connectivity and factors related to user behaviors. Fixing technical issues, tailoring to individual differences, soliciting organizational supports, and harnessing interpersonal influences could facilitate delivery and enhance acceptance. Conclusions: It is acceptable and feasible to deliver an SB intervention with an IoT system that involves a wearable activity tracking device, an app, and a digitally augmented everyday object (eg, cup). More industrial design and technological development work on WorkMyWay is warranted to improve delivery. Future research should seek to establish the broad acceptability of similar IoT-enabled interventions while expanding the range of digitally augmented objects as the modes of delivery to meet diverse needs. UR - https://www.jmir.org/2023/1/e43502 UR - http://dx.doi.org/10.2196/43502 UR - http://www.ncbi.nlm.nih.gov/pubmed/36848183 ID - info:doi/10.2196/43502 ER - TY - JOUR AU - Arigo, Danielle AU - Gray, C. Robert AU - Dallal, H. Diane AU - Villareale, Jennifer AU - Zhu, Jichen PY - 2023/2/27 TI - Selection of and Response to Physical Activity?Based Social Comparisons in a Digital Environment: Series of Daily Assessment Studies JO - JMIR Hum Factors SP - e41239 VL - 10 KW - social comparison KW - physical activity KW - motivation KW - web platform KW - selection KW - exercise KW - fitness KW - mobile phone N2 - Background: Innovative approaches are needed to understand barriers to and facilitators of physical activity among insufficiently active adults. Although social comparison processes (ie, self-evaluations relative to others) are often used to motivate physical activity in digital environments, user preferences and responses to comparison information are poorly understood. Objective: We used an iterative approach to better understand users? selection of comparison targets, how they interacted with their selected targets, and how they responded to these targets. Methods: Across 3 studies, different samples of insufficiently active college students used the Fitbit system (Fitbit LLC) to track their steps per day as well as a separate, adaptive web platform each day for 7 to 9 days (N=112). The adaptive platform was designed with different layouts for each study; each allowed participants to select their preferred comparison target from various sets of options, view the desired amount of information about their selected target, and rate their physical activity motivation before and after viewing information about their selected target. Targets were presented as achieving physical activity at various levels below and above their own, which were accessed via the Fitbit system each day. We examined the types of comparison target selections, time spent viewing and number of elements viewed for each type of target, and day-level associations between comparison selections and physical activity outcomes (motivation and behavior). Results: Study 1 (n=5) demonstrated that the new web platform could be used as intended and that participants? interactions with the platform (ie, the type of target selected, the time spent viewing the selected target?s profile, and the number of profile elements viewed) varied across the days. Studies 2 (n=53) and 3 (n=54) replicated these findings; in both studies, age was positively associated with time spent viewing the selected target?s profile and the number of profile elements viewed. Across all studies, upward targets (who had more steps per day than the participant) were selected more often than downward targets (who had fewer steps per day than the participant), although only a subset of either type of target selection was associated with benefits for physical activity motivation or behavior. Conclusions: Capturing physical activity?based social comparison preferences is feasible in an adaptive digital environment, and day-to-day differences in preferences for social comparison targets are associated with day-to-day changes in physical activity motivation and behavior. Findings show that participants only sometimes focus on the comparison opportunities that support their physical activity motivation or behavior, which helps explain previous, equivocal findings regarding the benefits of physical activity?based comparisons. Additional investigation of day-level determinants of comparison selections and responses is needed to fully understand how best to harness comparison processes in digital tools to promote physical activity. UR - https://humanfactors.jmir.org/2023/1/e41239 UR - http://dx.doi.org/10.2196/41239 UR - http://www.ncbi.nlm.nih.gov/pubmed/36848204 ID - info:doi/10.2196/41239 ER - TY - JOUR AU - Aggarwal, Abhishek AU - Tam, Chi Cheuk AU - Wu, Dezhi AU - Li, Xiaoming AU - Qiao, Shan PY - 2023/2/24 TI - Artificial Intelligence?Based Chatbots for Promoting Health Behavioral Changes: Systematic Review JO - J Med Internet Res SP - e40789 VL - 25 KW - chatbot KW - artificial intelligence KW - AI KW - health behavior change KW - engagement KW - efficacy KW - intervention KW - feasibility KW - usability KW - acceptability KW - mobile phone N2 - Background: Artificial intelligence (AI)?based chatbots can offer personalized, engaging, and on-demand health promotion interventions. Objective: The aim of this systematic review was to evaluate the feasibility, efficacy, and intervention characteristics of AI chatbots for promoting health behavior change. Methods: A comprehensive search was conducted in 7 bibliographic databases (PubMed, IEEE Xplore, ACM Digital Library, PsycINFO, Web of Science, Embase, and JMIR publications) for empirical articles published from 1980 to 2022 that evaluated the feasibility or efficacy of AI chatbots for behavior change. The screening, extraction, and analysis of the identified articles were performed by following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Of the 15 included studies, several demonstrated the high efficacy of AI chatbots in promoting healthy lifestyles (n=6, 40%), smoking cessation (n=4, 27%), treatment or medication adherence (n=2, 13%), and reduction in substance misuse (n=1, 7%). However, there were mixed results regarding feasibility, acceptability, and usability. Selected behavior change theories and expert consultation were used to develop the behavior change strategies of AI chatbots, including goal setting, monitoring, real-time reinforcement or feedback, and on-demand support. Real-time user-chatbot interaction data, such as user preferences and behavioral performance, were collected on the chatbot platform to identify ways of providing personalized services. The AI chatbots demonstrated potential for scalability by deployment through accessible devices and platforms (eg, smartphones and Facebook Messenger). The participants also reported that AI chatbots offered a nonjudgmental space for communicating sensitive information. However, the reported results need to be interpreted with caution because of the moderate to high risk of internal validity, insufficient description of AI techniques, and limitation for generalizability. Conclusions: AI chatbots have demonstrated the efficacy of health behavior change interventions among large and diverse populations; however, future studies need to adopt robust randomized control trials to establish definitive conclusions. UR - https://www.jmir.org/2023/1/e40789 UR - http://dx.doi.org/10.2196/40789 UR - http://www.ncbi.nlm.nih.gov/pubmed/36826990 ID - info:doi/10.2196/40789 ER - TY - JOUR AU - Yang, Xiao AU - Knights, Jonathan AU - Bangieva, Victoria AU - Kambhampati, Vinayak PY - 2023/2/22 TI - Association Between the Severity of Depressive Symptoms and Human-Smartphone Interactions: Longitudinal Study JO - JMIR Form Res SP - e42935 VL - 7 KW - depression KW - human-smartphone interaction KW - longitudinal data analysis KW - within-person effect KW - between-person effect KW - nonergodicity N2 - Background: Various behavioral sensing research studies have found that depressive symptoms are associated with human-smartphone interaction behaviors, including lack of diversity in unique physical locations, entropy of time spent in each location, sleep disruption, session duration, and typing speed. These behavioral measures are often tested against the total score of depressive symptoms, and the recommended practice to disaggregate within- and between-person effects in longitudinal data is often neglected. Objective: We aimed to understand depression as a multidimensional process and explore the association between specific dimensions and behavioral measures computed from passively sensed human-smartphone interactions. We also aimed to highlight the nonergodicity in psychological processes and the importance of disaggregating within- and between-person effects in the analysis. Methods: Data used in this study were collected by Mindstrong Health, a telehealth provider that focuses on individuals with serious mental illness. Depressive symptoms were measured by the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) Self-Rated Level 1 Cross-Cutting Symptom Measure-Adult Survey every 60 days for a year. Participants? interactions with their smartphones were passively recorded, and 5 behavioral measures were developed and were expected to be associated with depressive symptoms according to either theoretical proposition or previous empirical evidence. Multilevel modeling was used to explore the longitudinal relations between the severity of depressive symptoms and these behavioral measures. Furthermore, within- and between-person effects were disaggregated to accommodate the nonergodicity commonly found in psychological processes. Results: This study included 982 records of DSM Level 1 depressive symptom measurements and corresponding human-smartphone interaction data from 142 participants (age range 29-77 years; mean age 55.1 years, SD 10.8 years; 96 female participants). Loss of interest in pleasurable activities was associated with app count (?10=?0.14; P=.01; within-person effect). Depressed mood was associated with typing time interval (?05=0.88; P=.047; within-person effect) and session duration (?05=?0.37; P=.03; between-person effect). Conclusions: This study contributes new evidence for associations between human-smartphone interaction behaviors and the severity of depressive symptoms from a dimensional perspective, and it highlights the importance of considering the nonergodicity of psychological processes and analyzing the within- and between-person effects separately. UR - https://formative.jmir.org/2023/1/e42935 UR - http://dx.doi.org/10.2196/42935 UR - http://www.ncbi.nlm.nih.gov/pubmed/36811951 ID - info:doi/10.2196/42935 ER - TY - JOUR AU - Yang, Lin AU - Kuang, Angela AU - Xu, Claire AU - Shewchuk, Brittany AU - Singh, Shaminder AU - Quan, Hude AU - Zeng, Yong PY - 2023/2/22 TI - Design Principles in mHealth Interventions for Sustainable Health Behavior Changes: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e39093 VL - 12 KW - behavior change KW - intervention KW - mHealth KW - personalization KW - dialogue KW - mobile health KW - mobile app KW - self-management N2 - Background: In recent years, mHealth has increasingly been used to deliver behavioral interventions for disease prevention and self-management. Computing power in mHealth tools can provide unique functions beyond conventional interventions in provisioning personalized behavior change recommendations and delivering them in real time, supported by dialogue systems. However, design principles to incorporate these features in mHealth interventions have not been systematically evaluated. Objective: The goal of this review is to identify best practices for the design of mHealth interventions targeting diet, physical activity, and sedentary behavior. We aim to identify and summarize the design characteristics of current mHealth tools with a focus on the following features: (1) personalization, (2) real-time functions, and (3) deliverable resources. Methods: We will conduct a systematic search of electronic databases, including MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science for studies published since 2010. First, we will use keywords that combine mHealth, interventions, chronic disease prevention, and self-management. Second, we will use keywords that cover diet, physical activity, and sedentary behavior. Literature found in the first and second steps will be combined. Finally, we will use keywords for personalization and real-time functions to limit the results to interventions that have reported these design features. We expect to perform narrative syntheses for each of the 3 target design features. Study quality will be evaluated using the Risk of Bias 2 assessment tool. Results: We have conducted a preliminary search of existing systematic reviews and review protocols on mHealth-supported behavior change interventions. We have identified several reviews that aimed to evaluate the efficacy of mHealth behavior change interventions in a range of populations, evaluate methodologies for assessing mHealth behavior change randomized trials, and assess the diversity of behavior change techniques and theories in mHealth interventions. However, syntheses on the unique features of mHealth intervention design are absent in the literature. Conclusions: Our findings will provide a basis for developing best practices for designing mHealth tools for sustainable behavior change. Trial Registration: PROSPERO CRD42021261078; https://tinyurl.com/m454r65t International Registered Report Identifier (IRRID): PRR1-10.2196/39093 UR - https://www.researchprotocols.org/2023/1/e39093 UR - http://dx.doi.org/10.2196/39093 UR - http://www.ncbi.nlm.nih.gov/pubmed/36811938 ID - info:doi/10.2196/39093 ER - TY - JOUR AU - Kyaw, Lin Tun AU - Ng, Nawi AU - Theocharaki, Margarita AU - Wennberg, Patrik AU - Sahlen, Klas-Göran PY - 2023/2/16 TI - Cost-effectiveness of Digital Tools for Behavior Change Interventions Among People With Chronic Diseases: Systematic Review JO - Interact J Med Res SP - e42396 VL - 12 KW - digital tools KW - chronic diseases KW - cost-effectiveness KW - lifestyle KW - behavior KW - systematic review KW - mobile phone N2 - Background: Chronic diseases, including cardiovascular diseases, diabetes, chronic obstructive pulmonary disease, and cerebrovascular diseases, contribute to the most significant disease burden worldwide, negatively impacting patients and their family members. People with chronic diseases have common modifiable behavioral risk factors, including smoking, alcohol overconsumption, and unhealthy diets. Digital-based interventions for promoting and sustaining behavioral changes have flourished in recent years, although evidence of the cost-effectiveness of such interventions remains inconclusive. Objective: In this study, we aimed to investigate the cost-effectiveness of digital health interventions for behavioral changes among people with chronic diseases. Methods: This systematic review evaluated published studies focused on the economic evaluation of digital tools for behavioral change among adults with chronic diseases. We followed the Population, Intervention, Comparator, and Outcomes framework to retrieve relevant publications from 4 databases: PubMed, CINAHL, Scopus, and Web of Science. We used the Joanna Briggs Institute?s criteria for economic evaluation and randomized controlled trials to assess the risk of bias in the studies. Two researchers independently screened, assessed the quality, and extracted data from the studies selected for the review. Results: In total, 20 studies published between 2003 and 2021 fulfilled our inclusion criteria. All the studies were conducted in high-income countries. These studies used telephones, SMS text messaging, mobile health apps, and websites as digital tools for behavior change communication. Most digital tools for interventions focused on diet and nutrition (17/20, 85%) and physical activity (16/20, 80%), and a few focused on smoking and tobacco control (8/20, 40%), alcohol reduction (6/20, 30%), and reduction of salt intake (3/20, 15%). Most studies (17/20, 85%) used the health care payer perspective for economic analysis, and only 15% (3/20) used the societal perspective. Only 45% (9/20) of studies conducted a full economic evaluation. Most studies (7/20, 35%) based on full economic evaluation and 30% (6/20) of studies based on partial economic evaluation found digital health interventions to be cost-effective and cost-saving. Most studies had short follow-ups and failed to include proper indicators for economic evaluation, such as quality-adjusted life-years, disability-adjusted life-years, lack of discounting, and sensitivity analysis. Conclusions: Digital health interventions for behavioral change among people with chronic diseases are cost-effective in high-income settings and can therefore be scaled up. Similar evidence from low- and middle-income countries based on properly designed studies for cost-effectiveness evaluation is urgently required. A full economic evaluation is needed to provide robust evidence for the cost-effectiveness of digital health interventions and their potential for scaling up in a wider population. Future studies should follow the National Institute for Health and Clinical Excellence recommendations to take a societal perspective, apply discounting, address parameter uncertainty, and apply a lifelong time horizon. UR - https://www.i-jmr.org/2023/1/e42396 UR - http://dx.doi.org/10.2196/42396 UR - http://www.ncbi.nlm.nih.gov/pubmed/36795470 ID - info:doi/10.2196/42396 ER - TY - JOUR AU - Vis, Christiaan AU - Schuurmans, Josien AU - Aouizerate, Bruno AU - Atipei Craggs, Mette AU - Batterham, Philip AU - Bührmann, Leah AU - Calear, Alison AU - Cerga Pashoja, Arlinda AU - Christensen, Helen AU - Dozeman, Els AU - Duedal Pedersen, Claus AU - Ebert, Daniel David AU - Etzelmueller, Anne AU - Fanaj, Naim AU - Finch, L. Tracy AU - Hanssen, Denise AU - Hegerl, Ulrich AU - Hoogendoorn, Adriaan AU - Mathiasen, Kim AU - May, Carl AU - Meksi, Andia AU - Mustafa, Sevim AU - O'Dea, Bridianne AU - Oehler, Caroline AU - Piera-Jiménez, Jordi AU - Potthoff, Sebastian AU - Qirjako, Gentiana AU - Rapley, Tim AU - Rosmalen, Judith AU - Sacco, Ylenia AU - Samalin, Ludovic AU - Skjoth, Maria Mette AU - Tarp, Kristine AU - Titzler, Ingrid AU - Van der Eycken, Erik AU - van Genugten, Rosalie Claire AU - Whitton, Alexis AU - Zanalda, Enrico AU - Smit, H. Jan AU - Riper, Heleen PY - 2023/2/3 TI - Effectiveness of Self-guided Tailored Implementation Strategies in Integrating and Embedding Internet-Based Cognitive Behavioral Therapy in Routine Mental Health Care: Results of a Multicenter Stepped-Wedge Cluster Randomized Trial JO - J Med Internet Res SP - e41532 VL - 25 KW - common mental health disorders KW - internet-based cognitive behavioral therapy KW - iCBT KW - implementation strategies KW - tailored implementation KW - mobile phone N2 - Background: Internet-based cognitive behavioral therapy (iCBT) services for common mental health disorders have been found to be effective. There is a need for strategies that improve implementation in routine practice. One-size-fits-all strategies are likely to be ineffective. Tailored implementation is considered as a promising approach. The self-guided integrated theory-based Framework for intervention tailoring strategies toolkit (ItFits-toolkit) supports local implementers in developing tailored implementation strategies. Tailoring involves identifying local barriers; matching selected barriers to implementation strategies; developing an actionable work plan; and applying, monitoring, and adapting where necessary. Objective: This study aimed to compare the effectiveness of the ItFits-toolkit with implementation-as-usual (IAU) in implementing iCBT services in 12 routine mental health care organizations in 9 countries in Europe and Australia. Methods: A stepped-wedge cluster randomized trial design with repeated measures was applied. The trial period lasted 30 months. The primary outcome was the normalization of iCBT delivery by service providers (therapists, referrers, IT developers, and administrators), which was measured with the Normalization Measure Development as a proxy for implementation success. A 3-level linear mixed-effects modeling was applied to estimate the effects. iCBT service uptake (referral and treatment completion rates) and implementation effort (hours) were used as secondary outcomes. The perceived satisfaction (Client Satisfaction Questionnaire), usability (System Usability Scale), and impact of the ItFits-toolkit by implementers were used to assess the acceptability of the ItFits-toolkit. Results: In total, 456 mental health service providers were included in this study. Compared with IAU, the ItFits-toolkit had a small positive statistically significant effect on normalization levels in service providers (mean 0.09, SD 0.04; P=.02; Cohen d=0.12). The uptake of iCBT by patients was similar to that of IAU. Implementers did not spend more time on implementation work when using the ItFits-toolkit and generally regarded the ItFits-toolkit as usable and were satisfied with it. Conclusions: The ItFits-toolkit performed better than the usual implementation activities in implementing iCBT services in routine practice. There is practical utility in the ItFits-toolkit for supporting implementers in developing and applying effective tailored implementation strategies. However, the effect on normalization levels among mental health service providers was small. These findings warrant modesty regarding the effectiveness of self-guided tailored implementation of iCBT services in routine practice. Trial Registration: ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-020-04686-4 UR - https://www.jmir.org/2023/1/e41532 UR - http://dx.doi.org/10.2196/41532 UR - http://www.ncbi.nlm.nih.gov/pubmed/36735287 ID - info:doi/10.2196/41532 ER - TY - JOUR AU - Zoellner, Jamie AU - Reid, Annie AU - Porter, Kathleen AU - Frederick, Christina AU - Hilgart, Michelle AU - Ritterband, Lee PY - 2023/2/1 TI - Development of a Digital Behavioral Intervention to Reduce the Consumption of Sugar-Sweetened Beverages Among Rural Appalachian Adults: Multiphased, Human-Centered Design Approach JO - JMIR Hum Factors SP - e41262 VL - 10 KW - eHealth KW - human-centered design KW - internet-based intervention KW - digital technology KW - Model for Internet Interventions KW - beverages KW - behavioral research KW - rural population KW - mobile phone N2 - Background: To avoid the low engagement and limited efficacy of digital behavioral health interventions, robust human-centered design (HCD) processes are needed. Objective: The primary objective of this study was to describe a flexible, step-by-step HCD process to develop digital behavioral health interventions by illustrating iSIPsmarter as an example. iSIPsmarter is a digital intervention for reducing the consumption of sugar-sweetened beverages (SSBs) that comprises 6 internet-based cores metered out over time to deliver the program content, an integrated SMS text message strategy to engage users in reporting SSB behaviors, and an electronic cellular-enabled scale for in-home weighing. The secondary objective is to illustrate the key components and characteristics of iSIPsmarter that resulted from the HCD process. Methods: The methods were guided by the Model for Internet Interventions and by best practices in HCD and instructional design processes (eg, rapid prototype development and think-aloud protocol). The 3-phased (ie, contextual, prototype testing, end user testing phases) process followed in this study included a series of 13 semistructured one-on-one interviews with 7 advisory team participants from the targeted Appalachian user group. The interviews were content coded by 2 researchers and then deductively coded to the suggested areas of digital behavioral health interventions. Results: The participants provided rich perspectives pertaining to iSIPsmarter?s appearance, behavioral prescriptions, burdens, content, delivery, message, participation, and assessment. These inputs included requests for built-in flexibility to account for varying internet and SMS text message accessibility among users; ideas to resolve the issues and problems encountered when using the prototypes, including those related to navigation and comprehension of content; ideas to enhance personalized feedback to support motivation and goal setting for SSB consumption and weight; and feedback to refine the development of realistic and relatable vignettes. The participants were able to interact with multiple prototype drafts, allowing researchers to capture and incorporate feedback related to the iSIPsmarter dashboard, daily SSB and weight diaries, action planning, core content, interactions, and vignettes. Conclusions: Using scientific models and established processes is critical for building robust and efficacious interventions. By applying an existing model and HCD and instructional design processes, we were able to identify assumptions and address the key areas of the iSIPsmarter intervention that were hypothesized to support users? engagement and promote behavior change. As evidenced by the rich feedback received from the advisory team members and the resulting iSIPsmarter product, the HCD methodology was instrumental in the development process. Although the final iSIPsmarter content is specific to improving SSB consumption behaviors among adults in rural areas, the intent is that this HCD process will have wide applications in the development of digital behavioral health interventions across multiple geographic and behavioral contexts. UR - https://humanfactors.jmir.org/2023/1/e41262 UR - http://dx.doi.org/10.2196/41262 UR - http://www.ncbi.nlm.nih.gov/pubmed/36724036 ID - info:doi/10.2196/41262 ER - TY - JOUR AU - d'Offay, Christine AU - Ng, Yi Xin AU - Alexander, Laura AU - Grant, Alison AU - Grahamslaw, Julia AU - Pagliari, Claudia AU - Reed, J. Matthew AU - Carson, Alan AU - Gillespie, C. David AU - Jamjoom, B. Aimun A. PY - 2023/2/1 TI - A Digital Health Intervention for Concussion: Development and Clinical Feasibility Study JO - JMIR Form Res SP - e43557 VL - 7 KW - concussion KW - digital intervention KW - behavior change KW - feasibility study N2 - Background: Concussion is a common condition that can lead to a constellation of symptoms that affect quality of life, social integration, and return to work. There are several evidence-based behavioral and psychological interventions that have been found to improve postconcussion symptom burden. However, these are not routinely delivered, and individuals receive limited support during their concussion recovery. Objective: This study aimed to develop and test the feasibility of a digital health intervention using a systematic evidence-, theory-, and person-based approach. Methods: This was a mixed methodology study involving a scoping review (n=21), behavioral analysis, and logic model to inform the intervention design and content. During development, the intervention was optimized with feedback from individuals who had experienced concussions (n=12) and health care professionals (n=11). The intervention was then offered to patients presenting to the emergency department with a concussion (n=50). Participants used the intervention freely and input symptom data as part of the program. A number of outcome measures were obtained, including participant engagement with the intervention, postconcussion symptom burden, and attitudes toward the intervention. A selection of participants (n=15) took part in in-depth qualitative interviews to understand their attitudes toward the intervention and how to improve it. Results: Engagement with the intervention functionality was 90% (45/50) for the symptom diary, 62% (31/50) for sleep time setting, 56% (28/50) for the alcohol tracker, 48% (24/50) for exercise day setting, 34% (17/50) for the thought diary, and 32% (16/50) for the goal setter. Metrics indicated high levels of early engagement that trailed off throughout the course of the intervention, with an average daily completion rate of the symptom diary of 28.23% (494/1750). A quarter of the study participants (13/50, 26%) were classified as high engagers who interacted with all the functionalities within the intervention. Quantitative and qualitative feedback indicated a high level of usability and positive perception of the intervention. Daily symptom diaries (n=494) demonstrated a wide variation in individual participant symptom burden but a decline in average burden over time. For participants with Rivermead scores on completion of HeadOn, there was a strong positive correlation (r=0.86; P<.001) between their average daily HeadOn symptom diary score and their end-of-program Rivermead score. Insights from the interviews were then fed back into development to optimize the intervention and facilitate engagement. Conclusions: Using this systematic approach, we developed a digital health intervention for individuals who have experienced a concussion that is designed to facilitate positive behavior change. Symptom data input as part of the intervention provided insights into postconcussion symptom burden and recovery trajectories. Trial Registration: ClinicalTrials.gov NCT05069948; https://clinicaltrials.gov/ct2/show/NCT05069948 UR - https://formative.jmir.org/2023/1/e43557 UR - http://dx.doi.org/10.2196/43557 UR - http://www.ncbi.nlm.nih.gov/pubmed/36724010 ID - info:doi/10.2196/43557 ER - TY - JOUR AU - Hojeij, Batoul AU - Schoenmakers, Sam AU - Willemsen, Sten AU - van Rossem, Lenie AU - Dinnyes, Andras AU - Rousian, Melek AU - Steegers-Theunissen, PM Regine PY - 2023/1/31 TI - The Effect of an eHealth Coaching Program (Smarter Pregnancy) on Attitudes and Practices Toward Periconception Lifestyle Behaviors in Women Attempting Pregnancy: Prospective Study JO - J Med Internet Res SP - e39321 VL - 25 KW - diet KW - lifestyle KW - attitudes KW - practices KW - eHealth KW - pregnancy KW - Smarter Pregnancy N2 - Background: Lifestyle behaviors during the periconception period contribute to achievement of a successful pregnancy. Assessment of attitudes and practices toward these modifiable behaviors can aid in identifying gaps in unhealthy lifestyle behaviors with impact on intervention effectiveness. Objective: This study investigates the effectiveness of coaching by the eHealth program Smarter Pregnancy during the periconception period on improvement of attitudes and practices toward fruit and vegetable intake and smoking in women attempting pregnancy through assisted reproductive technology (ART) or natural conception. Methods: Women attempting pregnancy through ART (n=1060) or natural conception (n=631) were selected during the periconception period. The intervention groups, conceived through ART or naturally, received Smarter Pregnancy coaching for 24 weeks, whereas the control group conceived through ART and did not receive coaching. Attitudes and practices at baseline and follow-up periods were obtained from self-administered online questionnaire provided by the program. Attitudes were assessed in women with unhealthy behaviors as their intention to increase their fruit and vegetable intake and to quit smoking using a yes/no question. Outcomes on practices, suggesting effectiveness, included daily fruit (pieces) and vegetable (grams) intake, and if women smoked (yes/no). Changes in attitudes and practices were compared at 12 and 24 weeks with baseline between the ART intervention and ART control groups, and within the intervention groups between ART and natural conception. Changes in practices at 12 and 24 weeks were also compared with baseline between women with negative attitude and positive attitude within the intervention groups: ART and natural conception. Analysis was performed using linear and logistic regression models adjusted for maternal confounders and baseline attitudes and practices. Results: The ART intervention group showed higher vegetable intake and lower odds for negative attitudes toward vegetable intake after 12 weeks (?adj=25.72 g, P<.001; adjusted odds ratio [ORadj] 0.24, P<.001) and 24 weeks of coaching (?adj=23.84 g, P<.001; ORadj 0.28, P<.001) compared with ART controls. No statistically significant effect was observed on attitudes and practices toward fruit intake (12 weeks: P=.16 and .08, respectively; 24 weeks: P=.16 and .08, respectively) and smoking behavior (12 weeks: P=.87; 24 weeks: P=.92). No difference was observed for the studied attitudes and practices between the ART intervention and natural conception intervention groups. Women with persistent negative attitude toward fruit and vegetable intake at week 12 showed lower fruit and vegetable intake at week 24 compared with women with positive attitude (?adj=?.49, P<.001; ?adj=?30.07, P<.001, respectively). Conclusions: The eHealth Smarter Pregnancy program may improve vegetable intake?related attitudes and practices in women undergoing ART treatment. Women with no intention to increase fruit and vegetable intake had less improvement in their intakes. Despite small changes, this study demonstrates again that Smarter Pregnancy can be used to improve vegetable intake, which can complemented by blended care that combines face-to-face and online care to also improve fruit intake and smoking behavior. UR - https://www.jmir.org/2023/1/e39321 UR - http://dx.doi.org/10.2196/39321 UR - http://www.ncbi.nlm.nih.gov/pubmed/36719733 ID - info:doi/10.2196/39321 ER - TY - JOUR AU - Kim, Keonhee AU - Shin, Sangyoon AU - Kim, Seungyeon AU - Lee, Euni PY - 2023/1/30 TI - The Relation Between eHealth Literacy and Health-Related Behaviors: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e40778 VL - 25 KW - eHealth literacy KW - digital health literacy KW - online health information KW - health-related behaviors KW - health-promoting behavior KW - meta-analysis N2 - Background: With widespread use of the internet and mobile devices, many people have gained improved access to health-related information online for health promotion and disease management. As the health information acquired online can affect health-related behaviors, health care providers need to take into account how each individual?s online health literacy (eHealth literacy) can affect health-related behaviors. Objective: To determine whether an individual?s level of eHealth literacy affects actual health-related behaviors, the correlation between eHealth literacy and health-related behaviors was identified in an integrated manner through a systematic literature review and meta-analysis. Methods: The MEDLINE, Embase, Cochrane, KoreaMed, and Research Information Sharing Service databases were systematically searched for studies published up to March 19, 2021, which suggested the relationship between eHealth literacy and health-related behaviors. Studies were eligible if they were conducted with the general population, presented eHealth literacy according to validated tools, used no specific control condition, and measured health-related behaviors as the outcomes. A meta-analysis was performed on the studies that could be quantitatively synthesized using a random effect model. A pooled correlation coefficient was generated by integrating the correlation coefficients, and the risk of bias was assessed using the modified Newcastle-Ottawa Scale. Results: Among 1922 eHealth literacy?related papers, 29 studies suggesting an association between eHealth literacy and health-related behaviors were included. All retrieved studies were cross-sectional studies, and most of them used the eHealth Literacy Scale (eHEALS) as a measurement tool for eHealth literacy. Of the 29 studies, 22 presented positive associations between eHealth literacy and health-related behaviors. The meta-analysis was performed on 14 studies that presented the correlation coefficient for the relationship between eHealth literacy and health-related behaviors. When the meta-analysis was conducted by age, morbidity status, and type of health-related behavior, the pooled correlation coefficients were 0.37 (95% CI 0.29-0.44) for older adults (aged ?65 years), 0.28 (95% CI 0.17-0.39) for individuals with diseases, and 0.36 (95% CI 0.27-0.41) for health-promoting behavior. The overall estimate of the correlation between eHealth literacy and health-related behaviors was 0.31 (95% CI 0.25-0.34), which indicated a moderate correlation between eHealth literacy and health-related behaviors. Conclusions: Our results of a positive correlation between eHealth literacy and health-related behaviors indicate that eHealth literacy can be a mediator in the process by which health-related information leads to changes in health-related behaviors. Larger-scale studies with stronger validity are needed to evaluate the detailed relationship between the proficiency level of eHealth literacy and health-related behaviors for health promotion in the future. UR - https://www.jmir.org/2023/1/e40778 UR - http://dx.doi.org/10.2196/40778 UR - http://www.ncbi.nlm.nih.gov/pubmed/36716080 ID - info:doi/10.2196/40778 ER - TY - JOUR AU - Yount, M. Kathryn AU - Cheong, Fai Yuk AU - Bergenfeld, Irina AU - Trang, Thu Quach AU - Sales, M. Jessica AU - Li, Yiman AU - Minh, Hung Tran PY - 2023/1/27 TI - Impacts of GlobalConsent, a Web-Based Social Norms Edutainment Program, on Sexually Violent Behavior and Bystander Behavior Among University Men in Vietnam: Randomized Controlled Trial JO - JMIR Public Health Surveill SP - e35116 VL - 9 KW - behavior change communication KW - bystander behavior KW - campus sexual assault KW - educational entertainment (edutainment) KW - sexual violence KW - social cognitive theory KW - social norms theory KW - Vietnam KW - mobile phone N2 - Background: Sexual violence against women is prevalent worldwide. Prevention programs that treat men as allies and integrate a bystander framework are emerging in lower income settings, but evidence of their effectiveness is conflicting. Objective: This study aimed to test the impact of GlobalConsent on sexually violent behavior and prosocial bystander behavior among university men in Vietnam. Methods: We used a double-blind, parallel intervention versus control group design with 1:1 randomization at 2 universities. A total of 793 consenting heterosexual or bisexual men aged 18-24 years who matriculated in September 2019 were enrolled and assigned randomly to GlobalConsent or an attention-control adolescent health education (AHEAD) program. GlobalConsent is an adapted, theory-based, 6-module web-based intervention with diverse behavior change techniques and a locally produced serial drama. AHEAD is a customized, 6-module attention-control program on adolescent health. Both the programs were delivered to computers and smartphones over 12 weeks. Self-reported sexually violent behaviors toward women in the prior 6 months and prosocial bystander behaviors in the prior year were measured at 0, 6, and 12 months. Results: More than 92.7% (735/793) of men in both study arms completed at least 1 program module, and >90.2% (715/793) of men completed all 6 modules. At baseline, a notable percentage of men reported any sexually violent behavior (GlobalConsent: 123/396, 31.1%; AHEAD: 103/397, 25.9%) in the prior 6 months. Among men receiving GlobalConsent, the odds of reporting a high level (at least 2 acts) of sexually violent behavior at the endline were 1.3 times the odds at baseline. Among men receiving AHEAD, the corresponding odds ratio was higher at 2.7. The odds of reporting any bystander behavior at endline were 0.7 times the odds at baseline for GlobalConsent, and the corresponding odds ratio for AHEAD was lower at 0.5. Conclusions: Compared with a health attention-control condition, GlobalConsent has sustained favorable impacts on sexually violent behavior and prosocial bystander behavior among matriculating university men in Vietnam, who would otherwise face increasing risks of sexually violent behavior. GlobalConsent shows promise for national scale-up and regional adaptations. Trial Registration: ClinicalTrials.gov NCT04147455; https://clinicaltrials.gov/ct2/show/NCT04147455 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-020-09454-2 UR - https://publichealth.jmir.org/2023/1/e35116 UR - http://dx.doi.org/10.2196/35116 UR - http://www.ncbi.nlm.nih.gov/pubmed/36705965 ID - info:doi/10.2196/35116 ER - TY - JOUR AU - Park, Junghwan AU - Norman, J. Gregory AU - Klasnja, Predrag AU - Rivera, E. Daniel AU - Hekler, Eric PY - 2023/1/27 TI - Development and Validation of Multivariable Prediction Algorithms to Estimate Future Walking Behavior in Adults: Retrospective Cohort Study JO - JMIR Mhealth Uhealth SP - e44296 VL - 11 KW - mobile health KW - mHealth KW - physical activity KW - walk KW - prediction KW - classification KW - multilayered perceptron KW - microrandomized trial KW - MRT KW - just-in-time adaptive intervention KW - JITAI KW - prevention KW - female KW - development KW - validation KW - application N2 - Background: Physical inactivity is associated with numerous health risks, including cancer, cardiovascular disease, type 2 diabetes, increased health care expenditure, and preventable, premature deaths. The majority of Americans fall short of clinical guideline goals (ie, 8000-10,000 steps per day). Behavior prediction algorithms could enable efficacious interventions to promote physical activity by facilitating delivery of nudges at appropriate times. Objective: The aim of this paper is to develop and validate algorithms that predict walking (ie, >5 min) within the next 3 hours, predicted from the participants? previous 5 weeks? steps-per-minute data. Methods: We conducted a retrospective, closed cohort, secondary analysis of a 6-week microrandomized trial of the HeartSteps mobile health physical-activity intervention conducted in 2015. The prediction performance of 6 algorithms was evaluated, as follows: logistic regression, radial-basis function support vector machine, eXtreme Gradient Boosting (XGBoost), multilayered perceptron (MLP), decision tree, and random forest. For the MLP, 90 random layer architectures were tested for optimization. Prior 5-week hourly walking data, including missingness, were used for predictors. Whether the participant walked during the next 3 hours was used as the outcome. K-fold cross-validation (K=10) was used for the internal validation. The primary outcome measures are classification accuracy, the Mathew correlation coefficient, sensitivity, and specificity. Results: The total sample size included 6 weeks of data among 44 participants. Of the 44 participants, 31 (71%) were female, 26 (59%) were White, 36 (82%) had a college degree or more, and 15 (34%) were married. The mean age was 35.9 (SD 14.7) years. Participants (n=3, 7%) who did not have enough data (number of days <10) were excluded, resulting in 41 (93%) participants. MLP with optimized layer architecture showed the best performance in accuracy (82.0%, SD 1.1), whereas XGBoost (76.3%, SD 1.5), random forest (69.5%, SD 1.0), support vector machine (69.3%, SD 1.0), and decision tree (63.6%, SD 1.5) algorithms showed lower performance than logistic regression (77.2%, SD 1.2). MLP also showed superior overall performance to all other tried algorithms in Mathew correlation coefficient (0.643, SD 0.021), sensitivity (86.1%, SD 3.0), and specificity (77.8%, SD 3.3). Conclusions: Walking behavior prediction models were developed and validated. MLP showed the highest overall performance of all attempted algorithms. A random search for optimal layer structure is a promising approach for prediction engine development. Future studies can test the real-world application of this algorithm in a ?smart? intervention for promoting physical activity. UR - https://mhealth.jmir.org/2023/1/e44296 UR - http://dx.doi.org/10.2196/44296 UR - http://www.ncbi.nlm.nih.gov/pubmed/36705954 ID - info:doi/10.2196/44296 ER - TY - JOUR AU - Oh, Jung Yoo AU - Hoffmann, J. Thomas AU - Fukuoka, Yoshimi PY - 2023/1/27 TI - A Novel Approach to Assess Weekly Self-efficacy for Meeting Personalized Physical Activity Goals Via a Cellphone: 12-Week Longitudinal Study JO - JMIR Form Res SP - e38877 VL - 7 KW - self-efficacy KW - physical activity KW - exercise KW - cellphone KW - mobile phone KW - application KW - app KW - Ecological Momentary Assessment N2 - Background: Despite the health benefits of engaging in regular physical activity (PA), the majority of American adults do not meet the PA guidelines for aerobic and muscle-strengthening activities. Self-efficacy, the belief that one can execute specific actions, has been suggested to be a strong determinant of PA behaviors. With the increasing availability of digital technologies, collecting longitudinal real-time self-efficacy and PA data has become feasible. However, evidence in longitudinal real-time assessment of self-efficacy in relation to objectively measured PA is scarce. Objective: This study aimed to examine a novel approach to measure individuals' real-time weekly self-efficacy in response to their personalized PA goals and performance over the 12-week intervention period in community-dwelling women who were not meeting PA guidelines. Methods: In this secondary data analysis, 140 women who received a 12-week PA intervention were asked to report their real-time weekly self-efficacy via a study mobile app. PA (daily step counts) was measured by an accelerometer every day for 12 weeks. Participants rated their self-efficacy on meeting PA goals (ranging from ?not confident? to ?very confident?) at the end of each week via a mobile app. We used a logistic mixed model to examine the association between weekly self-efficacy and weekly step goal success, controlling for age, BMI, self-reported White race, having a college education or higher, being married, and being employed. Results: The mean age was 52.7 (SD 11.5, range 25-68) years. Descriptive analyses showed the dynamics of real-time weekly self-efficacy on meeting PA goals and weekly step goal success. The majority (74.4%) of participants reported being confident in the first week, whereas less than half of them (46.4%) reported confidence in the final week of the intervention. Participants who met weekly step goals were 4.41 times more likely to be confident about achieving the following week's step goals than those who did not meet weekly step goals (adjusted odds ratio 4.41; 95% CI 2.59-7.50; P<.001). Additional analysis revealed that participants who were confident about meeting the following week?s step goals were 2.07 times more likely to meet their weekly step goals in the following week (adjusted odds ratio 2.07; 95% CI 1.16-3.70; P=.01). The significant bidirectional association between real-time self-efficacy and weekly step goal success was confirmed in a series of sensitivity analyses. Conclusions: This study demonstrates the potential utility of a novel approach to examine self-efficacy in real time for analysis of self-efficacy in conjunction with objectively measured PA. Discovering the dynamic patterns and changes in weekly self-efficacy on meeting PA goals may aid in designing a personalized PA intervention. Evaluation of this novel approach in an RCT is warranted. UR - https://formative.jmir.org/2023/1/e38877 UR - http://dx.doi.org/10.2196/38877 UR - http://www.ncbi.nlm.nih.gov/pubmed/36705945 ID - info:doi/10.2196/38877 ER - TY - JOUR AU - Gray, Gabrielle Hannah AU - Tchao, Danielle AU - Lewis-Fung, Samantha AU - Pardini, Susanna AU - Harris, R. Laurence AU - Appel, Lora PY - 2023/1/24 TI - Virtual Reality Therapy for People With Epilepsy and Related Anxiety: Protocol for a 3-Phase Pilot Clinical Trial JO - JMIR Res Protoc SP - e41523 VL - 12 KW - epilepsy KW - anxiety KW - virtual reality KW - exposure therapy KW - eHealth KW - digital health KW - virtual reality exposure therapy KW - cognitive behavioral therapy KW - CBT KW - nonpharmacological intervention KW - biomedical technology N2 - Background: Anxiety is one of the most common psychiatric comorbidities in people with epilepsy and often involves fears specifically related to the condition, such as anxiety related to the fear of having another seizure. These epilepsy- or seizure-related fears have been reported as being more disabling than the seizures themselves and significantly impact quality of life. Although research has suggested that exposure therapy (ET) is helpful in decreasing anxiety in people with epilepsy, no research to our knowledge has been conducted on ET in people with epilepsy using virtual reality (VR). The use of novel technologies such as an immersive VR head-mounted display for ET in this population offers several benefits. Indeed, using VR can increase accessibility for people with epilepsy with transportation barriers (eg, those who live outside urban centers or who have a suspended driver?s license owing to their condition), among other advantages. In the present research protocol, we describe the design of an innovative VR-ET program administered in the home that focuses on decreasing anxiety in people with epilepsy, specifically anxiety related to their epilepsy or seizures. Objective: Our primary objective is to examine the feasibility of the study protocol and proposed treatment as well as identify suggestions for improvement when designing subsequent larger clinical trials. Our secondary objective is to evaluate whether VR-ET is effective in decreasing anxiety in a pilot study. We hypothesize that levels of anxiety in people with epilepsy will decrease from using VR-ET. Methods: This mixed methods study comprises 3 phases. Phase 1 involves engaging with those with lived experience through a web-based questionnaire to validate assumptions about anxiety in people with epilepsy. Phase 2 involves filming videos using a 360° camera for the VR-ET intervention (likely consisting of 3 sets of scenes, each with 3 intensity levels) based on the epilepsy- and seizure-related fears most commonly reported in the phase 1 questionnaire. Finally, phase 3 involves evaluating the at-home VR-ET intervention and study methods using a series of validated scales, as well as semistructured interviews. Results: This pilot study was funded in November 2021. Data collection for phase 1 was completed as of August 7, 2022, and had a final sample of 18 participants. Conclusions: Our findings will add to the limited body of knowledge on anxiety in people with epilepsy and the use of VR in this population. We anticipate that the insights gained from this study will lay the foundation for a novel and accessible VR intervention for this underrecognized and undertreated comorbidity in people with epilepsy. Trial Registration: ClinicalTrials.gov NCT05296057; https://clinicaltrials.gov/ct2/show/NCT05296057 International Registered Report Identifier (IRRID): DERR1-10.2196/41523 UR - https://www.researchprotocols.org/2023/1/e41523 UR - http://dx.doi.org/10.2196/41523 UR - http://www.ncbi.nlm.nih.gov/pubmed/36692939 ID - info:doi/10.2196/41523 ER - TY - JOUR AU - Hietbrink, G. Eclaire A. AU - Middelweerd, Anouk AU - van Empelen, Pepijn AU - Preuhs, Katharina AU - Konijnendijk, J. Annemieke A. AU - Oude Nijeweme-d?Hollosy, Wendy AU - Schrijver, K. Laura AU - Laverman, D. Gozewijn AU - Vollenbroek-Hutten, R. Miriam M. PY - 2023/1/12 TI - A Digital Lifestyle Coach (E-Supporter 1.0) to Support People With Type 2 Diabetes: Participatory Development Study JO - JMIR Hum Factors SP - e40017 VL - 10 KW - eHealth KW - mHealth KW - diet KW - nutrition KW - physical activity KW - lifestyle change KW - coaching KW - dynamic tailoring KW - behavior change KW - blended care KW - type 2 diabetes KW - design KW - treatment KW - chronic disease KW - behavioral KW - theory KW - intervention KW - acceptability KW - usability KW - cost N2 - Background: A healthy lifestyle, including regular physical activity and a healthy diet, is becoming increasingly important in the treatment of chronic diseases. eHealth interventions that incorporate behavior change techniques (BCTs) and dynamic tailoring strategies could effectively support a healthy lifestyle. E-Supporter 1.0 is an eCoach designed to support physical activity and a healthy diet in people with type 2 diabetes (T2D). Objective: This paper aimed to describe the systematic development of E-Supporter 1.0. Methods: Our systematic design process consisted of 3 phases. The definition phase included the selection of the target group and formulation of intervention objectives, and the identification of behavioral determinants based on which BCTs were selected to apply in the intervention. In the development phase, intervention content was developed by specifying tailoring variables, intervention options, and decision rules. In the last phase, E-Supporter 1.0 integrated in the Diameter app was evaluated using a usability test in 9 people with T2D to assess intervention usage and acceptability. Results: The main intervention objectives were to stimulate light to moderate-vigorous physical activities or adherence to the Dutch dietary guidelines in people with T2D. The selection of behavioral determinants was informed by the health action process approach and theories explaining behavior maintenance. BCTs were included to address relevant behavioral determinants (eg, action control, self-efficacy, and coping planning). Development of the intervention resulted in 3 types of intervention options, consisting of motivational messages, behavioral feedback, and tailor-made supportive exercises. On the basis of IF-THEN rules, intervention options could be tailored to, among others, type of behavioral goal and (barriers to) goal achievement. Data on these variables could be collected using app data, activity tracker data, and daily ecological momentary assessments. Usability testing revealed that user experiences were predominantly positive, despite some problems in the fixed delivery of content. Conclusions: The systematic development approach resulted in a theory-based and dynamically tailored eCoach. Future work should focus on expanding intervention content to other chronic diseases and lifestyle behaviors, enhancing the degree of tailoring and evaluating intervention effects on acceptability, use, and cost-effectiveness. UR - https://humanfactors.jmir.org/2023/1/e40017 UR - http://dx.doi.org/10.2196/40017 UR - http://www.ncbi.nlm.nih.gov/pubmed/36633898 ID - info:doi/10.2196/40017 ER - TY - JOUR AU - Miles, M. Lisa AU - Hawkes, E. Rhiannon AU - French, P. David PY - 2023/1/11 TI - How the Behavior Change Content of a Nationally Implemented Digital Diabetes Prevention Program Is Understood and Used by Participants: Qualitative Study of Fidelity of Receipt and Enactment JO - J Med Internet Res SP - e41214 VL - 25 KW - diabetes prevention KW - digital interventions KW - behavior change KW - fidelity KW - receipt KW - enactment KW - mobile phone N2 - Background: The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a program for adults in England at risk of developing type 2 diabetes mellitus (T2DM). It is based on NHS England specifications that stipulate specific behavior change techniques (BCTs), that is, active ingredients to produce behavior change to target diet and physical activity. Now rolled out nationally, the NHS-DDPP is being delivered by 4 independent providers as a 9-month intervention via apps, educational material, and remote health coaching. To optimize effectiveness, participants need to be able to understand and use behavior change content (eg, goal setting and problem solving) of an intervention delivered to them digitally. Previous research has shown that people benefit from support to aid the understanding and use of BCTs. Objective: The objectives of this qualitative study were to evaluate how participants in the NHS-DDPP understand and use BCT content, investigate how participants describe the role of health coaches in supporting their behavior change, and examine how the understanding and use of behavior change content of the NHS-DDPP varies across providers. Methods: In total, 45 service users were interviewed twice by telephone at 2 to 4 months into, and at the end of, the program. Topics included participants? understanding and use of key BCTs to support self-regulation (eg, goal setting) and the support they received via the program. Transcripts were analyzed thematically, informed by the framework method. Results: Participants described their understanding and use of some behavior change content of the program as straightforward: use of BCTs (eg, self-monitoring of behavior) delivered digitally via provider apps. Participants valued the role of health coaches in supporting their behavior change through the emotional support they offered and their direct role in delivery and application of some BCTs (eg, problem solving) to their specific circumstances. Participants expressed frustration over the lack of monitoring or feedback regarding their T2DM risk within the program. Variations in the understanding and use of behavior change content of the NHS-DDPP were present across provider programs. Conclusions: Health coaches? support in delivery of key components of the program seems to be pivotal. To improve the understanding and use of BCTs in digital interventions, it is important to consider routes of delivery that offer additional interactive human support. Understanding of some self-regulatory BCTs may benefit from this support more than others; thus, identifying the optimal mode of delivery for behavior change content is a priority for future research. The NHS-DDPP could be improved by explicitly setting out the need for health coaches to support understanding of some self-regulatory BCT content such as problem solving in the service specification and amending the discharge process so that knowledge of any change in T2DM risk is available to participants. UR - https://www.jmir.org/2023/1/e41214 UR - http://dx.doi.org/10.2196/41214 UR - http://www.ncbi.nlm.nih.gov/pubmed/36630165 ID - info:doi/10.2196/41214 ER - TY - JOUR AU - Choukou, Mohamed-Amine AU - Olatoye, Funminiyi AU - Urbanowski, Reg AU - Caon, Maurizio AU - Monnin, Caroline PY - 2023/1/11 TI - Digital Health Technology to Support Health Care Professionals and Family Caregivers Caring for Patients With Cognitive Impairment: Scoping Review JO - JMIR Ment Health SP - e40330 VL - 10 KW - digital health KW - behavior change KW - mental health KW - cognitive impairment N2 - Background: Digital health technology is a promising way of supporting health care providers and family caregivers as they care for patients with cognitive impairment. Objective: This scoping review aimed to portray the use of digital health technology to assist health care providers and family caregivers in caring for patients with cognitive impairment who live in the community or in a facility. Methods: We conducted a scoping review of peer-reviewed scientific articles available in MEDLINE, PsycINFO, Scopus, and CINAHL with Full Text, as well as gray literature available in preprint servers, theses depositories, and various national and international dementia organizations? websites. The search yielded 975 articles, of which we included 7 (0.7%) in the review. Results: Of the 7 interventions included in the retrieved manuscripts, 2 (29%) were digital calendar reminder systems to support activities of daily living and medication management; 2 (29%) were apps on tablet devices to simulate the presence of family before therapy interventions; 1 (14%) was a social robot used in therapeutic sessions to include elements of musicotherapy, reminiscence, cognitive games, and relaxation; 1 (14%) was a commercially available computer system that provides access to various recreational leisure activities; and 1 (14%) was a web-based self-management support system that helps family caregivers to deal with behavior changes in a relative with dementia. Of the 7 articles, only 1 (14%) reported on the use of a behavior change theory, namely a comprehensive process model of engagement coupled with cognitive stimulation therapy. Conclusions: Literature on the topic is scarce, recent, and heterogeneous. There is a clear need for a theoretical framework to conceptualize and govern the use of behavior change models that incorporate technology for patients with cognitive impairment. UR - https://mental.jmir.org/2023/1/e40330 UR - http://dx.doi.org/10.2196/40330 UR - http://www.ncbi.nlm.nih.gov/pubmed/36630174 ID - info:doi/10.2196/40330 ER - TY - JOUR AU - Gosetto, Laetitia AU - Pittavino, Marta AU - Falquet, Gilles AU - Ehrler, Frederic PY - 2023/1/5 TI - Personalization of Mobile Apps for Health Behavior Change: Protocol for a Cross-sectional Study JO - JMIR Res Protoc SP - e38603 VL - 12 KW - mobile health KW - mHealth KW - personalization KW - mobile app KW - behavior change theory KW - gamification KW - functionalities N2 - Background: Mobile health apps have the potential to motivate people to adopt healthier behavior, but many fail to maintain this behavior over time. However, it has been suggested that long-term adherence can be improved by personalizing the proposed interventions. Based on the literature, we created a conceptual framework for selecting appropriate functionalities according to the user's profile. Objective: This cross-sectional study aims to investigate if the relationships linking functionalities and profiles proposed in our conceptual framework are confirmed by user preferences. Methods: A web-based questionnaire comprising several sections was developed to determine the mobile app functionalities most likely to promote healthier behavior. First, participants completed questionnaires to define the user profile (Big Five Inventory-10, Hexad Scale, and perception of the social norm using dimensions of the Theory of Planned Behavior). Second, participants were asked to select the 5 functionalities they considered to be the most relevant to motivate healthier behavior and to evaluate them on a score ranging from 0 to 100. We will perform logistic regressions with the selected functionalities as dependent variables and with the 3 profile scales as predictors to allow us to understand the effect of the participants? scores on each of the 3 profile scales on the 5 selected functionalities. In addition, we will perform logistic ordinal regressions with the motivation score of the functionalities chosen as dependent variables and with scores of the 3 profile scales as predictors to determine whether the scores on the different profile scales predict the functionality score. Results: Data collection was conducted between July and December 2021. Analysis of responses began in January 2022, with the publication of results expected by the end of 2022. Conclusions: This study will allow us to validate our conceptual model by defining the preferred functionalities according to user profiles. International Registered Report Identifier (IRRID): RR1-10.2196/38603 UR - https://www.researchprotocols.org/2023/1/e38603 UR - http://dx.doi.org/10.2196/38603 UR - http://www.ncbi.nlm.nih.gov/pubmed/36602850 ID - info:doi/10.2196/38603 ER - TY - JOUR AU - Hu, Qiuyue AU - Hu, Wei AU - Han, Wenjuan AU - Pan, Lingling PY - 2022/12/23 TI - Web-Based Short Video Intervention and Short Message Comparison of Repeat Blood Donation Behavior Based on an Extended Theory of Planned Behavior: Prospective Randomized Controlled Trial Study JO - J Med Internet Res SP - e37467 VL - 24 IS - 12 KW - extended theory of planned behavior KW - repeated blood donation intervention KW - randomized controlled trial KW - mobile phone N2 - Background: Although blood is an indispensable and important resource for clinical treatment, an imbalance between supply and demand may occur as the population ages and diversifies. Studies indicate that repeat blood donors are safe blood sources because of their voluntary blood donation education and frequent blood screening. However, the high rate of reduction in the number of first-time voluntary blood donors and low rate of repeated blood donation are common problems worldwide. Objective: This study aimed to evaluate the effect of an intervention in nonregular blood donors using web-based videos and SMS text messages, in which the former was guided by the extended theory of planned behavior, to discover effective intervention methods to improve repeat blood donation rates among nonregular blood donors. Methods: A total of 692 nonregular blood donors in Zhejiang province were randomly divided into intervention and control groups. The control group received regular, short reminder messages for a 6-month period, whereas the intervention group received web-based videos on the WeChat platform. The intervention group was guided by an extended theory of planned behavior, which included 9 factors: the respondents? attitude, subjective behavioral norms, perceived behavioral control, the willingness to donate blood, outcome expectations, self-identity, blood donation?related anxiety, cognition of the blood donation environment, and previous blood donation experience. The intervention group was divided into 2 stages: those with an intervention at 3 months and those with a follow-up 3 months later. After 6 months, the redonation rate was evaluated for the 2 groups, and the scale in the intervention group was determined both before and after the intervention. A t test, chi-square test, logistic stepwise regression, and ANOVA were performed. Results: The intervention group?s redonation rate was 16.14%, which was significantly higher than the control group?s redonation rate of 5.16%; P<.001. Men who were aged 31 to 45 years and had donated blood twice had a higher redonation rate after the web-based video intervention than after the SMS text messages; P<.05. The repeat donors? improved blood donation anxiety (P=.01), outcome expectations (P=.008), and cognition of the blood donation environment (P=.005) after the intervention were significantly higher than those of the nonrepeat donors. Conclusions: The web-based short video intervention based on the extended theory of planned behavior can effectively improve redonation rates. Outcome expectations, blood donation anxiety, and cognition of the blood donation environment can directly influence irregular blood donors to redonate blood. UR - https://www.jmir.org/2022/12/e37467 UR - http://dx.doi.org/10.2196/37467 UR - http://www.ncbi.nlm.nih.gov/pubmed/36379691 ID - info:doi/10.2196/37467 ER - TY - JOUR AU - Herrijgers, Corinne AU - Platteau, Tom AU - Vandebosch, Heidi AU - Poels, Karolien AU - Florence, Eric PY - 2022/12/21 TI - Using Intervention Mapping to Develop an mHealth Intervention to Support Men Who Have Sex With Men Engaging in Chemsex (Budd): Development and Usability Study JO - JMIR Res Protoc SP - e39678 VL - 11 IS - 12 KW - mobile health KW - chemsex KW - intervention mapping KW - harm reduction KW - men who have sex with men KW - intervention KW - mobile phone N2 - Background: Chemsex refers to the intentional use of drugs before or during sex among men who have sex with men (MSM). Engaging in chemsex has been linked to significant negative impacts on physical, psychological, and social well-being. However, no evidence-based support tools have addressed either these harms or the care needs of MSM who engage in chemsex. Objective: The purpose of this paper was to describe the development of a mobile health intervention (named Budd) using the intervention mapping protocol (IMP). Budd aims to support and inform MSM who participate in chemsex, reduce the negative impacts associated with chemsex, and encourage more reasoned participation. Methods: The IMP consists of 6 steps to develop, implement, and evaluate evidence-based health interventions. A needs assessment was carried out between September 2, 2019, and March 31, 2020, by conducting a literature study and in-depth interviews. Change objectives were selected based on these findings, after which theory-based intervention methods were selected. The first version of the intervention was developed in December 2020 and pilot-tested between February 1, 2021, and April 30, 2021. Adjustments were made based on the findings from this study. A separate article will be dedicated to the effectiveness study, conducted between October 15, 2021, and February 24, 2022, and implementation of the intervention. The Budd app went live in April 2022. Results: Budd aims to address individual factors and support chemsex participants in applying harm reduction measures when taking drugs (drug information, drug combination tool, and notebook), preparing for participation in a chemsex session (articles on chemsex, preparation tool, and event-specific checklist), planning sufficient time after a chemsex session to recover (planning tool), seeking support for their chemsex participation (overview of existing local health care and peer support services, reflection, personal statistics, and user testimonials), taking HIV medication or pre-exposure prophylaxis in a timely manner during a chemsex session (preparation tool), and contacting emergency services in case of an emergency and giving first aid to others (emergency information and personal buddy). Conclusions: The IMP proved to be a valuable tool in the planning and development of the Budd app. This study provides researchers and practitioners with valuable information that may help them to set up their own health interventions. International Registered Report Identifier (IRRID): RR1-10.2196/39678 UR - https://www.researchprotocols.org/2022/12/e39678 UR - http://dx.doi.org/10.2196/39678 UR - http://www.ncbi.nlm.nih.gov/pubmed/36542451 ID - info:doi/10.2196/39678 ER - TY - JOUR AU - Juarascio, S. Adrienne AU - Srivastava, Paakhi AU - Presseller, K. Emily AU - Lin, Mandy AU - Patarinski, G. Anna G. AU - Manasse, M. Stephanie AU - Forman, M. Evan PY - 2022/12/14 TI - Using Continuous Glucose Monitoring to Detect and Intervene on Dietary Restriction in Individuals With Binge Eating: The SenseSupport Withdrawal Design Study JO - JMIR Form Res SP - e38479 VL - 6 IS - 12 KW - binge eating KW - loss-of-control eating KW - continuous glucose monitoring KW - mobile phone N2 - Background: Dietary restraint is a key factor for maintaining engagement in binge eating among individuals with binge eating disorder (BED) and bulimia nervosa (BN). Reducing dietary restraint is a mechanism of change in cognitive behavioral therapy (CBT) for individuals with BN and BED. However, many individuals who undergo CBT fail to adequately reduce dietary restraint during treatment, perhaps owing to difficulty in using treatment skills (eg, regular eating) to reduce dietary restraint during their daily lives. The SenseSupport system, a novel just-in-time, adaptive intervention (JITAI) system that uses continuous glucose monitoring to detect periods of dietary restraint, may improve CBT to reduce dietary restraint during treatment by providing real-time interventions. Objective: This study aimed to describe the feasibility, acceptability, and initial evaluation of SenseSupport. We presented feasibility, acceptability, target engagement, and initial treatment outcome data from a small trial using an ABAB (A=continuous glucose monitoring data sharing and JITAIs-Off, B=continuous glucose monitoring data sharing and JITAIs-On) design (in which JITAIs were turned on for 2 weeks and then turned off for 2 weeks throughout the treatment). Methods: Participants (N=30) were individuals with BED or BN engaging in ?3 episodes of ?5 hours without eating per week at baseline. Participants received 12 sessions of CBT and wore continuous glucose monitors to detect eating behaviors and inform the delivery of JITAIs. Participants completed 4 assessments and reported eating disorder behaviors, dietary restraint, and barriers to app use weekly throughout treatment. Results: Retention was high (25/30, 83% after treatment). However, the rates of continuous glucose monitoring data collection were low (67.4% of expected glucose data were collected), and therapists and participants reported frequent app-related issues. Participants reported that the SenseSupport system was comfortable, minimally disruptive, and easy to use. The only form of dietary restraint that decreased significantly more rapidly during JITAIs-On periods relative to JITAIs-Off periods was the desire for an empty stomach (t43=1.69; P=.049; Cohen d=0.25). There was also a trend toward greater decrease in overall restraint during JITAs-On periods compared with JITAIs-Off periods, but these results were not statistically significant (t43=1.60; P=.06; Cohen d=0.24). There was no significant difference in change in the frequency of binge eating during JITAIs-On periods compared with JITAIs-Off periods (P=.23). Participants demonstrated clinically significant, large decreases in binge eating (t24=10.36; P<.001; Cohen d=2.07), compensatory behaviors (t24=3.40; P=.001; Cohen d=0.68), and global eating pathology (t24=6.25; P<.001; Cohen d=1.25) from pre- to posttreatment. Conclusions: This study describes the successful development and implementation of the first intervention system combining passive continuous glucose monitors and JITAIs to augment CBT for binge-spectrum eating disorders. Despite the lower-than-anticipated collection of glucose data, the high acceptability and promising treatment outcomes suggest that the SenseSupport system warrants additional investigation via future, fully powered clinical trials. Trial Registration: ClinicalTrials.gov NCT04126694; https://clinicaltrials.gov/ct2/show/NCT04126694 UR - https://formative.jmir.org/2022/12/e38479 UR - http://dx.doi.org/10.2196/38479 UR - http://www.ncbi.nlm.nih.gov/pubmed/36515992 ID - info:doi/10.2196/38479 ER - TY - JOUR AU - Kanning, Martina AU - Bollenbach, Lukas AU - Schmitz, Julian AU - Niermann, Christina AU - Fina, Stefan PY - 2022/11/25 TI - Analyzing Person-Place Interactions During Walking Episodes: Innovative Ambulatory Assessment Approach of Walking-Triggered e-Diaries JO - JMIR Form Res SP - e39322 VL - 6 IS - 11 KW - ecological momentary assessment KW - active transport KW - socio-ecological model KW - subjective well-being KW - mental health KW - urban health KW - GEMA KW - geographically explicit ecological momentary assessment KW - behaviour change KW - walking KW - experience KW - environment KW - monitoring KW - activity KW - tracking KW - e-diary KW - assessment N2 - Background: Walking behavior is positively associated with physiological and mental health as much evidence has already shown. Walking is also becoming a critical issue for health promotion in urban environments as it is the most often used form of active mobility and helps to replace carbon dioxide emissions from motorized forms of transport. It therefore contributes to mitigate the negative effects of climate change and heat islands within cities. However, to promote walking among urban dwellers and to utilize its health-enhancing potential, we need to know more about the way in which physical and social environments shape individual experiences during walking episodes. Such person-place interactions could not adequately be analyzed in former studies owing to methodological constraints. Objective: This study introduces walking-triggered e-diaries as an innovative ambulatory assessment approach for time-varying associations, and investigates its accuracy with 2 different validation strategies. Methods: The walking trigger consists of a combination of movement acceleration via an accelerometer and mobile positioning of the cellphone via GPS and transmission towers to track walking activities. The trigger starts an e-diary whenever a movement acceleration exceeds a predetermined threshold and participants' locations are identified as nonstationary outside a predefined place of residence. Every 420 (±300) seconds, repeated e-diaries were prompted as long as the trigger conditions were met. Data were assessed on 10 consecutive days. First, to investigate accuracy, we reconstructed walking routes and calculated a percentage score for all triggered prompts in relation to all walking routes where a prompt could have been triggered. Then, to provide data about its specificity, we used momentary self-reports and objectively assessed movement behavior to describe activity levels before the trigger prompted an e-diary. Results: Data of 67 participants could be analyzed and the walking trigger led to 3283 e-diary prompts, from which 2258 (68.8%) were answered. Regarding accuracy, the walking trigger prompted an e-diary on 732 of 842 (86.9%) reconstructed walking routes. Further, in 838 of 1206 (69.5%) triggered e-diaries, participants self-reported that they were currently walking outdoors. Steps and acceleration movement was higher during these self-reported walking episodes than when participants denied walking outdoors (steps: 106 vs 32; acceleration>0.2 g in 58.4% vs 19% of these situations). Conclusions: Accuracy analysis revealed that walking-triggered e-diaries are suitable to collect different data of individuals' current experiences in situations in which a person walks outdoors. Combined with environmental data, such an approach increases knowledge about person-place interactions and provides the possibility to gain knowledge about user preferences for health-enhancing urban environments. From a methodological viewpoint, however, specificity analysis showed how changes in trigger conditions (eg, increasing the threshold for movement acceleration) lead to changes in accuracy. UR - https://formative.jmir.org/2022/11/e39322 UR - http://dx.doi.org/10.2196/39322 UR - http://www.ncbi.nlm.nih.gov/pubmed/36427231 ID - info:doi/10.2196/39322 ER - TY - JOUR AU - Kaseva, Kaisa AU - Tervaniemi, Mari AU - Heikura, Enni AU - Kostilainen, Kaisamari AU - Pöyhönen-Alho, Maritta AU - Shoemaker, Kevin J. AU - Petrella, J. Robert AU - Peltonen, E. Juha PY - 2022/11/25 TI - Identifying Personality Characteristics and Indicators of Psychological Well-Being Associated With Attrition in the Motivation Makes the Move! Physical Activity Intervention: Randomized Technology-Supported Trial JO - JMIR Form Res SP - e30285 VL - 6 IS - 11 KW - randomized trial KW - physical activity KW - lifestyles KW - personality KW - psychological well-being KW - study attrition KW - mental health KW - lifestyle interventions N2 - Background: Data attrition has been a common problem in longitudinal lifestyle interventions. The contributors to attrition in technology-supported physical activity interventions have not been thoroughly studied. Objective: The present study examined the roles of personality characteristics and indicators of psychological well-being in data attrition within a technology-supported, longitudinal intervention study with overweight adults. Methods: Participants (N=89) were adults from the Motivation Makes the Move! intervention study. Data attrition was studied after a 3-month follow-up. Participants? personality characteristics were studied using the Short Five self-report questionnaire. Psychological well-being indicators were assessed with the RAND 36-item health survey, Positive and Negative Affect Schedule, and Beck Depression Inventory. Logistic regression analyses were conducted to assess the risk of discontinuing the study. The analyses were adjusted for sex, age, study group, and educational status. Results: At the 3-month follow-up, 65 of 89 participants (73% of the initial sample) had continued in the study. Participants? personality characteristics and indicators of psychological well-being were not associated with the risk of dropping out of the study (all P values >.05). The results remained the same after covariate controls. Conclusions: Participant attrition was not attributable to personality characteristics or psychological well-being in the Motivation Makes the Move! study conducted with overweight adults. As attrition remains a challenge within longitudinal, technology-supported lifestyle interventions, attention should be paid to the potentially dynamic natures of personality and psychological well-being, as well as other elements beyond these. Trial Registration: ClinicalTrials.gov NCT02686502; https://clinicaltrials.gov/ct2/show/NCT02686502 UR - https://formative.jmir.org/2022/11/e30285 UR - http://dx.doi.org/10.2196/30285 UR - http://www.ncbi.nlm.nih.gov/pubmed/36427239 ID - info:doi/10.2196/30285 ER - TY - JOUR AU - Tatar, Ovidiu AU - Abdel-Baki, Amal AU - Wittevrongel, Anne AU - Lecomte, Tania AU - Copeland, Jan AU - Lachance-Touchette, Pamela AU - Coronado-Montoya, Stephanie AU - Côté, José AU - Crockford, David AU - Dubreucq, Simon AU - L'Heureux, Sophie AU - Ouellet-Plamondon, Clairélaine AU - Roy, Marc-André AU - Tibbo, G. Philip AU - Villeneuve, Marie AU - Jutras-Aswad, Didier PY - 2022/11/25 TI - Reducing Cannabis Use in Young Adults With Psychosis Using iCanChange, a Mobile Health App: Protocol for a Pilot Randomized Controlled Trial (ReCAP-iCC) JO - JMIR Res Protoc SP - e40817 VL - 11 IS - 11 KW - psychological intervention KW - behavioral intervention KW - cannabis misuse KW - cannabis use disorder KW - drug use KW - substance use KW - cannabis KW - marijuana KW - young adult KW - teenager KW - psychosis KW - schizophrenia KW - mental health KW - disorder KW - dual diagnosis KW - telemedicine KW - mobile health KW - mHealth KW - digital health KW - eHealth KW - app KW - smartphone KW - mobile phone KW - randomized controlled trial KW - RCT KW - cognitive behavioral therapy KW - CBT KW - motivational interviewing KW - behavioral management KW - self-management KW - drug KW - substance KW - protocol KW - interview KW - behavior KW - outcome N2 - Background: Cannabis use is the most prevalent among adolescents and young adults; frequent consumption is associated with cannabis use disorder (CUD) and psychosis, with a high prevalence (up to 50%) of CUD in individuals with first-episode psychosis (FEP). Early Intervention Services (EIS) for psychosis include face-to-face psychosocial interventions for CUD, because reducing or discontinuing cannabis use improves clinical and health care service use outcomes. However, multiple barriers (eg, staff availability and limited access to treatment) can hinder the implementation of these interventions. Mobile health (mHealth) interventions may help circumvent some of these barriers; however, to date, no study has evaluated the effects of mHealth psychological interventions for CUD in individuals with FEP. Objective: This study describes the protocol for a pilot randomized controlled trial using a novel mHealth psychological intervention (iCanChange [iCC]) to address CUD in young adults with FEP. iCC was developed based on clinical evidence showing that in individuals without psychosis, integrating the principles of cognitive behavioral therapy, motivational interviewing, and behavioral self-management approaches are effective in improving cannabis use?related outcomes. Methods: Consenting individuals (n=100) meeting the inclusion criteria (eg, aged 18-35 years with FEP and CUD) will be randomly allocated in a 1:1 ratio to the intervention (iCC+modified EIS) or control (EIS) group. The iCC is fully automatized and contains 21 modules that are completed over a 12-week period and 3 booster modules available during the 3-month follow-up period. Validated self-report measures will be taken via in-person assessments at baseline and at 6, 12 (end point), and 24 weeks (end of trial); iCC use data will be collected directly from the mobile app. Primary outcomes are intervention completion and trial retention rates, and secondary outcomes are cannabis use quantity, participant satisfaction, app use, and trial recruiting parameters. Exploratory outcomes include severity of psychotic symptoms and CUD severity. For primary outcomes, we will use the chi-square test using data collected at week 12. We will consider participation in iCC acceptable if ?50% of the participants complete at least 11 out of 21 intervention modules and the trial feasible if attrition does not reach 50%. We will use analysis of covariance and mixed-effects models for secondary outcomes and generalized estimating equation multivariable analyses for exploratory outcomes. Results: Recruitment began in July 2022, and data collection is anticipated to be completed in July 2024. The main results are expected to be submitted for publication in 2024. We will engage patient partners and other stakeholders in creating a multifaceted knowledge translation plan to reach a diverse audience. Conclusions: If feasible, this study will provide essential data for a larger-scale efficacy trial of iCC on cannabis use outcomes in individuals with FEP and CUD. Trial Registration: ClinicalTrials.gov NCT05310981; https://www.clinicaltrials.gov/ct2/show/NCT05310981 International Registered Report Identifier (IRRID): PRR1-10.2196/40817 UR - https://www.researchprotocols.org/2022/11/e40817 UR - http://dx.doi.org/10.2196/40817 UR - http://www.ncbi.nlm.nih.gov/pubmed/36427227 ID - info:doi/10.2196/40817 ER - TY - JOUR AU - Mullan, Barbara AU - Liddelow, Caitlin AU - Haywood, Darren AU - Breare, Hayley PY - 2022/11/18 TI - Behavior Change Training for Health Professionals: Evaluation of a 2-Hour Workshop JO - JMIR Form Res SP - e42010 VL - 6 IS - 11 KW - behaviour change KW - psychology KW - psychological KW - BCT KW - health professional KW - health care professional KW - medical education KW - health care provider KW - continuing education KW - professional development KW - theory of planned behaviour KW - COM-B KW - workshop KW - intervention KW - clinical practice N2 - Background: Rates of noncommunicable diseases continue to rise worldwide. Many of these diseases are a result of engaging in risk behaviors. Without lifestyle and behavioral intervention, noncommunicable diseases can worsen and develop into more debilitating diseases. Behavioral interventions are an effective strategy to reduce the burden of disease. Behavior change techniques can be described as the ?active ingredients? in behavior change and address the components that need to be altered in order for the target behavior to change. Health professionals, such as pharmacists and nurses, can engage in opportunistic behavior change with their patients, to encourage positive health behaviors. Objective: We aimed to develop, implement, and evaluate a behavior change workshop targeted at health professionals in Australia, with the goal of increasing knowledge of behavior change techniques and psychological variables. Methods: A prospective study design was used to develop and evaluate a 2-hour behavior change workshop targeted at health professionals. The workshop was developed based on the Capability, Opportunity, Motivation, and Behavior Model and had five core objectives: (1) to detail the role of health professionals in delivering optimal care, (2) to demonstrate opportunities to change behavior, (3) to describe principles of behavior change, (4) to explain behavior change techniques, and (5) to determine the most appropriate behavior change techniques to use and when to use them. A total of 10 workshops were conducted. To evaluate the workshops and identify any potential long-term changes in behavior, we collected pre- and postworkshop data on knowledge and psychological constructs from the attendees. Results: A final sample of 41 health professionals comprising general practitioners, nurses, and pharmacists completed the pre- and postworkshop surveys. Following the workshops, there were significant improvements in knowledge of behavior change techniques (t40=?5.27, P<.001), subjective norms (t40=?3.49, P=.001), descriptive norms (t40=?3.65, P<.001), perceived behavioral control (t40=?3.30, P=.002), and intention (t36=?3.32, P=.002); each had a large effect size. There was no significant difference in postworkshop attitude (t40=0.78, P=.44). The participants also found the workshops to be highly acceptable. Conclusions: A 2-hour, theoretically informed workshop designed to facilitate the use of behavior change techniques by health professionals was shown to be largely effective. The workshops resulted in increases in knowledge, descriptive and subjective norms, perceived behavioral control, and intention, but not in attitude. The intervention was also shown to be highly acceptable, with the large majority of participants deeming the intervention to be needed, useful, appropriate, and applicable, as well as interesting and worth their time. Future research should examine the lasting impacts of the workshop on health professionals? practices. UR - https://formative.jmir.org/2022/11/e42010 UR - http://dx.doi.org/10.2196/42010 UR - http://www.ncbi.nlm.nih.gov/pubmed/36399382 ID - info:doi/10.2196/42010 ER - TY - JOUR AU - Anderson, M. Katherine AU - Stockman, K. Jamila PY - 2022/11/17 TI - Fear of COVID-19 and Prevention Behaviors: Cross-Lagged Panel Analysis JO - JMIR Form Res SP - e35730 VL - 6 IS - 11 KW - fear appeals KW - structural equation modelling KW - cross-lagged model KW - prevention behavior KW - COVID-19 KW - fear KW - women KW - behavior KW - change KW - health KW - physical distance KW - relationships KW - pandemic KW - research KW - association KW - prevention KW - experience KW - panel KW - interest KW - public KW - distancing N2 - Background: The ongoing COVID-19 pandemic has brought forth conversations about effective behavior change models for increasing prevention behavior, ranging from wearing masks in public to physical distancing. Among the considered behavior change techniques is the use of fear appeals, through which a negative possible outcome is emphasized to invoke fear, which in turn may promote prevention behaviors to counter the likelihood of the negative outcome. Although fear is hypothesized as health promoting in some theories of health behavior, little research has rigorously assessed the relationship. Objective: In our exploratory analyses, we aim to examine the association, including directionality of the association between fear of COVID-19 and COVID-19 prevention behaviors across 2 time points during the early COVID-19 pandemic among a sample of US women. Methods: The COPE study, a web-based survey of US women?s COVID-19 experiences, was deployed in May-June 2020 (time 1) with follow-up in December 2020-January 2021 (time 2; n=200). Demographic characteristics as well as fear of COVID-19 and COVID-19 prevention behaviors (eg, staying home except for essential activities, physical distancing in public, and masking in public) were measured. Descriptive and bivariate analyses were used to characterize COVID-19 prevention behaviors and fear of COVID-19 among participants. Cross-lagged panel analysis, a type of structural equation modeling that assesses directionality of temporal associations, was used to understand relationships, if any, between variables of interest. Results: We found cross-sectional associations between fear of COVID-19 and staying home and physical distancing, as well as temporal associations between fear at time 1 and time 2 and prevention behaviors at time 1 and time 2. However, results of the cross-lagged panel analysis indicated no cross-lagged temporal relationships between fear of COVID-19 and COVID-19 prevention behaviors 6 months apart. Conclusions: Fear of COVID-19 did not appear to predict COVID-19 prevention behaviors 6 months after initial measurements among the sample of women recruited for our study. Future research should rigorously test these associations longitudinally, and alternative methods of public health prevention promotion should be considered. UR - https://formative.jmir.org/2022/11/e35730 UR - http://dx.doi.org/10.2196/35730 UR - http://www.ncbi.nlm.nih.gov/pubmed/36346895 ID - info:doi/10.2196/35730 ER - TY - JOUR AU - Sha, Leihao AU - Yang, Xia AU - Deng, Renhao AU - Wang, Wen AU - Tao, YuJie AU - Cao, HaiLing AU - Ma, Qianshu AU - Wang, Hao AU - Nie, Yirou AU - Leng, Siqi AU - Lv, Qiuyue AU - Li, Xiaojing AU - Wang, Huiyao AU - Meng, Yajing AU - Xu, Jiajun AU - Greenshaw, J. Andrew AU - Li, Tao AU - Guo, Wan-jun PY - 2022/11/16 TI - Automated Digital Interventions and Smoking Cessation: Systematic Review and Meta-analysis Relating Efficiency to a Psychological Theory of Intervention Perspective JO - J Med Internet Res SP - e38206 VL - 24 IS - 11 KW - smoking cessation KW - automated KW - digital intervention KW - psychological theory KW - meta-analysis KW - systematic review KW - public health KW - side effects KW - interventions KW - randomized controlled trial KW - self-help N2 - Background: Smoking remains a highly significant preventable global public health problem. In this context, digital interventions offer great advantages in terms of a lack of biological side effects, possibility of automatic delivery, and consequent human resource savings relative to traditional interventions. Such interventions have been studied in randomized controlled trials (RCTs) but have not been systematically reviewed with the inclusion of text-based and multiplatform-based interventions. In addition, this area has not been evaluated from the perspective of the psychological theoretical basis of intervention. Objective: The aim of this paper is to assess the efficiency of digital interventions in RCT studies of smoking cessation and to evaluate the effectiveness of the strategies used for digital interventions. Methods: An electronic search of RCTs was conducted using PubMed, Embase, and the Cochrane Library by June 30, 2021. Eligible studies had to compare automated digital intervention (ADI) to the use of a self-help guideline or no intervention. Participants were current smokers (aged 16 years or older). As the main outcome, abstinence after endpoint was extracted from the studies. Systematic review and meta-analysis were conducted to assess the efficiency of ADIs. Metaregressions were conducted to assess the relationship between intervention theory and effectiveness. Results: A total of 19 trials (15,472 participants) were included in the analysis. The overall abstinence rate (95% CI) at the endpoint was 17.8% (17.0-18.7). The overall risk ratio of the intervention group compared to the controls at the endpoint was 17.8% (17.0-18.7). Cochrane risk-of-bias tool for randomized trials (ROB 2) suggested that most of the studies had a low risk of bias (56.3%). Psychological theory?related constructs or predictors, which refer to other theory-based concepts (rather than only behavioral theory) such as craving or anxiety, are associated with effectiveness. Conclusions: This study found that ADI had a clear positive effect compared to self-help guidelines or to no intervention, and effectiveness was associated with theory-related constructs or predictors. ADIs should be promoted by policy makers and clinical practitioners to address the huge gap between the need for smoking cessation and availability of traditional treatment resources. Possible increases in ADI efficiency may be achieved by optimally integrating psychotherapeutic theories and techniques. Trial Registration: PROSPERO CRD42021256593; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=256593 UR - https://www.jmir.org/2022/11/e38206 UR - http://dx.doi.org/10.2196/38206 UR - http://www.ncbi.nlm.nih.gov/pubmed/36383408 ID - info:doi/10.2196/38206 ER - TY - JOUR AU - Lightfoot, J. Courtney AU - Wilkinson, J. Thomas AU - Hadjiconstantinou, Michelle AU - Graham-Brown, Matthew AU - Barratt, Jonathan AU - Brough, Christopher AU - Burton, O. James AU - Hainsworth, Jenny AU - Johnson, Vicki AU - Martinez, Maria AU - Nixon, C. Andrew AU - Pursey, Victoria AU - Schreder, Sally AU - Vadaszy, Noemi AU - Wilde, Lucina AU - Willingham, Fiona AU - Young, L. Hannah M. AU - Yates, Thomas AU - Davies, J. Melanie AU - Smith, C. Alice PY - 2022/11/14 TI - The Codevelopment of ?My Kidneys & Me?: A Digital Self-management Program for People With Chronic Kidney Disease JO - J Med Internet Res SP - e39657 VL - 24 IS - 11 KW - kidney disease awareness KW - kidney disease knowledge KW - program development KW - eHealth KW - digital health KW - telehealth KW - mobile health KW - mHealth KW - health promotion KW - self-management behaviors KW - mobile phone N2 - Background: Health care self-management is important for people living with nondialysis chronic kidney disease (CKD). However, the few available resources are of variable quality. Objective: This work describes the systematic codevelopment of ?My Kidneys & Me? (MK&M), a theory-driven and evidence-based digital self-management resource for people with nondialysis CKD, guided by an established process used for the successful development of the diabetes education program MyDESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed, DESMOND). Methods: A multidisciplinary steering group comprising kidney health care professionals and researchers and specialists in the development of complex interventions and digital health provided expertise in the clinical and psychosocial aspects of CKD, self-management, digital health, and behavior change. A patient and public involvement group helped identify the needs and priorities of MK&M and co-design the resource. MK&M was developed in 2 sequential phases. Phase 1 involved the codevelopment process of the MK&M resource (content and materials), using Intervention Mapping (IM) as a framework. The first 4 IM steps guided the development process: needs assessment was conducted to describe the context of the intervention; intervention outcomes, performance objectives, and behavioral determinants were identified; theory- and evidence-based change methods and practical strategies to deliver change methods were selected; and program components were developed and refined. Phase 2 involved the adoption and adaptation of the existing MyDESMOND digital platform to suit the MK&M resource. Results: The needs assessment identified that individuals with CKD have multiple differing needs and that delivering a self-management program digitally would enable accessible, tailored, and interactive information and support. The intended outcomes of MK&M were to improve and maintain effective self-management behaviors, including physical activity and lifestyle, improve knowledge, promote self-care skills, increase self-efficacy, and enhance well-being. This was achieved through the provision of content and materials designed to increase CKD knowledge and patient activation, reduce health risks, manage symptoms, and improve physical function. Theories and behavior change techniques selected include Self-Management Framework, Capability, Opportunity, Motivation Behavior model components of Behaviour Change Wheel and taxonomy of behavior change techniques, Health Action Process Approach Model, Common Sense Model, and Social Cognitive Theory. The program components developed comprised educational and behavior change sessions, health trackers (eg, monitoring blood pressure, symptoms, and exercise), goal-setting features, and forums for social support. The MyDESMOND digital platform represented an ideal existing platform to host MK&M; thus, the MyDESMOND interface and features were adopted and adapted for MK&M. Conclusions: Applying the IM framework enabled the systematic application of theory, empirical evidence, and practical perspectives in the codevelopment of MK&M content and materials. Adopting and adapting a preexisting platform provided a cost- and time-efficient approach for developing our digital intervention. In the next stage of work, the efficacy of MK&M in increasing patient activation will be tested in a randomized controlled trial. UR - https://www.jmir.org/2022/11/e39657 UR - http://dx.doi.org/10.2196/39657 UR - http://www.ncbi.nlm.nih.gov/pubmed/36374538 ID - info:doi/10.2196/39657 ER - TY - JOUR AU - Weishaupt, Iris AU - Mages-Torluoglu, Jennifer AU - Kunze, Christophe AU - Weidmann, Christian AU - Steinhausen, Kirsten AU - Bailer, Christina Anja PY - 2022/11/14 TI - Mobile Digital Health Intervention to Promote Nutrition and Physical Activity Behaviors Among Long-term Unemployed in Rural Areas: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e40321 VL - 11 IS - 11 KW - digital health intervention KW - behavior changes KW - nutrition KW - physical activity KW - long-term unemployment KW - rural areas KW - Germany KW - mobile phone N2 - Background: Long-term unemployed have poor nutritional and physical activity statuses, and, therefore, special health promotion needs. Particularly in rural areas, however, they often do not have access to health promotion service. Thus, new promising strategies to improve the health of long-term unemployed are needed. Hence, a digital health intervention to promote nutritional and physical health behaviors was conceived, and the effectiveness of the intervention in combination with face-to-face sessions will be evaluated in a randomized controlled trial. Objective: The aim of this study is to elucidate the effectiveness of a mobile digital health intervention to promote the nutritional and physical activity behaviors of long-term unemployed in the rural areas of Germany. Methods: The 9-week intervention aims to promote nutritional or physical activity behavior by improving drinking habits, increasing the consumption of fruits, vegetables, and whole grains, increasing daily step count, strengthening muscles, and improving endurance. The intervention design is based on the transtheoretical model and is implemented in a mobile app using the MobileCoach open-source platform. The effectiveness of the intervention will be elucidated by a 9-week, 2-armed, parallel-designed trial. Therefore, long-term unemployed will be recruited by employees of the German social sector institutions and randomized either to receive information brochures; the digital intervention in the form of a mobile app; and 3 face-to-face sessions regarding technical support, healthy eating, and physical activity (n=100) or to receive a control treatment consisting of solely the hand over of information brochures (n=100). The effectiveness of the intervention will be assessed using questionnaires at baseline, after 9 weeks in face-to-face appointments, and after a 3-month follow-up period by postal contact. The use of the mobile app will be monitored, and qualitative interviews or focus groups with the participants will be conducted. Incentives of ?50 (US $49.7) will be paid to the participants and are tied to the completion of the questionnaires and not to the use of the mobile app or progress in the intervention. Results: The effectiveness of the intervention in promoting the nutritional and physical activity behaviors of long-term unemployed participants will be elucidated. The adherence of the participants to and the acceptance and usability of the mobile device app will be evaluated. Recruitment started in March 2022, and the final publication of the results is expected in the first half of 2023. Conclusions: Positive health-related changes made by the intervention would display the potency of digital health interventions to promote nutritional and physical activity behaviors among long-term unemployed in the rural areas of Germany, which would also contribute to an improved health status of the German population in general. Trial Registration: German Clinical Trials Register DRKS00024805; https://www.drks.de/DRKS00024805 International Registered Report Identifier (IRRID): PRR1-10.2196/40321 UR - https://www.researchprotocols.org/2022/11/e40321 UR - http://dx.doi.org/10.2196/40321 UR - http://www.ncbi.nlm.nih.gov/pubmed/36374540 ID - info:doi/10.2196/40321 ER - TY - JOUR AU - Sediva, Hana AU - Cartwright, Tina AU - Robertson, Claire AU - Deb, K. Sanjoy PY - 2022/11/9 TI - Behavior Change Techniques in Digital Health Interventions for Midlife Women: Systematic Review JO - JMIR Mhealth Uhealth SP - e37234 VL - 10 IS - 11 KW - menopause KW - midlife KW - women?s health KW - lifestyle KW - behavior change technique KW - BCT KW - behavioral intervention KW - digital health KW - mobile health KW - mHealth KW - menopausal symptom KW - behavior change KW - review KW - mobile phone N2 - Background: Digital health interventions are efficacious in health-promoting behaviors (eg, healthy eating and regular physical activity) that mitigate health risks and menopausal symptoms in midlife. However, integrated evidence-based knowledge about the mechanisms of change in these interventions is unclear. Objective: This systematic review aimed to evaluate studies on behavior change techniques (BCTs) and mechanisms of change in digital health interventions aimed at promoting health-enhancing behaviors in midlife women (aged 40-65 years). Methods: A systematic literature search of the electronic databases PubMed, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials in the Cochrane Library was conducted. In total, 2 independent reviewers selected the studies for inclusion, extracted data, and completed BCT mapping of eligible studies. The mechanism of action and intervention functions of eligible studies were evaluated using the behavior change wheel framework. Reporting of psychological theory use within these interventions was explored using the Theory Coding Scheme. Mode of delivery, psychological theory, and BCTs were presented as descriptive statistics. Results: In total, 13 interventions (including 1315 women) reviewed used 13 (SD 4.30, range 6-21) BCTs per intervention on average. The ?Shaping knowledge? and ?Repetition and substitution? behavior change categories were used most frequently, with 92% (12/13) of the interventions implementing at least one of the BCTs from these 2 categories. Only 13.98% (169/1209) of the 93 available BCTs were used, with ?Instructions on behaviour? most frequently used (12/13, 92%). The behavior change wheel mapping suggests that half of the intervention content aimed to increase ?Capability? (49/98, 50% of the intervention strategies), ?Motivation? (41/98, 42%), and ?Opportunity? (8/98, 8%). ?Behavioural Regulation? was the most frequently used mechanism of action (15/98, 15%), followed by increasing ?Knowledge? (13/98, 13%) and ?Cognitive and Interpersonal skills? (10/98, 10%). A total of 78% (7/9) of the intervention functions were used in the studies to change behavior, primarily through ?Enablement? (60/169, 35.5%), whereas no study used ?Restriction? or ?Modelling? functions. Although 69% (9/13) of the interventions mentioned a psychological theory or model, most (10/13, 77%) stated or suggested rather than demonstrated the use of a theoretical base, and none reported explicit links between all BCTs within the intervention and the targeted theoretical constructs. Technological components were primarily based on web-based (9/13, 69%) modes of delivery, followed by phone or SMS text message (8/13, 62%) and wearables (7/13, 54%). Conclusions: The findings of this review indicate an overall weak use of theory, low levels of treatment fidelity, insignificant outcomes, and insufficient description of several interventions to support the assessment of how specific BCTs were activated. Thus, the identified limitations in the current literature provide an opportunity to improve the design of lifestyle health-enhancing interventions for women in midlife. Trial Registration: PROSPERO CRD42021259246; https://tinyurl.com/4ph74a9u UR - https://mhealth.jmir.org/2022/11/e37234 UR - http://dx.doi.org/10.2196/37234 UR - http://www.ncbi.nlm.nih.gov/pubmed/36350694 ID - info:doi/10.2196/37234 ER - TY - JOUR AU - Kim, H. Lawrence AU - Saha, Gourab AU - Leon, Amelia Annel AU - King, C. Abby AU - Mauriello, Louis Matthew AU - Paredes, E. Pablo PY - 2022/11/9 TI - Shared Autonomy to Reduce Sedentary Behavior Among Sit-Stand Desk Users in the United States and India: Web-Based Study JO - JMIR Form Res SP - e35447 VL - 6 IS - 11 KW - shared autonomy KW - automation KW - sedentary behavior KW - sit-stand desk KW - nonvolitional behavior change KW - culture N2 - Background: Fitness technologies such as wearables and sit-stand desks are increasingly being used to fight sedentary lifestyles by encouraging physical activity. However, adherence to such technologies decreases over time because of apathy and increased dismissal of behavioral nudges. Objective: To address this problem, we introduced shared autonomy in the context of sit-stand desks, where user input is integrated with robot autonomy to control the desk and reduce sedentary behavior and investigated user reactions and preferences for levels of automation with a sit-stand desk. As demographics affect user acceptance of robotic technology, we also studied how perceptions of nonvolitional behavior change differ across cultures (United States and India), sex, familiarity, dispositional factors, and health priming messages. Methods: We conducted a web-based vignette study in the United States and India where a total of 279 participants watched video vignettes of a person interacting with sit-stand desks of various levels of automation and answered questions about their perceptions of the desks such as ranking of the different levels of automation. Results: Participants generally preferred either manual or semiautonomous desks over the fully autonomous option (P<.001). However, participants in India were generally more amenable to the idea of nonvolitional interventions from the desk than participants in the United States (P<.001). Male participants had a stronger desire for having control over the desk than female participants (P=.01). Participants who were more familiar with sit-stand desks were more likely to adopt autonomous sit-stand desks (P=.001). No effects of health priming messages were observed. We estimated the projected health outcome by combining ranking data and hazard ratios from previous work and found that the semiautonomous desk led to the highest projected health outcome. Conclusions: These results suggest that the shared autonomy desk is the optimal level of automation in terms of both user preferences and estimated projected health outcomes. Demographics such as culture and sex had significant effects on how receptive users were to autonomous intervention. As familiarity improves the likelihood of adoption, we propose a gradual behavior change intervention to increase acceptance and adherence, especially for populations with a high desire for control. UR - https://formative.jmir.org/2022/11/e35447 UR - http://dx.doi.org/10.2196/35447 UR - http://www.ncbi.nlm.nih.gov/pubmed/36350687 ID - info:doi/10.2196/35447 ER - TY - JOUR AU - Hallgren, A. Kevin PY - 2022/11/7 TI - Remotely Assessing Mechanisms of Behavioral Change in Community Substance Use Disorder Treatment to Facilitate Measurement-Informed Care: Pilot Longitudinal Questionnaire Study JO - JMIR Form Res SP - e42376 VL - 6 IS - 11 KW - addiction KW - clinical pilot KW - measurement-based care KW - mechanisms of change KW - mobile health KW - mHealth KW - mobile phone N2 - Background: Research shows that improvements in coping strategies, abstinence self-efficacy, craving, and depression are potential mechanisms of behavioral change (MOBC) in treatments for substance use disorders (SUDs). However, little is known about how these insights regarding MOBC can be applied to SUD treatment settings. One way to facilitate MOBC-informed care in frontline settings could be to measure and monitor changes in MOBC throughout treatment using brief, frequent questionnaires that patients complete by using mobile technologies (eg, smartphones). The results derived from these questionnaires could potentially be used for clinical monitoring (ie, measurement-based care) to better understand whether individual patients are experiencing treatment-related improvements on key clinical targets. Objective: This study evaluated whether brief, weekly MOBC questionnaires completed by patients remotely can potentially provide clinically meaningful information about changes in MOBC in the context of real-world, community-based SUD treatment. Methods: A total of 30 patients (14/30, 47% female; 13/30, 43% racial or ethnic minority) in a community SUD treatment clinic participated in a pilot study where they were invited to complete brief, weekly questionnaires that assessed various MOBC, including coping strategies, abstinence self-efficacy, craving, depression, and therapeutic alliance. Questionnaires were typically completed remotely via smartphone for up to 6 months; 618 questionnaires were completed in total. Participants also completed longer, psychometrically validated measures of the same MOBC at baseline and 6-month research appointments. Statistical analyses tested whether brief, weekly, remotely completed MOBC questionnaires exhibited characteristics that would be desirable for real-world longitudinal clinical monitoring, including a tendency to detect within-person changes in MOBC over time; cross-sectional and longitudinal associations with longer, psychometrically validated measures completed at research appointments; and similar patterns of associations with 6-month percentage of days abstinent as longer, psychometrically validated MOBC measures completed at research appointments. Results: The results of this study indicated that the brief, weekly, remotely completed MOBC measures exhibited characteristics that are desirable for clinical monitoring, including a tendency to vary longitudinally (within patients over time) more often than measures of alcohol and drug consumption, generally having medium to large cross-sectional and longitudinal correlations with longer psychometrically validated measures of MOBC completed at research appointments, and generally having similar patterns of association with 6-month percentage of days abstinent from alcohol and drugs as longer psychometrically validated MOBC measures completed at research appointments. Conclusions: The results of this pilot study provide initial evidence that incorporating brief, weekly, and remotely completed MOBC questionnaires into community SUD treatment may be a viable approach for facilitating MOBC-informed care. Such questionnaires can potentially support measurement-based care by providing meaningful information about within-patient changes in clinical domains that are often directly targeted in SUD treatments and predict long-term substance use outcomes. UR - https://formative.jmir.org/2022/11/e42376 UR - http://dx.doi.org/10.2196/42376 UR - http://www.ncbi.nlm.nih.gov/pubmed/36342773 ID - info:doi/10.2196/42376 ER - TY - JOUR AU - Fisher, Dominic AU - Louw, Quinette PY - 2022/10/26 TI - The Effect of Classroom-Based Interventions on Sedentary Behavior and Spinal Health in Schoolchildren: Systematic Review JO - Interact J Med Res SP - e39006 VL - 11 IS - 2 KW - sedentary behavior KW - classroom sitting KW - spinal health N2 - Background: Multifaceted school-based interventions involving many stakeholders show promise toward the reduction of sedentary behavior (SB) and improved musculoskeletal conditions in schoolchildren. In resource-limited contexts, where schools face multiple, complex demands, broad school-based interventions may not be possible. In these settings, less complex, resource-efficient interventions are more likely to be adopted and implemented. Interventions that are limited to classrooms and that do not require broader stakeholder participation may be more appropriate to lower-resource settings. Objective: The aim of this study was to systematically search for, identify, and summarize the literature on the effectiveness of classroom-based interventions on SB and spinal health in schoolchildren. Methods: PubMed, EBSCOhost CINAHL, Web of Science, and Scopus were searched between January 1, 2021, and April 30, 2021. We included experimental studies conducted exclusively in school classrooms that objectively measured classroom SB and spinal health. The search terms related to SB, classroom sitting, and classroom neck and back pain. Studies that reported on objectively measured classroom physical activity and instrumented observation of healthy spinal behavior were included in the review. The included studies were critically appraised using the McMaster critical review form for quantitative studies. The study findings were summarized in tables, and a meta-analysis of homogeneous review outcome data was conducted. Results: Overall, 12 experimental studies from high-income countries were included: 9 (75%) studies focused on SB, and 3 (25%) focused on spinal health. Of the 9 SB studies, 8 (89%) reported decreases in classroom sitting time. The pooled medium-term effects of a subset of SB interventions showed statistically significant decreases in sitting time (P=.03), whereas short-term effects and long-term effects were not significantly reduced (P=.13 and P=.23, respectively). A meta-analysis of spinal health studies demonstrated statistically significant improvements in spinal behavior during functional tasks (P=.005). Conclusions: Classroom-based interventions aimed at reducing SB and improving spinal health may be effective without placing an additional burden on teachers and parents. SB interventions must include strategies to overcome teachers? and learners? hedonic motivation to sit during class time. Standardized outcomes for school-based SB are encouraged so that findings from various settings may be pooled to determine the overall effect across studies. The use of standardized functional outcomes in spinal health studies will aid in determining the effectiveness of spinal health interventions across studies. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020176080; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020176080 UR - https://www.i-jmr.org/2022/2/e39006 UR - http://dx.doi.org/10.2196/39006 UR - http://www.ncbi.nlm.nih.gov/pubmed/36287590 ID - info:doi/10.2196/39006 ER - TY - JOUR AU - Goonesekera, Yenushka AU - Donkin, Liesje PY - 2022/10/20 TI - A Cognitive Behavioral Therapy Chatbot (Otis) for Health Anxiety Management: Mixed Methods Pilot Study JO - JMIR Form Res SP - e37877 VL - 6 IS - 10 KW - health anxiety KW - conversational agent KW - illness anxiety disorder KW - COVID-19 KW - iCBT KW - user experience KW - anthropomorphism N2 - Background: An increase in health anxiety was observed during the COVID-19 pandemic. However, due to physical distancing restrictions and a strained mental health system, people were unable to access support to manage health anxiety. Chatbots are emerging as an interactive means to deliver psychological interventions in a scalable manner and provide an opportunity for novel therapy delivery to large groups of people including those who might struggle to access traditional therapies. Objective: The aim of this mixed methods pilot study was to investigate the feasibility, acceptability, engagement, and effectiveness of a cognitive behavioral therapy (CBT)?based chatbot (Otis) as an early health anxiety management intervention for adults in New Zealand during the COVID-19 pandemic. Methods: Users were asked to complete a 14-day program run by Otis, a primarily decision tree?based chatbot on Facebook Messenger. Health anxiety, general anxiety, intolerance of uncertainty, personal well-being, and quality of life were measured pre-intervention, postintervention, and at a 12-week follow-up. Paired samples t tests and 1-way ANOVAs were conducted to investigate the associated changes in the outcomes over time. Semistructured interviews and written responses in the self-report questionnaires and Facebook Messenger were thematically analyzed. Results: The trial was completed by 29 participants who provided outcome measures at both postintervention and follow-up. Although an average decrease in health anxiety did not reach significance at postintervention (P=.55) or follow-up (P=.08), qualitative analysis demonstrated that participants perceived benefiting from the intervention. Significant improvement in general anxiety, personal well-being, and quality of life was associated with the use of Otis at postintervention and follow-up. Anthropomorphism, Otis? appearance, and delivery of content facilitated the use of Otis. Technical difficulties and high performance and effort expectancy were, in contrast, barriers to acceptance and engagement of Otis. Conclusions: Otis may be a feasible, acceptable, and engaging means of delivering CBT to improve anxiety management, quality of life, and personal well-being but might not significantly reduce health anxiety. UR - https://formative.jmir.org/2022/10/e37877 UR - http://dx.doi.org/10.2196/37877 UR - http://www.ncbi.nlm.nih.gov/pubmed/36150049 ID - info:doi/10.2196/37877 ER - TY - JOUR AU - Palacz-Poborczyk, Iga AU - Idziak, Paulina AU - Januszewicz, Anna AU - Luszczynska, Aleksandra AU - Quested, Eleanor AU - Naughton, Felix AU - Hagger, S. Martin AU - Pagoto, Sherry AU - Verboon, Peter AU - Robinson, Suzanne AU - Kwasnicka, Dominika PY - 2022/10/18 TI - Developing the "Choosing Health" Digital Weight Loss and Maintenance Intervention: Intervention Mapping Study JO - J Med Internet Res SP - e34089 VL - 24 IS - 10 KW - behavior change KW - behavior maintenance KW - behavioral theory KW - weight loss KW - overweight KW - obesity KW - randomized controlled trial KW - digital health KW - within-person design KW - Intervention Mapping N2 - Background: Digital health promotion programs tailored to the individual are a potential cost-effective and scalable solution to enable self-management and provide support to people with excess body weight. However, solutions that are widely accessible, personalized, and theory- and evidence-based are still limited. Objective: This study aimed to develop a digital behavior change program, Choosing Health, that could identify modifiable predictors of weight loss and maintenance for each individual and use these to provide tailored support. Methods: We applied an Intervention Mapping protocol to design the program. This systematic approach to develop theory- and evidence-based health promotion programs consisted of 6 steps: development of a logic model of the problem, a model of change, intervention design and intervention production, the implementation plan, and the evaluation plan. The decisions made during the Intervention Mapping process were guided by theory, existing evidence, and our own research?including 4 focus groups (n=40), expert consultations (n=12), and interviews (n=11). The stakeholders included researchers, public representatives (including individuals with overweight and obesity), and experts from a variety of relevant backgrounds (including nutrition, physical activity, and the health care sector). Results: Following a structured process, we developed a tailored intervention that has the potential to reduce excess body weight and support behavior changes in people with overweight and obesity. The Choosing Health intervention consists of tailored, personalized text messages and email support that correspond with theoretical domains potentially predictive of weight outcomes for each participant. The intervention content includes behavior change techniques to support motivation maintenance, self-regulation, habit formation, environmental restructuring, social support, and addressing physical and psychological resources. Conclusions: The use of an Intervention Mapping protocol enabled the systematic development of the Choosing Health intervention and guided the implementation and evaluation of the program. Through the involvement of different stakeholders, including representatives of the general public, we were able to map out program facilitators and barriers while increasing the ecological validity of the program to ensure that we build an intervention that is useful, user-friendly, and informative. We also summarized the lessons learned for the Choosing Health intervention development and for other health promotion programs. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-040183 UR - https://www.jmir.org/2022/10/e34089 UR - http://dx.doi.org/10.2196/34089 UR - http://www.ncbi.nlm.nih.gov/pubmed/36256827 ID - info:doi/10.2196/34089 ER - TY - JOUR AU - Kytö, Mikko AU - Koivusalo, Saila AU - Ruonala, Antti AU - Strömberg, Lisbeth AU - Tuomonen, Heli AU - Heinonen, Seppo AU - Jacucci, Giulio PY - 2022/10/12 TI - Behavior Change App for Self-management of Gestational Diabetes: Design and Evaluation of Desirable Features JO - JMIR Hum Factors SP - e36987 VL - 9 IS - 4 KW - gestational diabetes KW - mobile app KW - features KW - behavior change KW - digital health KW - eHealth KW - telehealth KW - self-tracking KW - self-management KW - personalized health care N2 - Background: Gestational diabetes (GDM) has considerable and increasing health effects as it raises both the mother?s and the offspring?s risk for short- and long-term health problems. GDM can usually be treated with a healthier lifestyle, such as appropriate dietary modifications and sufficient physical activity. Although telemedicine interventions providing weekly or more frequent feedback from health care professionals have shown the potential to improve glycemic control among women with GDM, apps without extensive input from health care professionals are limited and have not been shown to be effective. Different features in personalization and support have been proposed to increase the efficacy of GDM apps, but the knowledge of how these features should be designed is lacking. Objective: The aim of this study is to investigate how GDM apps should be designed, considering the desirable features based on the previous literature. Methods: We designed an interactive GDM prototype app that provided example implementations of desirable features, such as providing automatic and personalized suggestions and social support through the app. Women with GDM explored the prototype and provided feedback in semistructured interviews. Results: We identified that (1) self-tracking data in GDM apps should be extended with written feedback, (2) habits and goals should be highly customizable to be useful, (3) the app should have different functions to provide social support, and (4) health care professionals should be notified through the app if something unusual occurs. In addition, we found 2 additional themes. First, basic functionalities that are fast to learn by women with GDM who have recently received the diagnosis should be provided, but there should also be deeper features to maintain interest for women with GDM at a later stage of pregnancy. Second, as women with GDM may have feelings of guilt, the app should have a tolerance for and a supporting approach to unfavorable behavior. Conclusions: The feedback on the GDM prototype app supported the need for desirable features and provided new insights into how these features should be incorporated into GDM apps. We expect that following the proposed designs and feedback will increase the efficacy of GDM self-management apps. Trial Registration: ClinicalTrials.gov NCT03941652; https://clinicaltrials.gov/ct2/show/NCT03941652 UR - https://humanfactors.jmir.org/2022/4/e36987 UR - http://dx.doi.org/10.2196/36987 UR - http://www.ncbi.nlm.nih.gov/pubmed/36222806 ID - info:doi/10.2196/36987 ER - TY - JOUR AU - de Buisonjé, R. David AU - Reijnders, Thomas AU - Cohen Rodrigues, R. Talia AU - Prabhakaran, Santhanam AU - Kowatsch, Tobias AU - Lipman, A. Stefan AU - Bijmolt, A. Tammo H. AU - Breeman, D. Linda AU - Janssen, R. Veronica AU - Kraaijenhagen, A. Roderik AU - Kemps, C. Hareld M. AU - Evers, M. Andrea W. PY - 2022/10/6 TI - Investigating Rewards and Deposit Contract Financial Incentives for Physical Activity Behavior Change Using a Smartphone App: Randomized Controlled Trial JO - J Med Internet Res SP - e38339 VL - 24 IS - 10 KW - eHealth KW - behavior change KW - rewards KW - reward learning KW - financial incentives KW - deposit contracts KW - commitment contracts KW - physical activity KW - mobile phone N2 - Background: Financial incentive interventions for improving physical activity have proven to be effective but costly. Deposit contracts (in which participants pledge their own money) could be an affordable alternative. In addition, deposit contracts may have superior effects by exploiting the power of loss aversion. Previous research has often operationalized deposit contracts through loss framing a financial reward (without requiring a deposit) to mimic the feelings of loss involved in a deposit contract. Objective: This study aimed to disentangle the effects of incurring actual losses (through self-funding a deposit contract) and loss framing. We investigated whether incentive conditions are more effective than a no-incentive control condition, whether deposit contracts have a lower uptake than financial rewards, whether deposit contracts are more effective than financial rewards, and whether loss frames are more effective than gain frames. Methods: Healthy participants (N=126) with an average age of 22.7 (SD 2.84) years participated in a 20-day physical activity intervention. They downloaded a smartphone app that provided them with a personalized physical activity goal and either required a ?10 (at the time of writing: ?1=US $0.98) deposit up front (which could be lost) or provided ?10 as a reward, contingent on performance. Daily feedback on incentive earnings was provided and framed as either a loss or gain. We used a 2 (incentive type: deposit or reward) × 2 (feedback frame: gain or loss) between-subjects factorial design with a no-incentive control condition. Our primary outcome was the number of days participants achieved their goals. The uptake of the intervention was a secondary outcome. Results: Overall, financial incentive conditions (mean 13.10, SD 6.33 days goal achieved) had higher effectiveness than the control condition (mean 8.00, SD 5.65 days goal achieved; P=.002; ?p2=0.147). Deposit contracts had lower uptake (29/47, 62%) than rewards (50/50, 100%; P<.001; Cramer V=0.492). Furthermore, 2-way analysis of covariance showed that deposit contracts (mean 14.88, SD 6.40 days goal achieved) were not significantly more effective than rewards (mean 12.13, SD 6.17 days goal achieved; P=.17). Unexpectedly, loss frames (mean 10.50, SD 6.22 days goal achieved) were significantly less effective than gain frames (mean 14.67, SD 5.95 days goal achieved; P=.007; ?p2=0.155). Conclusions: Financial incentives help increase physical activity, but deposit contracts were not more effective than rewards. Although self-funded deposit contracts can be offered at low cost, low uptake is an important obstacle to large-scale implementation. Unexpectedly, loss framing was less effective than gain framing. Therefore, we urge further research on their boundary conditions before using loss-framed incentives in practice. Because of limited statistical power regarding some research questions, the results of this study should be interpreted with caution, and future work should be done to confirm these findings. Trial Registration: Open Science Framework Registries osf.io/34ygt; https://osf.io/34ygt UR - https://www.jmir.org/2022/10/e38339 UR - http://dx.doi.org/10.2196/38339 UR - http://www.ncbi.nlm.nih.gov/pubmed/36201384 ID - info:doi/10.2196/38339 ER - TY - JOUR AU - Yadav, Muskan AU - Neate, Sandra AU - Hassed, Craig AU - Chambers, Richard AU - Connaughton, Sherelle AU - Nag, Nupur PY - 2022/10/5 TI - Mining the Gems of a Web-Based Mindfulness Intervention: Qualitative Analysis of Factors Aiding Completion and Implementation JO - JMIR Form Res SP - e37406 VL - 6 IS - 10 KW - digital intervention KW - health education KW - mindfulness KW - online learning KW - behavior change KW - mental health KW - mental well-being KW - physical well-being KW - meditation KW - health promotion KW - digital health KW - eHealth KW - thematic analysis KW - attrition KW - participation KW - involvement KW - engagement KW - attitude KW - perspective KW - patient education KW - e-learning KW - user feedback N2 - Background: Digital health interventions provide a cost effective and accessible means for positive behavior change. However, high participant attrition is common and facilitators for implementation of behaviors are not well understood. Objective: The goal of the research was to identify elements of a digital mindfulness course that aided in course completion and implementation of teachings. Methods: Inductive thematic analysis was used to assess participant comments regarding positive aspects of the online mindfulness course Mindfulness for Well-being and Peak Performance. Participants were aged 18 years and older who had self-selected to register and voluntarily completed at least 90% the course. The course comprised educator-guided lessons and discussion forums for participant reflection and feedback. Participant comments from the final discussion forum were analyzed to identify common themes pertaining to elements of the course that aided in course completion and implementation of teachings. Results: Of 3355 course completers, 283 participants provided comments related to the research question. Key themes were (1) benefits from the virtual community, (2) appeal of content, (3) enablers to participation and implementation, and (4) benefits noted in oneself. Of subthemes identified, some, such as community support, variety of easily implementable content, and free content access, align with that reported previously in the literature, while other subthemes, including growing together, repeating the course, evidence-based teaching, and immediate benefits on physical and mental well-being, were novel findings. Conclusions: Themes identified as key elements for aiding participant completion of a mindfulness digital health intervention and the implementation of teachings may inform the effective design of future digital health interventions to drive positive health behaviors. Future research should focus on understanding motivations for participation, identification of effective methods for participant retention, and behavior change techniques to motivate long-term adherence to healthy behaviors. UR - https://formative.jmir.org/2022/10/e37406 UR - http://dx.doi.org/10.2196/37406 UR - http://www.ncbi.nlm.nih.gov/pubmed/36197709 ID - info:doi/10.2196/37406 ER - TY - JOUR AU - Martinengo, Laura AU - Jabir, Ishqi Ahmad AU - Goh, Tin Westin Wei AU - Lo, Wai Nicholas Yong AU - Ho, Ringo Moon-Ho AU - Kowatsch, Tobias AU - Atun, Rifat AU - Michie, Susan AU - Tudor Car, Lorainne PY - 2022/10/3 TI - Conversational Agents in Health Care: Scoping Review of Their Behavior Change Techniques and Underpinning Theory JO - J Med Internet Res SP - e39243 VL - 24 IS - 10 KW - behavior change KW - behavior change techniques KW - conversational agent KW - chatbot KW - mHealth N2 - Background: Conversational agents (CAs) are increasingly used in health care to deliver behavior change interventions. Their evaluation often includes categorizing the behavior change techniques (BCTs) using a classification system of which the BCT Taxonomy v1 (BCTTv1) is one of the most common. Previous studies have presented descriptive summaries of behavior change interventions delivered by CAs, but no in-depth study reporting the use of BCTs in these interventions has been published to date. Objective: This review aims to describe behavior change interventions delivered by CAs and to identify the BCTs and theories guiding their design. Methods: We searched PubMed, Embase, Cochrane?s Central Register of Controlled Trials, and the first 10 pages of Google and Google Scholar in April 2021. We included primary, experimental studies evaluating a behavior change intervention delivered by a CA. BCTs coding followed the BCTTv1. Two independent reviewers selected the studies and extracted the data. Descriptive analysis and frequent itemset mining to identify BCT clusters were performed. Results: We included 47 studies reporting on mental health (n=19, 40%), chronic disorders (n=14, 30%), and lifestyle change (n=14, 30%) interventions. There were 20/47 embodied CAs (43%) and 27/47 CAs (57%) represented a female character. Most CAs were rule based (34/47, 72%). Experimental interventions included 63 BCTs, (mean 9 BCTs; range 2-21 BCTs), while comparisons included 32 BCTs (mean 2 BCTs; range 2-17 BCTs). Most interventions included BCTs 4.1 ?Instruction on how to perform a behavior? (34/47, 72%), 3.3 ?Social support? (emotional; 27/47, 57%), and 1.2 ?Problem solving? (24/47, 51%). A total of 12/47 studies (26%) were informed by a behavior change theory, mainly the Transtheoretical Model and the Social Cognitive Theory. Studies using the same behavior change theory included different BCTs. Conclusions: There is a need for the more explicit use of behavior change theories and improved reporting of BCTs in CA interventions to enhance the analysis of intervention effectiveness and improve the reproducibility of research. UR - https://www.jmir.org/2022/10/e39243 UR - http://dx.doi.org/10.2196/39243 UR - http://www.ncbi.nlm.nih.gov/pubmed/36190749 ID - info:doi/10.2196/39243 ER - TY - JOUR AU - Baillot, Aurélie AU - St-Pierre, Maxime AU - Lapointe, Josyanne AU - Bernard, Paquito AU - Bond, Dale AU - Romain, Jérôme Ahmed AU - Garneau, Y. Pierre AU - Biertho, Laurent AU - Tchernof, André AU - Blackburn, Patricia AU - Langlois, Marie-France AU - Brunet, Jennifer PY - 2022/9/29 TI - Acceptability and Feasibility of the Telehealth Bariatric Behavioral Intervention to Increase Physical Activity: Protocol for a Single-Case Experimental Study JO - JMIR Res Protoc SP - e39633 VL - 11 IS - 9 KW - behavior change intervention KW - bariatric surgery KW - physical activity KW - telehealth KW - single-case experimental design KW - self-determination KW - self-efficacy KW - behavior change techniques KW - mobile phone N2 - Background: Regular physical activity (PA) is recommended to optimize weight and health outcomes in patients who have undergone metabolic and bariatric surgery (MBS). However, >70% of patients have low PA levels before MBS that persist after MBS. Although behavioral interventions delivered face-to-face have shown promise for increasing PA among patients who have undergone MBS, many may experience barriers, preventing enrollment into and adherence to such interventions. Delivering PA behavior change interventions via telehealth to patients who have undergone MBS may be an effective strategy to increase accessibility and reach, as well as adherence. Objective: This paper reports the protocol for a study that aims to assess the feasibility and acceptability of the protocol or methods and the Telehealth Bariatric Behavioral Intervention (TELE-BariACTIV). The intervention is designed to increase moderate-to-vigorous intensity PA (MVPA) in patients awaiting bariatric surgery and is guided by a multitheory approach and a patient perspective. Another objective is to estimate the effect of the TELE-BariACTIV intervention on presurgical MVPA to determine the appropriate sample size for a multicenter trial. Methods: This study is a multicenter trial using a repeated (ABAB?A) single-case experimental design. The A phases are observational phases without intervention (A1=pre-MBS phase; A2=length personalized according to the MBS date; A3=7 months post-MBS phase). The B phases are interventional phases with PA counseling (B1=6 weekly pre-MBS sessions; B2=3 monthly sessions starting 3 months after MBS). The target sample size is set to 12. Participants are inactive adults awaiting sleeve gastrectomy who have access to a computer with internet and an interface with a camera. The participants are randomly allocated to a 1- or 2-week baseline period (A1). Protocol and intervention feasibility and acceptability (primary outcomes) will be assessed by recording missing data, refusal, recruitment, retention, attendance, and attrition rates, as well as via web-based acceptability questionnaires and semistructured interviews. Data collected via accelerometry (7-14 days) on 8 occasions and via questionnaires on 10 occasions will be analyzed to estimate the effect of the intervention on MVPA. Generalization measures assessing the quality of life, anxiety and depressive symptoms, and theory-based constructs (ie, motivational regulations for PA, self-efficacy to overcome barriers to PA, basic psychological needs satisfaction and frustration, PA enjoyment, and social support for PA; secondary outcomes for a future large-scale trial) will be completed via web-based questionnaires on 6-10 occasions. The institutional review board provided ethics approval for the study in June 2021. Results: Recruitment began in September 2021, and all the participants were enrolled (n=12). Data collection is expected to end in fall 2023, depending on the MBS date of the recruited participants. Conclusions: The TELE-BariACTIV intervention has the potential for implementation across multiple settings owing to its collaborative construction that can be offered remotely. International Registered Report Identifier (IRRID): DERR1-10.2196/39633 UR - https://www.researchprotocols.org/2022/9/e39633 UR - http://dx.doi.org/10.2196/39633 UR - http://www.ncbi.nlm.nih.gov/pubmed/36173668 ID - info:doi/10.2196/39633 ER - TY - JOUR AU - Hesseldal, Laura AU - Christensen, Reffstrup Jeanette AU - Olesen, Bastholm Thomas AU - Olsen, Hecht Michael AU - Jakobsen, Ravn Pernille AU - Laursen, Hjorth Ditte AU - Lauridsen, Trankjær Jørgen AU - Nielsen, Bo Jesper AU - Søndergaard, Jens AU - Brandt, Joakim Carl PY - 2022/9/23 TI - Long-term Weight Loss in a Primary Care?Anchored eHealth Lifestyle Coaching Program: Randomized Controlled Trial JO - J Med Internet Res SP - e39741 VL - 24 IS - 9 KW - obesity KW - digital behavioral coaching KW - health behavior change KW - interactive advice KW - lifestyle change KW - mobile intervention KW - patient engagement KW - telemedicine KW - eHealth KW - digital health KW - digital coach KW - weight loss KW - coaching KW - training KW - engagement KW - behavior changes KW - diabetes KW - type 2 diabetes KW - T2D N2 - Background: Long-term weight loss in people living with obesity can reduce the risk and progression of noncommunicable diseases. Observational studies suggest that digital coaching can lead to long-term weight loss. Objective: We investigated whether an eHealth lifestyle coaching program for people living with obesity with or without type 2 diabetes led to significant, long-term (12-month) weight loss compared to usual care. Methods: In a randomized controlled trial that took place in 50 municipalities in Denmark, 340 people living with obesity with or without type 2 diabetes were enrolled from April 16, 2018, to April 1, 2019, and randomized via an automated computer algorithm to an intervention (n=200) or a control (n=140) group. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The digital coaching intervention consisted of an initial 1-hour face-to-face motivational interview followed by digital coaching using behavioral change techniques enabled by individual live monitoring. The primary outcome was change in body weight from baseline to 12 months. Results: Data were assessed for 200 participants, including 127 from the intervention group and 73 from the control group, who completed 12 months of follow-up. After 12 months, mean body weight and BMI were significantly reduced in both groups but significantly more so in the intervention group than the control group (?4.5 kg, 95% CI ?5.6 to ?3.4 vs ?1.5 kg, 95% CI ?2.7 to ?0.2, respectively; P<.001; and ?1.5 kg/m2, 95% CI ?1.9 to ?1.2 vs ?0.5 kg/m2, 95% CI ?0.9 to ?0.1, respectively; P<.001). Hemoglobin A1c was significantly reduced in both the intervention (?6.0 mmol/mol, 95% CI ?7.7 to ?4.3) and control (?4.9 mmol/mol, 95% CI ?7.4 to ?2.4) groups, without a significant group difference (all P>.46). Conclusions: Compared to usual care, digital lifestyle coaching can induce significant weight loss for people living with obesity, both with and without type 2 diabetes, after 12 months. Trial Registration: ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915 UR - https://www.jmir.org/2022/9/e39741 UR - http://dx.doi.org/10.2196/39741 UR - http://www.ncbi.nlm.nih.gov/pubmed/36149735 ID - info:doi/10.2196/39741 ER - TY - JOUR AU - Ludwig, Rebecca AU - Rippee, Michael AU - D?Silva, J. Linda AU - Radel, Jeff AU - Eakman, M. Aaron AU - Morris, Jill AU - Drerup, Michelle AU - Siengsukon, Catherine PY - 2022/9/23 TI - Assessing Cognitive Behavioral Therapy for Insomnia to Improve Sleep Outcomes in Individuals With a Concussion: Protocol for a Delayed Randomized Controlled Trial JO - JMIR Res Protoc SP - e38608 VL - 11 IS - 9 KW - sleep KW - concussion KW - cognitive behavioral therapy KW - CBT KW - insomnia KW - brain KW - injury KW - RCT KW - randomized controlled trial KW - protocol KW - recovery KW - pilot study N2 - Background: Sleep disturbances post concussion have been associated with more frequent and severe concussion symptoms and may contribute to poorer recovery. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment for insomnia; however, it remains unclear if this treatment method is effective in improving sleep outcomes and reducing concomitant postconcussion symptoms. Objective: The hypotheses for this study are that (1) CBT-I will improve sleep outcomes and (2) CBT-I will improve concomitant postconcussion symptoms. Methods: In total, 40 individuals who are within ?4 weeks of postconcussion injury and have insomnia symptoms will be enrolled in this randomized controlled trial. Participants will be randomized into either a group that starts a 6-week CBT-I program immediately after baseline or a waitlist control group that starts CBT-I following a 6-week waiting period. All participants will be reassessed 6, 12, and 18 weeks after baseline. Standardized assessments measuring sleep outcomes, postconcussion symptoms, and mood will be used. Linear regression and t tests will be used for statistical analyses. Results: Enrollment of 40 participants was completed July 2022, data collection will be completed in November 2022, and publication of main findings is anticipated in May 2023. It is anticipated that participants experience reduced insomnia symptoms and postconcussion symptoms following CBT-I and these improvements will be retained for at least 12 weeks. Additionally, we expect to observe a positive correlation between sleep and postconcussion symptom improvement. Conclusions: Successful completion of this pilot study will allow for a better understanding of the treatment of insomnia and postconcussion symptoms in individuals following a concussion. Trial Registration: ClinicalTrials.gov NCT04885205; https://clinicaltrials.gov/ct2/show/NCT04885205 International Registered Report Identifier (IRRID): DERR1-10.2196/38608 UR - https://www.researchprotocols.org/2022/9/e38608 UR - http://dx.doi.org/10.2196/38608 UR - http://www.ncbi.nlm.nih.gov/pubmed/36149737 ID - info:doi/10.2196/38608 ER - TY - JOUR AU - Oh, Taek Kyue AU - Ko, Jisu AU - Shin, Jaemyung AU - Ko, Minsam PY - 2022/9/21 TI - Using Wake-Up Tasks for Morning Behavior Change: Development and Usability Study JO - JMIR Form Res SP - e39497 VL - 6 IS - 9 KW - health app design KW - morning behavior change KW - wake-up task KW - mobile alarm KW - productivity N2 - Background: Early morning behaviors between waking up and beginning daily work can develop into productive habits. However, sleep inertia limits the level of human ability immediately after waking, lowering a person?s motivation and available time for productive morning behavior. Objective: This study explores a design for morning behavior change using a wake-up task, a simple assignment the user needs to finish before alarm dismissal. Specifically, we set two research objectives: (1) exploring key factors that relate to morning behavior performance, including the use of wake-up tasks in an alarm app and (2) understanding the general practice of affecting morning behavior change by implementing wake-up tasks. Methods: We designed and implemented an apparatus that provides wake-up task alarms and facilities for squat exercises. We recruited 36 participants to perform squat exercises in the early morning using the wake-up tasks for 2 weeks. First, we conducted a generalized estimating equation (GEE) analysis for the first research objective. Next, we conducted a thematic analysis of the postsurvey answers to identify key themes about morning behavior change with the wake-up tasks for the second objective. Results: The use of wake-up tasks was significantly associated with both the completion of the target behavior (math task: P=.005; picture task: P<.001) and the elapsed time (picture task: P=.08); the time to alarm dismissal was significantly related to the elapsed time to completion (P<.001). Moreover, the theory of planned behavior (TPB) variables, common factors for behavior change, were significant, but their magnitudes and directions differed slightly from the other domains. Furthermore, the survey results reveal how the participants used the wake-up tasks and why they were effective for morning behavior performance. Conclusions: The results reveal the effectiveness of wake-up tasks in accomplishing the target morning behavior and address key factors for morning behavior change, such as (1) waking up on time, (2) escaping from sleep inertia, and (3) quickly starting the desired target behavior. UR - https://formative.jmir.org/2022/9/e39497 UR - http://dx.doi.org/10.2196/39497 UR - http://www.ncbi.nlm.nih.gov/pubmed/36129742 ID - info:doi/10.2196/39497 ER - TY - JOUR AU - Park, J. Jennifer AU - King, L. Daniel AU - Wilkinson-Meyers, Laura AU - Rodda, N. Simone PY - 2022/9/9 TI - Content and Effectiveness of Web-Based Treatments for Online Behavioral Addictions: Systematic Review JO - JMIR Ment Health SP - e36662 VL - 9 IS - 9 KW - systematic review KW - gambling KW - gaming KW - internet intervention KW - pornography KW - treatment KW - social media N2 - Background: Very few people seek in-person treatment for online behavioral addictions including gaming and gambling or problems associated with shopping, pornography use, or social media use. Web-based treatments have the potential to address low rates of help seeking due to their convenience, accessibility, and capacity to address barriers to health care access (eg, shame, stigma, cost, and access to expert care). However, web-based treatments for online behavioral addictions have not been systematically evaluated. Objective: This review aimed to systematically describe the content of web-based treatments for online behavioral addictions and describe their therapeutic effectiveness on symptom severity and consumption behavior. Methods: A database search of MEDLINE, Embase, PsycInfo, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar was conducted in June 2022. Studies were eligible if the study design was a randomized controlled trial or a pre-post study with at least 1 web-based intervention arm for an online behavioral addiction and if the study included the use of a validated measure of problem severity, frequency, or duration of online behavior. Data on change techniques were collected to analyze intervention content, using the Gambling Intervention System of CharacTerization. Quality assessment was conducted using the Effective Public Health Practice Project Quality Assessment Tool. Results: The review included 12 studies with 15 intervention arms, comprising 7 randomized controlled trials and 5 pre-post studies. The primary focus of interventions was gaming (n=4), followed by internet use inclusive of screen time and smartphone use (n=3), gambling (n=3), and pornography (n=2). A range of different technologies were used to deliver content, including websites (n=6), email (n=2), computer software (n=2), social media messaging (n=1), smartphone app (n=1), virtual reality (n=1), and videoconferencing (n=1). Interventions contained 15 different change techniques with an average of 4 per study. The techniques most frequently administered (>30% of intervention arms) were cognitive restructuring, relapse prevention, motivational enhancement, goal setting, and social support. Assessment of study quality indicated that 7 studies met the criteria for moderate or strong global ratings, but only 8 out of 12 studies evaluated change immediately following the treatment. Across included studies, two-thirds of participants completed after-treatment evaluation, and one-quarter completed follow-up evaluation. After-intervention evaluation indicated reduced severity (5/9, 56%), frequency (2/3, 67%), and duration (3/7, 43%). Follow-up evaluation indicated that 3 pre-post studies for gaming, gambling, and internet use demonstrated reduced severity, frequency, and duration of consumption. At 3-month evaluation, just 1 pre-post study indicated significant change to mental health symptoms. Conclusions: Web-based treatments for online behavioral addictions use an array of mechanisms to deliver cognitive and behavioral change techniques. Web-based treatments demonstrate promise for short-term reduction in symptoms, duration, or frequency of online addictive behaviors. However, there is limited evidence on the effectiveness of web-based treatments over the longer term due to the absence of controlled trials. UR - https://mental.jmir.org/2022/9/e36662 UR - http://dx.doi.org/10.2196/36662 UR - http://www.ncbi.nlm.nih.gov/pubmed/36083612 ID - info:doi/10.2196/36662 ER - TY - JOUR AU - Peynenburg, Vanessa AU - Hadjistavropoulos, Heather AU - Thiessen, David AU - Titov, Nickolai AU - Dear, Blake PY - 2022/9/7 TI - Internet-Delivered Cognitive Behavioral Therapy for Postsecondary Students: Randomized Factorial Trial for Examining Motivational Interviewing and Booster Lessons JO - J Med Internet Res SP - e40637 VL - 24 IS - 9 KW - postsecondary students KW - transdiagnostic KW - boosters KW - motivational interviewing KW - internet-delivered cognitive behavioral therapy N2 - Background: Internet-delivered cognitive behavioral therapy (ICBT) can improve access to mental health care for students, although high attrition rates are concerning and little is known about long-term outcomes. Motivational interviewing (MI) exercises and booster lessons can improve engagement and outcomes in face-to-face cognitive behavioral therapy. Objective: This study aimed to examine the use of pretreatment MI exercises and booster lessons in ICBT for postsecondary students. Methods: In this factorial trial (factor 1: web-based MI before treatment; factor 2: self-guided booster lesson 1 month after treatment), 308 clients were randomized to 1 of 4 treatment conditions, with 277 (89.9%) clients starting treatment. All clients received a 5-week transdiagnostic ICBT course (the UniWellbeing course). Primary outcomes included changes in depression, anxiety, and perceived academic functioning from before treatment to after treatment and at the 1-month and 3-month follow-ups. Results: Overall, 54% (150/277) of students completed treatment and reported large improvements in symptoms of depression and anxiety and small improvements in academic functioning after treatment, which were maintained at the 1-month and 3-month follow-ups. Pretreatment MI did not contribute to better treatment completion or engagement, although small between-group effects favored MI for reductions in depression (Cohen d=0.23) and anxiety (Cohen d=0.25) after treatment. Only 30.9% (43/139) of students randomized to one of the booster conditions accessed the booster. Overall, no main effects were found for the booster. Subanalyses revealed that clients who accessed the booster had larger decreases in depressive symptoms (Cohen d=0.31) at the 3-month follow-up. No interactions were found between MI and the booster. Conclusions: Rather than offering MI before treatment, clients may experience more benefits from MI exercises later in ICBT when motivation wanes. The low uptake of the self-guided booster limited our conclusions regarding its effectiveness. Future research should examine offering a booster for a longer duration after treatment, with therapist support and a longer follow-up period. Trial Registration: ClinicalTrials.gov NCT04264585; https://clinicaltrials.gov/ct2/show/NCT04264585 UR - https://www.jmir.org/2022/9/e40637 UR - http://dx.doi.org/10.2196/40637 UR - http://www.ncbi.nlm.nih.gov/pubmed/36069785 ID - info:doi/10.2196/40637 ER - TY - JOUR AU - Liang, Wei AU - Duan, Yanping AU - Wang, Yanping AU - Lippke, Sonia AU - Shang, Borui AU - Lin, Zhihua AU - Wulff, Hagen AU - Baker, Steven Julien PY - 2022/9/7 TI - Psychosocial Mediators of Web-Based Interventions for Promoting a Healthy Lifestyle Among Chinese College Students: Secondary Analysis of a Randomized Controlled Trial JO - J Med Internet Res SP - e37563 VL - 24 IS - 9 KW - web-based intervention KW - physical activity KW - fruit and vegetable consumption KW - college students KW - psychosocial mediators KW - lifestyle KW - randomized controlled trial KW - RCT KW - mobile phone N2 - Background: Web-based multiple health behavior change (MHBC) interventions have demonstrated effectiveness in promoting physical activity (PA) and fruit and vegetable consumption (FVC) among Chinese college students. However, there is limited research examining their effects on promoting a healthy lifestyle (ie, adhering to both PA and FVC behavioral recommendations) among Chinese college students. In addition, the salient psychosocial mediators of successful MHBC interventions need to be researched. Objective: This study aims to examine the effectiveness of a previous 8-week web-based MHBC program for promoting a healthy lifestyle and enhancing the psychosocial determinants (intention, self-efficacy, planning, and social support) of behavior change among Chinese college students. Furthermore, the study aims to identify whether changes in these psychosocial determinants mediate intervention effectiveness on the immediate and sustained lifestyle changes. Methods: This was a secondary analysis for a 3-arm randomized controlled trial. Chinese college students (N=552) were randomly assigned to 1 of 3 groups: a PA-first group (4-week PA intervention followed by 4-week FVC intervention), an FVC-first group (4-week FVC intervention followed by 4-week PA intervention), and a placebo control group. The intervention content was designed based on the health action process approach model. Data for analyses were collected at baseline (T0), postintervention assessment (T1), and 12-week follow-up assessment (T2). Results: At baseline, 13.9% (77/552) of the participants maintained a healthy lifestyle. After 8 weeks, more (200/552, 36.2%) participants achieved a healthy lifestyle. PA-first and FVC-first groups were, respectively, 3.24 times and 5 times more likely to adopt a healthy lifestyle than the control group at T1. After 12 weeks, 35.5% (196/552) of the participants adopted a healthy lifestyle. Intervention groups were approximately 2.99 times (PA first) and 4.07 times (FVC first) more likely to adopt a healthy lifestyle than the control group at T2. Intervention effects favored both intervention groups in self-efficacy and planning for PA and in intention and planning for FVC compared with the control condition. In addition, changes in PA self-efficacy and FVC intention mediated intervention effectiveness on the immediate lifestyle change after 8 weeks. Changes in FVC intention were identified as a salient mediator for facilitating sustained lifestyle change after 12 weeks. Conclusions: This study provides empirical evidence for the effectiveness of an 8-week theory- and web-based MHBC intervention program on promoting a healthy lifestyle, self-efficacy and planning for PA, and intention and planning for FVC among Chinese college students. These research findings add new knowledge to the underlying psychosocial mechanisms of successful MHBC interventions. Overall, this study has considerable implications for future web-based MHBC research and practice in terms of addressing PA self-efficacy and FVC intention and helping students to adopt and maintain a healthy lifestyle independently of whether PA or FVC is addressed first. Trial Registration: ClinicalTrials.gov NCT03627949; https://clinicaltrials.gov/ct2/show/NCT03627949 UR - https://www.jmir.org/2022/9/e37563 UR - http://dx.doi.org/10.2196/37563 UR - http://www.ncbi.nlm.nih.gov/pubmed/36069840 ID - info:doi/10.2196/37563 ER - TY - JOUR AU - Tang, W. Wymann S. AU - Ng, Y. Tricia J. AU - Wong, A. Joseph Z. AU - Ho, H. Cyrus S. PY - 2022/8/29 TI - The Role of Serious Video Games in the Treatment of Disordered Eating Behaviors: Systematic Review JO - J Med Internet Res SP - e39527 VL - 24 IS - 8 KW - serious video games KW - serious games KW - video games KW - gamification KW - digital health KW - eHealth KW - mobile health KW - mHealth KW - disordered eating KW - eating disorders N2 - Background: Eating disorders and other forms of disordered eating cause significant complications and comorbidities in patients. However, full remission with current standard treatment remains low. Challenges to treatment include underdiagnosis and high dropout rates, as well as difficulties in addressing underlying emotion dysregulation, poor impulse control, and personality traits. Serious video games (SVGs), which have the advantages of being highly engaging and accessible, may be potential tools for delivering various forms of treatment in addressing the underlying psychopathology of disordered eating. Objective: This review aims to provide an overview of the possible mechanisms by which SVGs may affect the clinical course of disordered eating, while evaluating the outcomes of studies that have assessed the role of SVGs in the treatment of disordered eating. Methods: A systematic search was performed on PubMed, PsycINFO, and Embase, using keywords related to SVGs, disordered eating, and eating disorders. A narrative synthesis was subsequently carried out. Results: In total, 2151 papers were identified, of which 11 (0.51%) were included. Of these 11 studies, 10 (91%) were randomized controlled trials, and 1 (9%) was a quasi-experimental study. The types of SVG interventions varied across the studies and targeted different mechanisms of disordered eating, ranging from addressing problem-solving and emotion regulation skills to neurocognitive training for inhibitory control. Most (10/11, 91%) of the studies showed some benefit of the SVGs in improving certain physical, behavioral, or psychological outcomes related to disordered eating. Some (4/11, 36%) of the studies also showed encouraging evidence of the retention of these benefits at follow-up. Conclusions: The studies included in this review provide collective evidence to suggest the various roles SVGs can play in plugging potential gaps in conventional therapy. Nonetheless, challenges exist in designing these games to prevent potential pitfalls, such as excessive stress arising from the SVGs themselves or potential gaming addiction. Further studies will also be required to assess the long-term benefits of SVGs as well as explore their potential preventive, and not just curative, effects on disordered eating. UR - https://www.jmir.org/2022/8/e39527 UR - http://dx.doi.org/10.2196/39527 UR - http://www.ncbi.nlm.nih.gov/pubmed/36036967 ID - info:doi/10.2196/39527 ER - TY - JOUR AU - Ichimiya, Megumi AU - Gerard, Raquel AU - Mills, Sarah AU - Brodsky, Alexa AU - Cantrell, Jennifer AU - Evans, Douglas W. PY - 2022/8/25 TI - The Measurement of Dose and Response for Smoking Behavior Change Interventions in the Digital Age: Systematic Review JO - J Med Internet Res SP - e38470 VL - 24 IS - 8 KW - digital health KW - digital media KW - social media KW - behavior change interventions KW - smoking KW - vaping KW - dose-response KW - telehealth KW - mobile health KW - mHealth KW - mobile phone N2 - Background: There is little consensus regarding effective digital health interventions for diverse populations, which is due in part to the difficulty of quantifying the impact of various media and content and the lack of consensus on evaluating dosage and outcomes. In particular, digital smoking behavior change intervention is an area where consistency of measurement has been a challenge because of emerging products and rapid policy changes. This study reviewed the contents and outcomes of digital smoking interventions and the consistency of reporting to inform future research. Objective: This study aims to systematically review digital smoking behavior change interventions and evaluate the consistency in measuring and reporting intervention contents, channels, and dose and response outcomes. Methods: PubMed, Embase, Scopus, PsycINFO, and PAIS databases were used to search the literature between January and May 2021. General and journal-based searches were combined. All records were imported into Covidence systematic review software (Veritas Health Innovation) and duplicates were removed. Titles and abstracts were screened by 4 trained reviewers to identify eligible full-text literature. The data synthesis scheme was designed based on the concept that exposure to digital interventions can be divided into intended doses that were planned by the intervention and enacted doses that were completed by participants. The intended dose comprised the frequency and length of the interventions, and the enacted dose was assessed as the engagement. Response measures were assessed for behaviors, intentions, and psychosocial outcomes. Measurements of the dose-response relationship were reviewed for all studies. Results: A total of 2916 articles were identified through a database search. Of these 2916 articles, the title and abstract review yielded 324 (11.11%) articles for possible eligibility, and 19 (0.65%) articles on digital smoking behavior change interventions were ultimately included for data extraction and synthesis. The analysis revealed a lack of prevention studies (0/19, 0%) and dose-response studies (3/19, 16%). Of the 19 studies, 6 (32%) reported multiple behavioral measures, and 5 (23%) reported multiple psychosocial measures as outcomes. For dosage measures, 37% (7/19) of studies used frequency of exposure, and 21% (4/19) of studies mentioned the length of exposure. The assessment of clarity of reporting revealed that the duration of intervention and data collection tended to be reported vaguely in the literature. Conclusions: This review revealed a lack of studies assessing the effects of digital media interventions on smoking outcomes. Data synthesis showed that measurement and reporting were inconsistent across studies, illustrating current challenges in this field. Although most studies focused on reporting outcomes, the measurement of exposure, including intended and enacted doses, was unclear in a large proportion of studies. Clear and consistent reporting of both outcomes and exposures is needed to develop further evidence in intervention research on digital smoking behavior change. UR - https://www.jmir.org/2022/8/e38470 UR - http://dx.doi.org/10.2196/38470 UR - http://www.ncbi.nlm.nih.gov/pubmed/36006682 ID - info:doi/10.2196/38470 ER - TY - JOUR AU - De Jesús-Romero, Robinson AU - Wasil, Akash AU - Lorenzo-Luaces, Lorenzo PY - 2022/8/24 TI - Willingness to Use Internet-Based Versus Bibliotherapy Interventions in a Representative US Sample: Cross-sectional Survey Study JO - JMIR Form Res SP - e39508 VL - 6 IS - 8 KW - psychotherapy KW - digital mental health KW - digital health KW - eHealth KW - adoption KW - preference KW - self-help KW - bibliotherapy KW - iCBT KW - CBT KW - internet-based intervention KW - self-guided intervention KW - mental health KW - print media KW - cognitive behavioral therapy KW - digital health intervention KW - patient education KW - psychoeducation KW - health resource KW - health information KW - health education KW - education material N2 - Background: Self-help interventions have the potential to increase access to evidence-based mental health care. Self-help can be delivered via different formats, including print media or digital mental health interventions (DMHIs). However, we do not know which delivery format is more likely to result in higher engagement. Objective: The aims of this study were to identify if there is a preference for engaging in print media versus DMHIs and whether there are individual differences in relative preferences. Methods: Participants were 423 adults between the ages of 18 and 82 years (201/423, 47.5% female) recruited on Prolific as a nationally representative sample of the US population, including non-Hispanic White (293/423, 69.2%), non-Hispanic Black (52/423, 12%), Asian (31/423, 7%), Hispanic (25/423, 6%), and other individuals (22/423, 5%). We provided individuals with psychoeducation in different self-help formats and measured their willingness to use print media versus DMHIs. We also assessed participants? demographics, personality, and perception of each format?s availability and helpfulness and used these to predict individual differences in the relative preferences. Results: Participants reported being more willing to engage with print media than with DMHIs (B=0.41, SE 0.08; t422=4.91; P<.001; d=0.24, 95% CI 0.05-0.43). This preference appeared to be influenced by education level (B=0.22, SE 0.09; t413=2.41; P=.02; d=0.13, 95% CI ?0.06 to 0.32), perceived helpfulness (B=0.78, SE 0.06; t411=13.66; P<.001; d=0.46, 95% CI 0.27-0.66), and perceived availability (B=0.20, SE 0.58; t411=3.25; P=.001; d=0.12, 95% CI 0.07-0.30) of the self-help format. Conclusions: This study suggests an overall preference for print media over DMHIs. Future work should investigate whether receiving mental health treatment via participants? preferred delivery format can lead to higher engagement. UR - https://formative.jmir.org/2022/8/e39508 UR - http://dx.doi.org/10.2196/39508 UR - http://www.ncbi.nlm.nih.gov/pubmed/36001373 ID - info:doi/10.2196/39508 ER - TY - JOUR AU - Milios, Athena AU - Xiong, Ting AU - McEwan, Karen AU - McGrath, Patrick PY - 2022/8/18 TI - Personality, Attitudes, and Behaviors Predicting Perceived Benefit in Online Support Groups for Caregivers: Mixed Methods Study JO - JMIR Nursing SP - e36167 VL - 5 IS - 1 KW - online support groups KW - personality KW - support group KW - online support KW - peer support KW - caregiver KW - caregiving KW - caring KW - mother KW - father KW - usage pattern KW - extraversion KW - neuroticism KW - neurotic KW - agreeable KW - benefit KW - eHealth KW - Canada KW - North America KW - parent KW - neurodevelopment disorder KW - attitude KW - online behavior KW - emotional support KW - perceived benefit N2 - Background: Online support groups (OSGs) are distance-delivered, easily accessible health interventions offering emotional, informational, and experience-based support and companionship or network support for caregivers managing chronic mental and physical health conditions. Objective: This study aimed to examine the relative contribution of extraversion, agreeableness, neuroticism, positive attitudes toward OSGs on social networking sites, and typical past OSG use patterns in predicting perceived OSG benefit in an OSG for parents and caregivers of children with neurodevelopmental disorders. Methods: A mixed methods, longitudinal design was used to collect data from 81 parents across Canada. Attitudes toward OSGs and typical OSG use patterns were assessed using the author-developed Attitudes Toward OSGs subscale (eg, ?Online support groups are a place to get and give emotional support?) and Past Behaviors in OSGs subscale (eg, ?How often would you typically comment on posts??) administered at baseline?before OSG membership. The personality traits of extraversion, agreeableness, and neuroticism were assessed at baseline using the Ten-Item Personality Inventory. Perceived OSG benefit was assessed using the author-developed Perceived OSG Benefit scale (eg, ?Overall, did you feel supported by other members in this group??), administered 2 months after the initiation of OSG membership. Results: A hierarchical regression analysis found that extraversion was the only variable that significantly predicted perceived OSG benefit (R2=0.125; P<.001). Conclusions: The key suggestions for improving future OSGs were facilitating more in-depth, customized, and interactive content in OSGs. UR - https://nursing.jmir.org/2022/1/e36167 UR - http://dx.doi.org/10.2196/36167 UR - http://www.ncbi.nlm.nih.gov/pubmed/35980741 ID - info:doi/10.2196/36167 ER - TY - JOUR AU - Tuijnman, Anouk AU - Kleinjan, Marloes AU - Olthof, Merlijn AU - Hoogendoorn, Evert AU - Granic, Isabela AU - Engels, CME Rutger PY - 2022/8/17 TI - A Game-Based School Program for Mental Health Literacy and Stigma on Depression (Moving Stories): Cluster Randomized Controlled Trial JO - JMIR Ment Health SP - e26615 VL - 9 IS - 8 KW - depression KW - help-seeking behavior KW - helping behavior KW - health literacy KW - stigma KW - video games KW - adolescence KW - secondary schools KW - mental health KW - digital health N2 - Background: Depressive symptoms are highly prevalent among adolescents in Western countries. However, although treatment for depressive symptoms is available, many adolescents do not seek help when they need it. Important barriers to help-seeking among adolescents include low mental health literacy and high stigma. Therefore, we have developed a game-based school program, Moving Stories, which combines mental health literacy training for depression with contact with someone with lived experience both in the digital and nondigital world. Objective: The aim of this study is to conduct a first test of the effectiveness of the newly developed game-based program, Moving Stories, using a cluster randomized controlled trial. Methods: A total of 185 adolescents participated, divided over 10 classes from 4 schools. Half of the classes were randomly selected to follow the Moving Stories program, whereas the other half were in the control group, where no intervention was provided. The adolescents filled out digital questionnaires at 4 time points, with questions on mental health literacy, stigma, depressive symptoms, and the program itself (before the program, after the program, 3-month follow-up, and 6-month follow-up). Using R (R Foundation for Statistical Computing), we ran linear mixed-effects models for all continuous outcome variables and generalized linear mixed-effects models for all binary outcome variables. Results: Compared with the control group, participants in the Moving Stories group improved after the program in personal stigma (b=?0.53, 95% CI ?1.02 to ?0.03; t179.16=?2.08; P=.04). Effects on personal stigma lasted over time (3-month follow-up: b=?0.57, 95% CI ?1.11 to ?0.03; t174.39=?2.07; P=.04). Most adolescents in the Moving Stories group participated in the introduction (97/99, 98%) and contact session (93/99, 94%), played the game for 4 or 5 days (83/99, 83%), and indicated that they would recommend the game to their peers (90/98, 92%). Conclusions: The results of this study show the potential of Moving Stories as a stigma reduction program. With changes in the program to improve its effects on mental health literacy, Moving Stories could be implemented in schools to improve help-seeking in adolescents and reduce the negative consequences and burden of depressive symptoms. Trial Registration: Dutch Trial Register NTR7033; https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7033 International Registered Report Identifier (IRRID): RR2-10.2196/11255 UR - https://mental.jmir.org/2022/8/e26615 UR - http://dx.doi.org/10.2196/26615 UR - http://www.ncbi.nlm.nih.gov/pubmed/35976200 ID - info:doi/10.2196/26615 ER - TY - JOUR AU - Pedamallu, Havisha AU - Ehrhardt, J. Matthew AU - Maki, Julia AU - Carcone, Idalski April AU - Hudson, M. Melissa AU - Waters, A. Erika PY - 2022/8/9 TI - Technology-Delivered Adaptations of Motivational Interviewing for the Prevention and Management of Chronic Diseases: Scoping Review JO - J Med Internet Res SP - e35283 VL - 24 IS - 8 KW - motivational interviewing KW - technology KW - telehealth KW - health behavior KW - chronic disease KW - socioeconomic factors KW - health promotion KW - disease management KW - primary prevention KW - secondary prevention KW - minority health N2 - Background: Motivational interviewing (MI) can increase health-promoting behaviors and decrease health-damaging behaviors. However, MI is often resource intensive, precluding its use with people with limited financial or time resources. Mobile health?based versions of MI interventions or technology-delivered adaptations of MI (TAMIs) might increase reach. Objective: We aimed to understand the characteristics of existing TAMIs. We were particularly interested in the inclusion of people from marginalized sociodemographic groups, whether the TAMI addressed sociocontextual factors, and how behavioral and health outcomes were reported. Methods: We employed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews to conduct our scoping review. We searched PubMed, CINAHL, and PsycInfo from January 1, 1996, to April 6, 2022, to identify studies that described interventions incorporating MI into a mobile or electronic health platform. For inclusion, the study was required to (1) describe methods/outcomes of an MI intervention, (2) feature an intervention delivered automatically via a mobile or electronic health platform, and (3) report a behavioral or health outcome. The exclusion criteria were (1) publication in a language other than English and (2) description of only in-person intervention delivery (ie, no TAMI). We charted results using Excel (Microsoft Corp). Results: Thirty-four studies reported the use of TAMIs. Sample sizes ranged from 10 to 2069 participants aged 13 to 70 years. Most studies (n=27) directed interventions toward individuals engaging in behaviors that increased chronic disease risk. Most studies (n=22) oversampled individuals from marginalized sociodemographic groups, but few (n=3) were designed specifically with marginalized groups in mind. TAMIs used text messaging (n=8), web-based intervention (n=22), app + text messaging (n=1), and web-based intervention + text messaging (n=3) as delivery platforms. Of the 34 studies, 30 (88%) were randomized controlled trials reporting behavioral and health-related outcomes, 23 of which reported statistically significant improvements in targeted behaviors with TAMI use. TAMIs improved targeted health behaviors in the remaining 4 studies. Moreover, 11 (32%) studies assessed TAMI feasibility, acceptability, or satisfaction, and all rated TAMIs highly in this regard. Among 20 studies with a disproportionately high number of people from marginalized racial or ethnic groups compared with the general US population, 16 (80%) reported increased engagement in health behaviors or better health outcomes. However, no TAMIs included elements that addressed sociocontextual influences on behavior or health outcomes. Conclusions: Our findings suggest that TAMIs may improve some health promotion and disease management behaviors. However, few TAMIs were designed specifically for people from marginalized sociodemographic groups, and none included elements to help address sociocontextual challenges. Research is needed to determine how TAMIs affect individual health outcomes and how to incorporate elements that address sociocontextual factors, and to identify the best practices for implementing TAMIs into clinical practice. UR - https://www.jmir.org/2022/8/e35283 UR - http://dx.doi.org/10.2196/35283 UR - http://www.ncbi.nlm.nih.gov/pubmed/35943775 ID - info:doi/10.2196/35283 ER - TY - JOUR AU - Johnson, W. Rowan AU - White, K. Becky AU - Gucciardi, F. Daniel AU - Gibson, Noula AU - Williams, A. Sian PY - 2022/8/9 TI - Intervention Mapping of a Gamified Therapy Prescription App for Children With Disabilities: User-Centered Design Approach JO - JMIR Pediatr Parent SP - e34588 VL - 5 IS - 3 KW - neurodevelopmental disability KW - mobile health KW - self-determination theory KW - gamification KW - physiotherapy KW - occupational therapy KW - speech pathology KW - behavior change KW - mobile phone N2 - Background: Mobile health (mHealth) apps for children are increasing in availability and scope. Therapy (physiotherapy, speech pathology, and occupational therapy) prescription apps to improve home or school program adherence work best when developed to be highly engaging for children and when they incorporate behavior change techniques (BCTs) within their design. Objective: The aim of this study was to describe the development of a user-centered therapy prescription app for children (aged 6-12 years) with neurodevelopmental disabilities (eg, cerebral palsy, autism spectrum disorder, and intellectual disability) incorporating intervention mapping (IM) and gamified design. Methods: We used an iterative, user-centered app development model incorporating the first 3 steps of IM. We conducted a needs analysis with user feedback from our previous mHealth app study, a literature review, and a market audit. Change objectives were then specified in alignment with the psychological needs of autonomy, competence, and relatedness identified in self-determination theory. From these objectives, we then selected BCTs, stipulating parameters for effectiveness and how each BCT would be operationalized. A gamification design was planned and implemented focusing on maximizing engagement in children. In total, 2 rounds of consultations with parents, teachers, and therapists and 1 round of prototype app testing with children were conducted to inform app development, with a final iteration developed for further testing. Results: The IM process resulted in the specification of app elements, self-determination theory?informed BCTs, that were embedded into the app design. The gamification design yielded the selection of a digital pet avatar with a fantasy anime visual theme and multiple layers of incentives earned by completing prescribed therapy activities. Consultation groups with professionals working with children with disabilities (4 therapists and 3 teachers) and parents of children with disabilities (n=3) provided insights into the motivation of children and the pragmatics of implementing app-delivered therapy programs that informed the app development. User testing with children with disabilities (n=4) highlighted their enthusiasm for the app and the need for support in the initial phase of learning the app. App quality testing (Mobile Application Rating Scale-user version) with the children yielded means (out of 5) of 4.5 (SD 0.8) for engagement, 3.3 (SD 1.6) for function, 3.3 (SD 1.7) for aesthetics, and 4.3 (SD 1.1) for subjective quality. Conclusions: mHealth apps designed for children can be greatly enhanced with a systematic yet flexible development process considering the specific contextual needs of the children with user-centered design, addressing the need for behavior change using the IM process, and maximizing engagement with gamification and strong visual design. UR - https://pediatrics.jmir.org/2022/3/e34588 UR - http://dx.doi.org/10.2196/34588 UR - http://www.ncbi.nlm.nih.gov/pubmed/35943782 ID - info:doi/10.2196/34588 ER - TY - JOUR AU - Walker, Elizabeth Ruth AU - Quong, Sara AU - Olivier, Patrick AU - Wu, Ling AU - Xie, Jue AU - Boyle, Jacqueline PY - 2022/8/5 TI - Understanding Preconception Women?s Needs and Preferences for Digital Health Resources: Qualitative Study JO - JMIR Form Res SP - e39280 VL - 6 IS - 8 KW - digital health KW - preconception KW - health promotion KW - behavior change KW - women's health KW - maternal health KW - digital health resource KW - healthy life style KW - qualitative analysis KW - online health information N2 - Background: Improving preconception health can benefit all women, their children, and their families regardless of their individual pregnancy intentions. Rapidly increasing access to information technology and online engagement have created opportunities to use digital health resources to engage with preconception women regarding lifestyle behaviors. Objective: This study explores how preconception women engage with digital health resources and online platforms to inform the design and development of a digital health resource to support women to make positive behavior change for their preconception health. Methods: This codesign research followed the Double Diamond process, which focuses on contextualization and explorative processes in phase 1 and ideation and development processes in phase 2. Phase 1 is reported on in this study and was undertaken via a series of 1-on-1 in-depth interviews with female participants (N=12) aged 18-45 years over 3 months. Interviews were designed to explore participants? lived experiences in relation to their health and desired supports for healthy lifestyle behaviors. The first interview focused on participants? perceptions of health and health behaviors, the second interview focused on social connections for health, and the third interview focused on digital health information and supports. Conversations from the first interview informed the development of the second interview, and conversations from the second interview informed the development of the third interview. Community advisors (N=8) met to provide feedback and advice to the researchers throughout the interview process. Qualitative analyses of transcripts from interviews were undertaken by 2 researchers before a deductive process identified themes mapped to the capability, opportunity, motivation, and behavior (COM-B) framework. Results: In total, 9 themes and 8 subthemes were identified from 124 codes. In relation to digital health resources, specifically, participants were already engaging with a range of digital health resources and had high expectations of these. Digital health resources needed to be easy to access, make women?s busy lives easier, be evidence based, and be reputable. Social connectedness was also highly important to our participants, with information and advice from peers with similar experiences being preferred over yet more online health information. Online communities facilitated these social interactions. Participants were open to the idea of chatbots and virtual assistants but acknowledged that they would not replace authentic social interactions. Conclusions: Codesigned digital health resources should be evidence based, reputable, and easy to access. Social connections were considered highly important to women, and designers of digital health resources should consider how they can increase opportunities for women to connect and learn from each other to promote health behaviors. UR - https://formative.jmir.org/2022/8/e39280 UR - http://dx.doi.org/10.2196/39280 UR - http://www.ncbi.nlm.nih.gov/pubmed/35930344 ID - info:doi/10.2196/39280 ER - TY - JOUR AU - Lee, Daehyoung AU - Frey, C. Georgia AU - Cothran, J. Donetta AU - Harezlak, Jaroslaw AU - Shih, C. Patrick PY - 2022/7/28 TI - Effects of a Gamified, Behavior Change Technique?Based Mobile App on Increasing Physical Activity and Reducing Anxiety in Adults With Autism Spectrum Disorder: Feasibility Randomized Controlled Trial JO - JMIR Form Res SP - e35701 VL - 6 IS - 7 KW - gamification KW - behavior change techniques KW - physical activity KW - sedentary behavior KW - anxiety KW - autism KW - mobile app KW - mental health KW - mHealth KW - mobile phone N2 - Background: Physical activity (PA) has an impact on physical and mental health in neurotypical populations, and addressing these variables may improve the prevalent burden of anxiety in adults with autism spectrum disorder (ASD). Gamified mobile apps using behavior change techniques present a promising way of increasing PA and reducing sedentary time, thus reducing anxiety in adults with ASD. Objective: This study aimed to compare the effectiveness of a gamified and behavior change technique?based mobile app, PuzzleWalk, versus a commercially available app, Google Fit, on increasing PA and reducing sedentary time as an adjunct anxiety treatment for this population. Methods: A total of 24 adults with ASD were assigned to either the PuzzleWalk or Google Fit group for 5 weeks using a covariate-adaptive randomization design. PA and anxiety were assessed over 7 days at 3 different data collection periods (ie, baseline, intervention start, and intervention end) using triaxial accelerometers and the Beck Anxiety Inventory. Group differences in outcome variables were assessed using repeated-measures analysis of covariance, adjusting for age, sex, and BMI. Results: The findings indicated that the PuzzleWalk group spent a significantly longer amount of time on app use compared with the Google Fit group (F2,38=5.07; P=.01; partial ?2=0.21), whereas anxiety was unfavorably associated with increases in light PA and decreases in sedentary time after intervention (all P<.05). Conclusions: Further research is needed to clarify the determinants of physical and mental health and their interrelationship in adults with ASD to identify the factors that facilitate the use and adoption of mobile health technologies in these individuals. Despite these mixed results, the small changes in PA or anxiety may be clinically significant for adults with ASD. Trial Registration: ClinicalTrials.gov NCT05466617; https://clinicaltrials.gov/show/NCT05466617 UR - https://formative.jmir.org/2022/7/e35701 UR - http://dx.doi.org/10.2196/35701 UR - http://www.ncbi.nlm.nih.gov/pubmed/35900808 ID - info:doi/10.2196/35701 ER - TY - JOUR AU - Rodda, N. Simone AU - Bagot, L. Kathleen AU - Merkouris, S. Stephanie AU - Youssef, George AU - Lubman, I. Dan AU - Thomas, C. Anna AU - Dowling, A. Nicki PY - 2022/7/26 TI - Smartphone App Delivery of a Just-In-Time Adaptive Intervention for Adult Gamblers (Gambling Habit Hacker): Protocol for a Microrandomized Trial JO - JMIR Res Protoc SP - e38919 VL - 11 IS - 7 KW - Just-In-Time Adaptive Intervention KW - JITAI KW - ecological momentary assessment KW - EMA KW - ecological momentary intervention KW - EMI KW - gambling KW - behavior change technique KW - implementation intentions KW - action planning KW - coping planning KW - microrandomized trial KW - mobile phone N2 - Background: People with gambling problems frequently report repeated unsuccessful attempts to change their behavior. Although many behavior change techniques are available to individuals to reduce gambling harm, they can be challenging to implement or maintain. The provision of implementation support tailored for immediate, real-time, individualized circumstances may improve attempts at behavior change. Objective: We aimed to develop and evaluate a Just-In-Time Adaptive Intervention (JITAI) for individuals who require support to adhere to their gambling limits. JITAI development is based on the principles of the Health Action Process Approach with delivery, in alignment with the principles of self-determination theory. The primary objective was to determine the effect of action- and coping planning compared with no intervention on the goal of subsequently adhering to gambling expenditure limits. Methods: Gambling Habit Hacker is delivered as a JITAI providing in-the-moment support for adhering to gambling expenditure limits (primary proximal outcome). Delivered via a smartphone app, this JITAI delivers tailored behavior change techniques related to goal setting, action planning, coping planning, and self-monitoring. The Gambling Habit Hacker app will be evaluated using a 28-day microrandomized trial. Up to 200 individuals seeking support for their own gambling from Australia and New Zealand will set a gambling expenditure limit (ie, goal). They will then be asked to complete 3 time-based ecological momentary assessments (EMAs) per day over a 28-day period. EMAs will assess real-time adherence to gambling limits, strength of intention to adhere to goals, goal self-efficacy, urge self-efficacy, and being in high-risk situations. On the basis of the responses to each EMA, participants will be randomized to the control (a set of 25 self-enactable strategies containing names only and no implementation information) or intervention (self-enactable strategy implementation information with facilitated action- and coping planning) conditions. This microrandomized trial will be supplemented with a 6-month within-group follow-up that explores the long-term impact of the app on gambling expenditure (primary distal outcome) and a range of secondary outcomes, as well as an evaluation of the acceptability of the JITAI via postintervention surveys, app use and engagement indices, and semistructured interviews. This trial has been approved by the Deakin University Human Research Ethics Committee (2020-304). Results: The intervention has been subject to expert user testing, with high acceptability scores. The results will inform a more nuanced version of the Gambling Habit Hacker app for wider use. Conclusions: Gambling Habit Hacker is part of a suite of interventions for addictive behaviors that deliver implementation support grounded in lived experience. This study may inform the usefulness of delivering implementation intentions in real time and in real-world settings. It potentially offers people with gambling problems new support to set their gambling intentions and adhere to their limits. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12622000497707; www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383568 International Registered Report Identifier (IRRID): DERR1-10.2196/38919 UR - https://www.researchprotocols.org/2022/7/e38919 UR - http://dx.doi.org/10.2196/38919 UR - http://www.ncbi.nlm.nih.gov/pubmed/35881441 ID - info:doi/10.2196/38919 ER - TY - JOUR AU - Gilmore, K. Amanda AU - Leone, M. Ruschelle AU - Oesterle, W. Daniel AU - Davis, Cue Kelly AU - Orchowski, M. Lindsay AU - Ramakrishnan, Viswanathan AU - Kaysen, Debra PY - 2022/7/22 TI - Web-Based Alcohol and Sexual Assault Prevention Program With Tailored Content Based on Gender and Sexual Orientation: Preliminary Outcomes and Usability Study of Positive Change (+Change) JO - JMIR Form Res SP - e23823 VL - 6 IS - 7 KW - sexual assault prevention KW - alcohol KW - college students KW - sexual and gender minorities N2 - Background: Alcohol use and sexual assault are common on college campuses in the United States, and the rates of occurrence differ based on gender identity and sexual orientation. Objective: We aimed to provide an assessment of the usability and preliminary outcomes of Positive Change (+Change), a program that provides integrated personalized feedback to target alcohol use, sexual assault victimization, sexual assault perpetration, and bystander intervention among cisgender heterosexual men, cisgender heterosexual women, and sexual minority men and women. Methods: Participants included 24 undergraduate students from a large university in the Southwestern United States aged between 18 and 25 years who engaged in heavy episodic drinking in the past month. All procedures were conducted on the web, and participants completed a baseline survey, +Change, and a follow-up survey immediately after completing +Change. Results: Our findings indicated that +Change was acceptable and usable among all participants, despite gender identity or sexual orientation. Furthermore, there were preliminary outcomes indicating the benefit for efficacy testing of +Change. Conclusions: Importantly, +Change is the first program to target alcohol use, sexual assault victimization, sexual assault perpetration, and bystander intervention within the same program and to provide personalized content based on gender identity and sexual orientation. Trial Registration: ClinicalTrials.gov NCT04089137; https://clinicaltrials.gov/ct2/show/NCT04089137 UR - https://formative.jmir.org/2022/7/e23823 UR - http://dx.doi.org/10.2196/23823 UR - http://www.ncbi.nlm.nih.gov/pubmed/35867393 ID - info:doi/10.2196/23823 ER - TY - JOUR AU - Bao, Yuhan AU - Wang, Chunxiang AU - Xu, Haiping AU - Lai, Yongjie AU - Yan, Yupei AU - Ma, Yuanyuan AU - Yu, Ting AU - Wu, Yibo PY - 2022/7/14 TI - Effects of an mHealth Intervention for Pulmonary Tuberculosis Self-management Based on the Integrated Theory of Health Behavior Change: Randomized Controlled Trial JO - JMIR Public Health Surveill SP - e34277 VL - 8 IS - 7 KW - ITHBC KW - mHealth KW - RCT KW - pulmonary tuberculosis N2 - Background: Improving the health self-management level of patients with tuberculosis (TB) is significant for reducing drug resistance, improving the cure rate, and controlling the prevalence of TB. Mobile health (mHealth) interventions based on behavioral science theories may be promising to achieve this goal. Objective: This study aims to explore and conduct an mHealth intervention based on the Integrated Theory of Health Behavior Change (ITHBC) in patients with pulmonary TB to increase their ability of self-care management. Methods: A prospective randomized controlled study was conducted from May to November 2020. A total of 114 patients who were admitted consecutively to the TB clinic of Harbin Chest Hospital, China from May 2020 to August 2020 were recruited by convenience sampling. Patients were divided into the control group and intervention group, and all received a 3-month intervention. Patients in the intervention group and the control group received routine medical and nursing care in the TB clinic, including the supervision of their medications. In addition, pharmacist-assisted mHealth (WeChat) intervention based on the ITHBC theory about TB management was provided to the intervention group. The primary outcome was self-management behavior, while the secondary outcomes were TB awareness, self-efficacy, social support, and degree of satisfaction with health education. The outcomes were measured using web-based self-designed and standard questionnaires administered at baseline and at the end point of the study. Intergroup data were assessed using the Mann-Whitney U test, whereas intragroup data were assessed with the Wilcoxon test (for paired samples). Results: A total of 112 patients (59 in intervention group and 53 in control group) completed the study. After the intervention, a statistically significant increase was noted in the scores of each item of self-care management behaviors compared with the scores at the baseline (P<.001) in the intervention group. The scores of all self-care management behaviors of the control group were lower than those of all self-care management behaviors in the intervention group (all P<.05), except for the item ?cover your mouth and nose when coughing or sneezing? (P=.23) and item ?wash hands properly? (P=.60), which had no statistically significant difference from those in the intervention group. Compared with those at baseline, TB knowledge awareness, self-efficacy, social support, and degree of satisfaction with health education in the intervention group increased significantly (P<.001), and the intervention group had significantly higher scores than the control group (P<.001). Conclusions: mHealth intervention for TB self-management based on ITHBC could deepen the understanding of patients with TB about their disease and improve their objective initiative and self-care management behaviors, which were beneficial for promoting compliance behavior and quality of prevention and control for pulmonary TB. Trial Registration: Chinese Clinical Trial Registry ChiCTR2200055557; https://tinyurl.com/4ray3xnw UR - https://publichealth.jmir.org/2022/7/e34277 UR - http://dx.doi.org/10.2196/34277 UR - http://www.ncbi.nlm.nih.gov/pubmed/35834302 ID - info:doi/10.2196/34277 ER - TY - JOUR AU - Stoeten, Claudia AU - de Haan, Arnoud Hein AU - Postel, Gerda Marloes AU - Brusse-Keizer, Marjolein AU - ter Huurne, Daniëlle Elke PY - 2022/6/30 TI - Therapeutic Alliance in Web-Based Treatment for Eating Disorders: Secondary Analysis of a Randomized Controlled Trial JO - JMIR Form Res SP - e33813 VL - 6 IS - 6 KW - therapeutic alliance KW - TA KW - treatment completion KW - cognitive behavioral therapy KW - CBT KW - web-CBT KW - eating disorders N2 - Background: In face-to-face therapy for eating disorders, therapeutic alliance (TA) is an important predictor of symptom reduction and treatment completion. To date, however, little is known about TA during web-based cognitive behavioral therapy (web-CBT) and its association with symptom reduction, treatment completion, and the perspectives of patients versus therapists. Objective: This study aimed to investigate TA ratings measured at interim and after treatment, separately for patients and therapists; the degree of agreement between therapists and patients (treatment completers and noncompleters) for TA ratings; and associations between patient and therapist TA ratings and both eating disorder pathology and treatment completion. Methods: A secondary analysis was performed on randomized controlled trial data of a web-CBT intervention for eating disorders. Participants were 170 females with bulimia nervosa (n=33), binge eating disorder (n=68), or eating disorder not otherwise specified (n=69); the mean age was 39.6 (SD 11.5) years. TA was operationalized using the Helping Alliance Questionnaire (HAQ). Paired t tests were conducted to assess the change in TA from interim to after treatment. Intraclass correlations were calculated to determine cross-informant agreement with regard to HAQ scores between patients and therapists. A total of 2 stepwise regressive procedures (at interim and after treatment) were used to examine which HAQ scores predicted eating disorder pathology and therapy completion. Results: For treatment completers (128/170, 75.3%), the HAQ-total scores and HAQ-Helpfulness scores for both patients and therapists improved significantly from interim to post treatment. For noncompleters (42/170, 24.7%), all HAQ scores decreased significantly. For all HAQ scales, the agreement between patients and therapists was poor. However, the agreement was slightly better after treatment than at interim. Higher patient scores on the helpfulness subscale of the HAQ at interim and after treatment were associated with less eating disorder psychopathology. A positive association was found between the HAQ-total patient scores at interim and treatment completion. Finally, posttreatment HAQ-total patient scores and posttreatment HAQ-Helpfulness scores of therapists were positively associated with treatment completion. Conclusions: Our study showed that TA in web-CBT is predictive of eating disorder pathology and treatment completion. Of particular importance is patients? confidence in their abilities as measured with the HAQ-Helpfulness subscale when predicting posttreatment eating disorder pathology and treatment completion. UR - https://formative.jmir.org/2022/6/e33813 UR - http://dx.doi.org/10.2196/33813 UR - http://www.ncbi.nlm.nih.gov/pubmed/35771608 ID - info:doi/10.2196/33813 ER - TY - JOUR AU - Bergevi, Julia AU - Andermo, Susanne AU - Woldamanuel, Yohannes AU - Johansson, Unn-Britt AU - Hagströmer, Maria AU - Rossen, Jenny PY - 2022/6/28 TI - User Perceptions of eHealth and mHealth Services Promoting Physical Activity and Healthy Diets: Systematic Review JO - JMIR Hum Factors SP - e34278 VL - 9 IS - 2 KW - acceptability KW - behavior change KW - engagement KW - health technology KW - noncommunicable diseases KW - usability KW - user feedback KW - qualitative studies KW - physical activity KW - healthy diet N2 - Background: Physical activity and a diet that follows general recommendations can help to prevent noncommunicable diseases. However, most adults do not meet current recommended guidelines, and support for behavior change needs to be strengthened. There is growing evidence that shows the benefits of eHealth and mobile health (mHealth) services in promoting healthy habits; however, their long-term effectiveness is uncertain because of nonadherence. Objective: We aimed to explore users? perceptions of acceptability, engagement, and usability of eHealth and mHealth services that promote physical activity, healthy diets, or both in the primary or secondary prevention of noncommunicable diseases. Methods: We conducted a systematic review with a narrative synthesis. We performed the literature search in PubMed, PsycINFO, and CINAHL electronic databases in February 2021 and July 2021. The search was limited to papers published in English between 2016 and 2021. Papers on qualitative and mixed method studies that encompassed eHealth and mHealth services for adults with a focus on physical activity, healthy diet, or both in the primary or secondary prevention of noncommunicable diseases were included. Three authors screened the studies independently, and 2 of the authors separately performed thematic analysis of qualitative data. Results: With an initial finding of 6308 articles and the removal of 427 duplicates, 23 articles were deemed eligible for inclusion in the review. Based on users? preferences, an overarching theme?eHealth and mHealth services provide value but need to be tailored to individual needs?and 5 subthemes?interactive and integrated; varying and multifunctional; easy, pedagogic, and attractive; individualized and customizable; and reliable?emerged. Conclusions: New evidence on the optimization of digital services that promote physical activity and healthy diets has been synthesized. The findings represent users? perceptions of acceptability, engagement, and usability of eHealth and mHealth services and show that services should be personalized, dynamic, easily manageable, and reliable. These findings can help improve adherence to digital health-promoting services. UR - https://humanfactors.jmir.org/2022/2/e34278 UR - http://dx.doi.org/10.2196/34278 UR - http://www.ncbi.nlm.nih.gov/pubmed/35763339 ID - info:doi/10.2196/34278 ER - TY - JOUR AU - Tan, Xuan Sarah Yi AU - Chia, Airu AU - Tai, Choo Bee AU - Natarajan, Padmapriya AU - Goh, Lin Claire Marie Jie AU - Shek, P. Lynette AU - Saw, Mei Seang AU - Chong, Foong-Fong Mary AU - Müller-Riemenschneider, Falk PY - 2022/6/24 TI - A Web-Based, Time-Use App To Assess Children?s Movement Behaviors: Validation Study of My E-Diary for Activities and Lifestyle (MEDAL) JO - JMIR Pediatr Parent SP - e33312 VL - 5 IS - 2 KW - children KW - accelerometer KW - MEDAL KW - web-based app KW - self-report KW - validity KW - physical activity KW - movement behavior KW - pediatrics KW - sleep KW - digital health KW - behavior N2 - Background: Existing modes of collecting self-reported 24-hour movement information from children, including digital assessments, have not been demonstrated to be of acceptable validity when compared to objective measurements. My E-Diary for Activities and Lifestyle (MEDAL) is an interactive web-based diary developed to collect time-use information from children aged 10 years and older. Objective: This study evaluated the validity of MEDAL for assessing children?s movement behaviors by comparing self-reported and accelerometer-measured time spent in movement behavior among children in Singapore aged 10-11 years. Methods: Funding for this study was obtained in October 2017, and data were collected between April and August 2020. Participants recorded their daily activities using MEDAL over 2 specified weekdays and 2 weekend days and wore an Actigraph accelerometer on their nondominant wrist throughout the study to objectively assess movement behaviors. Spearman correlation coefficient and intraclass correlation coefficient (ICC) were used to compare the accelerometer measurements and self-reports for each movement behavior. Bland-Altman plots were generated to investigate trends of bias in the self-reports. Results: Among the participants aged 10-11 years (29/49, 59% boys), we observed that children reported lower light physical activity (LPA) and higher moderate-to-vigorous physical activity (MVPA), inactivity, and night sleep than that measured by the accelerometer. There was a moderate-to-strong correlation between self-reported and accelerometer-measured MVPA (r=0.37; 95% CI 0.20-0.54), inactivity (r=0.36; 95% CI 0.18-0.54), and night sleep (r=0.58; 95% CI 0.43-0.74); the correlation for LPA was poor (r=0.19; 95% CI 0.02-0.36). Agreement was poor for all behaviors (MVPA: ICC=0.24, 95% CI 0.07-0.40; LPA: ICC=0.19, 95% CI 0.01-0.36; inactivity: ICC=0.29, 95% CI 0.11-0.44; night sleep: ICC=0.45, 95% CI 0.29-0.58). There was stronger correlation and agreement on weekdays for inactivity and night sleep; conversely, there was stronger correlation and agreement for MVPA and LPA on weekend days. Finally, based on Bland-Altman plots, we observed that with increasing MVPA, children tended to report higher MVPA than that measured by the accelerometer. There were no clear trends for the other behaviors. Conclusions: MEDAL may be used to assess the movement behaviors of children. Based on self-reports, the children are able to estimate their time spent in MVPA, inactivity, and night sleep although actual time spent in these behaviors may differ from accelerometer-derived estimates; self-reported LPA warrant cautious interpretation. Observable differences in reporting accuracy exist between weekdays and weekend days. UR - https://pediatrics.jmir.org/2022/2/e33312 UR - http://dx.doi.org/10.2196/33312 UR - http://www.ncbi.nlm.nih.gov/pubmed/35749208 ID - info:doi/10.2196/33312 ER - TY - JOUR AU - Chwyl, Christina AU - Wright, Nicholas AU - M Turner-McGrievy, Gabrielle AU - L Butryn, Meghan AU - M Forman, Evan PY - 2022/6/23 TI - Remotely Delivered Behavioral Weight Loss Intervention Using an Ad Libitum Plant-Based Diet: Pilot Acceptability, Feasibility, and Preliminary Results JO - JMIR Form Res SP - e37414 VL - 6 IS - 6 KW - vegetarian diet KW - vegan diet KW - overweight KW - eHealth KW - behavioral intervention N2 - Background: Many traditional lifestyle interventions use calorie prescriptions, but most individuals have difficulty sustaining calorie tracking and thus weight loss. In contrast, whole food plant-based diets (WFPBDs) have previously shown significant weight loss without this issue. However, most WFPBD interventions are face-to-face and time-intensive, and do not leverage gold standard behavioral strategies for health behavior change. Objective: This open pilot trial was the first to evaluate the feasibility of a fully featured, remotely delivered behavioral weight loss intervention using an ad libitum WFPBD. Methods: Over 12 weeks, participants (N=15) with overweight or obesity received a newly designed program that integrated behavioral weight loss and a WFPBD prescription via weekly web-based modules and brief phone coaching calls. Assessments were performed at baseline, midtreatment (6 weeks), and after treatment (12 weeks). Results: The intervention was rated as highly acceptable (mean 4.40 out of 5, SE 0.18), and attrition was low (6.7%). In all, intention-to-treat analyses revealed that 69% (10.4/15) of the participants lost 5% of their weight (mean ?5.89, SE 0.68 kg). Predefined benchmarks for quality of life were met. Conclusions: A pilot digital behavioral weight loss intervention with a non?energy-restricted WFPBD was feasible, and the mean acceptability was high. Minimal contact time (80-150 minutes of study interventionist time per participant over 12 weeks) led to clinically relevant weight loss and dietary adherence for most participants (10.4/15, 69% and 11.8/15, 79%, respectively), and quality of life improvements (reliable change indices >1.53). We hope that this work will serve as a springboard for future larger scale randomized controlled studies evaluating the efficacy of such programs for weight loss, dietary change, and quality of life. Trial Registration: ClinicalTrials.gov NCT04892030; https://clinicaltrials.gov/ct2/show/NCT04892030 UR - https://formative.jmir.org/2022/6/e37414 UR - http://dx.doi.org/10.2196/37414 UR - http://www.ncbi.nlm.nih.gov/pubmed/35737443 ID - info:doi/10.2196/37414 ER - TY - JOUR AU - Sakur, Fareeya AU - Ward, Kanesha AU - Khatri, Nafees Neha AU - Lau, S. Annie Y. PY - 2022/6/21 TI - Self-care Behaviors and Technology Used During COVID-19: Systematic Review JO - JMIR Hum Factors SP - e35173 VL - 9 IS - 2 KW - self-care KW - self-management KW - chronic conditions KW - COVID-19 KW - pandemic KW - technology KW - digital health KW - telehealth KW - health technology N2 - Background: Self-care behaviors are essential for people living with chronic conditions; however, the outbreak of the COVID-19 pandemic has imposed additional complications on their daily routines. Few studies have analyzed how self-care behaviors have changed during COVID-19 and the role of digital technology, especially among people with chronic conditions. Objective: This study aims to review how self-care behaviors have changed for people with chronic conditions during the COVID-19 pandemic, and what technology they have adopted to manage their conditions during that period. Methods: A systematic review was conducted using narrative synthesis. Data were extracted from PubMed, MEDLINE, EMBASE, PsycINFO, CINAHL, and Google Scholar, including articles from December 2019 onward. Eligible studies focused on adults diagnosed with chronic conditions undertaking any self-care tasks in line with the middle-range theory of self-care of chronic illness (ie, self-care maintenance, monitoring, and management). The methodological quality of the included articles was assessed with the McMaster Critical Review Forms for Quantitative or Qualitative Studies. Results: In total, 36 primary research articles were included. Changes to self-care behaviors during COVID-19 among people with chronic conditions were organized according to the middle-range theory of self-care of chronic illness focusing on self-care maintenance (ie, medication adherence, physical activity, and diet control), self-care monitoring (ie, monitoring signs and symptoms), and self-care management (ie, consultations with health care providers). Positive self-care behaviors observed include the following: individuals trying to maintain good glycemic control during COVID-19 increased their medication adherence in 27% (10/36) of studies; and diet control improved in 50% (18/36) of studies. Negative self-care behaviors observed include the following: decline in physical activities and increased sedentariness were observed in 65% (23/36) of studies; poor diet control was observed in 57% (21/36) of studies; and self-monitoring of health status dropped in 43% (15/36) of studies. The use of technology to support self-care of chronic conditions during COVID-19 was reported in 72% (26/36) of studies. The actual use of telehealth in place of physical consultations during COVID-19 was observed in 50% (18/36) of studies, and other digital technologies (eg, social media apps, smartphone apps, web-based platforms, and web browsing) were used in 50% (18/36) of studies. Telehealth was discussed and recommended as the default technology in delivering future health care services during COVID-19 and beyond in 77% (28/36) of studies. Conclusions: This review highlighted the necessity to rethink how models of self-care should continue to address the demands of chronic conditions while being responsive to the imminent threats of infectious diseases. Perhaps the silver lining of COVID-19 is that adoption of digital technology (especially telehealth) among a vast cross-section of people with chronic conditions is possible. Future research should investigate effective ways to incorporate evidence-based digital health tools into these new models of self-care that address the challenges of chronic and infectious conditions. UR - https://humanfactors.jmir.org/2022/2/e35173 UR - http://dx.doi.org/10.2196/35173 UR - http://www.ncbi.nlm.nih.gov/pubmed/35442904 ID - info:doi/10.2196/35173 ER - TY - JOUR AU - Yang, Liuqing AU - Ji, Lili AU - Wang, Qiang AU - Xu, Yan AU - Yang, Guoping AU - Cui, Tingting AU - Shi, Naiyang AU - Zhu, Lin AU - Xiu, Shixin AU - Jin, Hui AU - Zhen, Shiqi PY - 2022/6/20 TI - Vaccination Intention and Behavior of the General Public in China: Cross-sectional Survey and Moderated Mediation Model Analysis JO - JMIR Public Health Surveill SP - e34666 VL - 8 IS - 6 KW - vaccine KW - theory of planned behavior KW - attitude KW - subjective norms KW - perceived behavior control KW - moderator KW - mediation N2 - Background: Promoting vaccination and eliminating vaccine hesitancy are key measures for controlling vaccine-preventable diseases. Objective: We aimed to understand the beliefs surrounding and drivers of vaccination behavior, and their relationships with and influence on vaccination intention and practices. Methods: We conducted a web-based survey in 31 provinces in mainland China from May 24, 2021 to June 15, 2021, with questions pertaining to vaccination in 5 dimensions: attitude, subjective norms, perceived behavioral control, intention, and behavior. We performed hierarchical regression analysis and structural equation modeling based on the theory of planned behavior?in which, the variables attitude, subjective norms, and intention each affect the variable intention; the variable intention mediates the relationships of attitude and subjective norms with behavior, and the variable perceived behavioral control moderates the strength of this mediation?to test the validity of the theoretical framework. Results: A total of 9924 participants, aged 18 to 59 years, were included in this study. Vaccination intention mediated the relationships of attitude and subjective norms with vaccination behavior. The indirect effect of attitude on vaccination behavior was 0.164 and that of subjective norms was 0.255, and the difference was statistically significant (P<.001). The moderated mediation analysis further indicated that perceived behavioral control would affect the mediation when used as moderator, and the interaction terms for attitude (?=?0.052, P<.001) and subjective norms (?=?0.028, P=.006) with perceived behavioral control were significant. Conclusions: Subjective norms have stronger positive influences on vaccination practices than attitudes. Perceived behavioral control, as a moderator, has a substitution relationship with attitudes and subjective norms and weakens their positive effects on vaccination behavior. UR - https://publichealth.jmir.org/2022/6/e34666 UR - http://dx.doi.org/10.2196/34666 UR - http://www.ncbi.nlm.nih.gov/pubmed/35723904 ID - info:doi/10.2196/34666 ER - TY - JOUR AU - Engelbrecht, Hendrik AU - van der Laan, Nynke Laura AU - van Enschot, Renske AU - Krahmer, Emiel PY - 2022/6/13 TI - The Role of Agency and Threat Immediacy in Interactive Digital Narrative Fear Appeals for the Prevention of Excessive Alcohol Use: Randomized Controlled Trial JO - JMIR Serious Games SP - e32218 VL - 10 IS - 2 KW - young adults KW - college students KW - alcohol abuse KW - drinking KW - EPPM KW - fear appeals KW - agency KW - serious games N2 - Background: Serious games for the training of prevention behaviors have been widely recognized as potentially valuable tools for adolescents and young adults across a variety of risk behaviors. However, the role of agency as a distinguishing factor from traditional health interventions has seldom been isolated and grounded in the persuasive health communication theory. Fear appeals have different effects on intentions to perform prevention behaviors depending on the immediacy of the consequences. Looking into how to increase self-efficacy beliefs for health behavior with distant consequences is the first step toward improving game-based interventions for adverse health outcomes. Objective: This study aimed to investigate the effect of agency on self-efficacy and the intention to drink less alcohol in an interactive digital narrative fear appeal. Furthermore, the communicated immediacy of threat outcomes was evaluated as a potential moderator of the effect of agency on self-efficacy. Methods: A web-based experimental study was conducted with university students (N=178). The participants were presented with a fear appeal outlining the consequences of excessive alcohol use in a fully automated web-based interactive narrative. Participants either had perceived control over the outcome of the narrative scenario (high agency) or no control over the outcome (low agency). The threat was either framed as a short-term (high immediacy) or long-term (low immediacy) negative health outcome resulting from the execution of the risk behavior (drinking too much alcohol). Results: A total of 123 valid cases were analyzed. Self-efficacy and intention to limit alcohol intake were not influenced by the agency manipulation. Self-efficacy was shown to be a significant predictor of behavioral intention. The immediacy of the threat did not moderate the relationship between agency and self-efficacy. Conclusions: Although agency manipulation was successful, we could not find evidence of an effect of agency or threat immediacy on self-efficacy. The implications for different operationalizations of different agency concepts, as well as the malleability of self-efficacy beliefs for long-term threats, are discussed. The use of repeated versus single interventions and different threat types (eg, health and social threats) should be tested empirically to establish a way forward for diversifying intervention approaches. Trial Registration: ClinicalTrials.gov NCT05321238; https://www.clinicaltrials.gov/ct2/show/NCT05321238 UR - https://games.jmir.org/2022/2/e32218 UR - http://dx.doi.org/10.2196/32218 UR - http://www.ncbi.nlm.nih.gov/pubmed/35699976 ID - info:doi/10.2196/32218 ER - TY - JOUR AU - Domin, Alex AU - Ouzzahra, Yacine AU - Vögele, Claus PY - 2022/6/9 TI - Features and Components Preferred by Adolescents in Smartphone Apps for the Promotion of Physical Activity: Focus Group Study JO - JMIR Hum Factors SP - e33972 VL - 9 IS - 2 KW - mHealth KW - physical activity KW - mobile phone KW - health KW - qualitative research KW - focus groups KW - smartphone apps KW - behavior change KW - mobile health KW - adolescents N2 - Background: There is solid evidence that lack of physical activity (PA) is a risk factor for chronic diseases. Sufficient levels of PA in childhood and adolescence are particularly important, as they can set the standards for PA levels in adulthood. The latest reports show that only a small percentage of adolescents reach the recommended levels of PA in European Union countries at the age of 15 years. In view of the scale of the problem, it is crucial to develop interventions that promote and support PA in adolescents. Considering their low implementation costs and ubiquitous presence, smartphone apps could be advantageous as a part of PA interventions. Objective: This study aimed at investigating the attitudes and preferences of adolescents aged 16-18 years toward various PA app features and components that could (1) make the app more attractive for them and consequently (2) increase their interest and engagement with the app. Methods: Two separate focus group discussions were conducted in 2 groups of adolescents (n=4 each) aged 16-18 years. Focus groups were carried out online via video conference. The discussions were conducted using a semistructured interview. Participants (n=8; 4 males and 4 females) had a mean age of 17.25 years (SD 0.82 years). Transcripts were analyzed following the approach by Krueger and Casey, that is, categorizing participants? answers and comments according to the questions and themes from the focus group schedule. Results: Features, such as ?goal setting and planning,? ?coaching and training programs,? ?activity tracking,? ?feedback,? and ?location tracking? were appraised as attractive, motivating, and interesting. An ?automatic activity recognition? feature was perceived as useful only under the condition that its precision was high. The ?reminders? component was also deemed as useful only if a range of conditions was fulfilled (timeliness, opportunity for customization, etc). The features ?mood and sleep tracking,? ?sharing workout results via social networks,? ?digital avatar and coach,? and ?rewards? were generally perceived negatively and considered as useless and not motivating. In general, participants preferred features with an easy-to-navigate interface and a clear, simplistic, and straightforward layout with a modern design. Customization and personalization qualities were highly appreciated throughout an app, together with data precision. Conclusions: This study contributes to the understanding of the features and components preferred by adolescents in apps promoting PA. Such apps should provide users with precise data, and have a simplistic modern design and a straightforward easy-to-use interface. Apps should be personalized and customizable. Desired features to be included in an app are goal setting and planning, feedback, coaching and training programs, and activity tracking. The features should involve high levels of data precision and timely delivery while taking into consideration the real-life context. UR - https://humanfactors.jmir.org/2022/2/e33972 UR - http://dx.doi.org/10.2196/33972 UR - http://www.ncbi.nlm.nih.gov/pubmed/35679113 ID - info:doi/10.2196/33972 ER - TY - JOUR AU - Kaveladze, T. Benjamin AU - Young, D. Sean AU - Schueller, M. Stephen PY - 2022/6/3 TI - Antifragile Behavior Change Through Digital Health Behavior Change Interventions JO - JMIR Form Res SP - e32571 VL - 6 IS - 6 KW - digital health behavior change interventions KW - behavior change KW - digital health KW - self-management KW - antifragile UR - https://formative.jmir.org/2022/6/e32571 UR - http://dx.doi.org/10.2196/32571 UR - http://www.ncbi.nlm.nih.gov/pubmed/35657665 ID - info:doi/10.2196/32571 ER - TY - JOUR AU - Goh, Shian Yong AU - Ow Yong, Yun Jenna Qing AU - Chee, Hui Bernice Qian AU - Kuek, Loong Jonathan Han AU - Ho, Hui Cyrus Su PY - 2022/6/2 TI - Machine Learning in Health Promotion and Behavioral Change: Scoping Review JO - J Med Internet Res SP - e35831 VL - 24 IS - 6 KW - machine learning KW - health promotion KW - health behavioral changes KW - artificial intelligence N2 - Background: Despite health behavioral change interventions targeting modifiable lifestyle factors underlying chronic diseases, dropouts and nonadherence of individuals have remained high. The rapid development of machine learning (ML) in recent years, alongside its ability to provide readily available personalized experience for users, holds much potential for success in health promotion and behavioral change interventions. Objective: The aim of this paper is to provide an overview of the existing research on ML applications and harness their potential in health promotion and behavioral change interventions. Methods: A scoping review was conducted based on the 5-stage framework by Arksey and O?Malley and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews) guidelines. A total of 9 databases (the Cochrane Library, CINAHL, Embase, Ovid, ProQuest, PsycInfo, PubMed, Scopus, and Web of Science) were searched from inception to February 2021, without limits on the dates and types of publications. Studies were included in the review if they had incorporated ML in any health promotion or behavioral change interventions, had studied at least one group of participants, and had been published in English. Publication-related information (author, year, aim, and findings), area of health promotion, user data analyzed, type of ML used, challenges encountered, and future research were extracted from each study. Results: A total of 29 articles were included in this review. Three themes were generated, which are as follows: (1) enablers, which is the adoption of information technology for optimizing systemic operation; (2) challenges, which comprises the various hurdles and limitations presented in the articles; and (3) future directions, which explores prospective strategies in health promotion through ML. Conclusions: The challenges pertained to not only the time- and resource-consuming nature of ML-based applications, but also the burden on users for data input and the degree of personalization. Future works may consider designs that correspondingly mitigate these challenges in areas that receive limited attention, such as smoking and mental health. UR - https://www.jmir.org/2022/6/e35831 UR - http://dx.doi.org/10.2196/35831 UR - http://www.ncbi.nlm.nih.gov/pubmed/35653177 ID - info:doi/10.2196/35831 ER - TY - JOUR AU - Bergeron, Lysa AU - Décary, Simon AU - Djade, Djignefa Codjo AU - Daniel, J. Sam AU - Tremblay, Martin AU - Rivest, Louis-Paul AU - Légaré, France PY - 2022/6/2 TI - Factors Associated With Specialists? Intention to Adopt New Behaviors After Taking Web-Based Continuing Professional Development Courses: Cross-sectional Study JO - JMIR Med Educ SP - e34299 VL - 8 IS - 2 KW - continuing professional development KW - CPD-Reaction KW - behavioral intention KW - medical specialists KW - web-based training KW - medical education KW - education KW - physician KW - psychosocial KW - online course N2 - Background: Web-based continuing professional development (CPD) is a convenient and low-cost way for physicians to update their knowledge. However, little is known about the factors that influence their intention to put this new knowledge into practice. Objective: We aimed to identify sociocognitive factors associated with physicians? intention to adopt new behaviors as well as indications of Bloom?s learning levels following their participation in 5 web-based CPD courses. Methods: We performed a cross-sectional study of specialist physicians who had completed 1 of 5 web-based CPD courses offered by the Federation of Medical Specialists of Quebec. The participants then completed CPD-Reaction, a questionnaire based on Godin?s integrated model for health professional behavior change and with evidence of validity that measures behavioral intention (dependent variable) and psychosocial factors influencing intention (n=4). We also assessed variables related to sociodemographics (n=5), course content (n=9), and course format (eg, graphic features and duration) (n=8). Content variables were derived from CanMEDS competencies, Bloom?s learning levels, and Godin?s integrated model. We conducted ANOVA single-factor analysis, calculated the intraclass correlation coefficient (ICC), and performed bivariate and multivariate analyses. Results: A total of 400 physicians participated in the courses (range: 38-135 physicians per course). Average age was 50 (SD 12) years; 56% (n=223) were female, and 44% (n=177) were male. Among the 259 who completed CPD-Reaction, behavioral intention scores ranged from 5.37 (SD 1.17) to 6.60 (SD 0.88) out of 7 and differed significantly from one course to another (P<.001). The ICC indicated that 17% of the total variation in the outcome of interest, the behavioral intention of physicians, could be explained at the level of the CPD course (ICC=0.17). In bivariate analyses, social influences (P<.001), beliefs about capabilities (P<.001), moral norm (P<.001), beliefs about consequences (P<.001), and psychomotor learning (P=.04) were significantly correlated with physicians? intention to adopt new behaviors. Multivariate analysis showed the same factors, except for social influences and psychomotor learning, as significantly correlated with intention. Conclusions: We observed average to high behavioral intention scores after all 5 web-based courses, with some variations by course taken. Factors affecting physicians? intention were beliefs about their capabilities and about the consequences of adopting new clinical behaviors, as well as doubts about whether the new behavior aligned with their moral values. Our results will inform design of future web-based CPD courses to ensure they contribute to clinical behavior change. UR - https://mededu.jmir.org/2022/2/e34299 UR - http://dx.doi.org/10.2196/34299 UR - http://www.ncbi.nlm.nih.gov/pubmed/35476039 ID - info:doi/10.2196/34299 ER - TY - JOUR AU - Phoo, Nge Nang Nge AU - Lobo, Roanna AU - Vujcich, Daniel AU - Reid, Alison PY - 2022/5/31 TI - Comparison of the ACASI Mode to Other Survey Modes in Sexual Behavior Surveys in Asia and Sub-Saharan Africa: Systematic Literature Review JO - J Med Internet Res SP - e37356 VL - 24 IS - 5 KW - ACASI KW - survey mode KW - sexual behaviors KW - HIV KW - STI KW - hepatitis KW - blood-borne virus KW - Asia KW - sub-Saharan Africa KW - review N2 - Background: Reliable data about sexual behaviors is fundamental in the prevention and control of HIV, hepatitis, and other sexually transmitted infections. Generally, sexual behaviors are regarded as a sociocultural taboo in Africa and Asia, and this results in biased sexual behavior survey data due to social desirability. Various modes of survey delivery, including audio computer-assisted self-interviews (ACASIs), have been investigated to improve data quality. Objective: This study aimed to review studies that compared the ACASI mode to other survey modes in sexual behavior surveys in Asia and sub-Saharan Africa to ascertain the impact of survey mode on responses to sexual behavior questions. Methods: A systematic literature review was conducted according to the Joanna Briggs Institute Manual for Evidence Synthesis. The review protocol was registered at PROSPERO (International Prospective Register of Systematic Reviews). Six databases were searched. Results: A total of 21 papers were included. The face-to-face interview (FTFI) mode was the survey mode most frequently compared to the ACASI mode. Among the most commonly reported outcome variable groups, ACASI participants were more likely to report sexual behaviors, such as ?forced sex,? ?multiple partners,? ?transactional sex,? and ?ever had sex,? as compared to FTFI participants. In addition to the survey mode effect, other factors were found to have had an impact on data quality, for example, participant characteristics, social norms, study design, and data collection setting. Conclusions: Use of ACASIs for administering sexual behavior surveys among populations in Asia and sub-Saharan Africa demonstrated higher reports for some sexual behaviors than the use of FTFIs. More studies that compare the ACASI mode to other survey modes would improve our understanding of the usefulness of ACASIs in sexual behavior surveys in these regions. UR - https://www.jmir.org/2022/5/e37356 UR - http://dx.doi.org/10.2196/37356 UR - http://www.ncbi.nlm.nih.gov/pubmed/35639465 ID - info:doi/10.2196/37356 ER - TY - JOUR AU - Li, Peiyi AU - Chen, Bo AU - Deveaux, Genevieve AU - Luo, Yunmei AU - Tao, Wenjuan AU - Li, Weimin AU - Wen, Jin AU - Zheng, Yuan PY - 2022/5/31 TI - Cross-Verification of COVID-19 Information Obtained From Unofficial Social Media Accounts and Associated Changes in Health Behaviors: Web-Based Questionnaire Study Among Chinese Netizens JO - JMIR Public Health Surveill SP - e33577 VL - 8 IS - 5 KW - COVID-19 KW - pandemic KW - social media KW - behavior change KW - information cross-verification KW - eHealth literacy N2 - Background: As social media platforms have become significant sources of information during the pandemic, a significant volume of both factual and inaccurate information related to the prevention of COVID-19 has been disseminated through social media. Thus, disparities in COVID-19 information verification across populations have the potential to promote the dissemination of misinformation among clustered groups of people with similar characteristics. Objective: This study aimed to identify the characteristics of social media users who obtained COVID-19 information through unofficial social media accounts and were (1) most likely to change their health behaviors according to web-based information and (2) least likely to actively verify the accuracy of COVID-19 information, as these individuals may be susceptible to inaccurate prevention measures and may exacerbate transmission. Methods: An online questionnaire consisting of 17 questions was disseminated by West China Hospital via its official online platforms, between May 18, 2020, and May 31, 2020. The questionnaire collected the sociodemographic information of 14,509 adults, and included questions surveying Chinese netizens? knowledge about COVID-19, personal social media use, health behavioral change tendencies, and cross-verification behaviors for web-based information during the pandemic. Multiple stepwise regression models were used to examine the relationships between social media use, behavior changes, and information cross-verification. Results: Respondents who were most likely to change their health behaviors after obtaining web-based COVID-19 information from celebrity sources had the following characteristics: female sex (P=.004), age ?50 years (P=.009), higher COVID-19 knowledge and health literacy (P=.045 and P=.03, respectively), non?health care professional (P=.02), higher frequency of searching on social media (P<.001), better health conditions (P<.001), and a trust rating score of more than 3 for information released by celebrities on social media (P=.005). Furthermore, among participants who were most likely to change their health behaviors according to social media information released by celebrities, female sex (P<.001), living in a rural residence rather than first-tier city (P<.001), self-reported medium health status and lower health care literacy (P=.007 and P<.001, respectively), less frequent search for COVID-19 information on social media (P<.001), and greater level of trust toward celebrities? social media accounts with a trust rating score greater than 1 (P?.04) were associated with a lack of cross-verification of information. Conclusions: The findings suggest that governments, health care agencies, celebrities, and technicians should combine their efforts to decrease the risk in vulnerable groups that are inclined to change health behaviors according to web-based information but do not perform any fact-check verification of the accuracy of the unofficial information. Specifically, it is necessary to correct the false information related to COVID-19 on social media, appropriately apply celebrities? star power, and increase Chinese netizens? awareness of information cross-verification and eHealth literacy for evaluating the veracity of web-based information. UR - https://publichealth.jmir.org/2022/5/e33577 UR - http://dx.doi.org/10.2196/33577 UR - http://www.ncbi.nlm.nih.gov/pubmed/35486529 ID - info:doi/10.2196/33577 ER - TY - JOUR AU - Asbjørnsen, Aune Rikke AU - Hjelmesæth, Jøran AU - Smedsrød, Lien Mirjam AU - Wentzel, Jobke AU - Ollivier, Marianne AU - Clark, M. Matthew AU - van Gemert-Pijnen, C. Julia E. W. AU - Solberg Nes, Lise PY - 2022/5/27 TI - Combining Persuasive System Design Principles and Behavior Change Techniques in Digital Interventions Supporting Long-term Weight Loss Maintenance: Design and Development of eCHANGE JO - JMIR Hum Factors SP - e37372 VL - 9 IS - 2 KW - eHealth KW - weight loss maintenance KW - behavior change KW - persuasive technology KW - digital health interventions KW - design thinking KW - co-design KW - Agile development KW - human-centered design KW - mobile phone N2 - Background: Long-term weight maintenance after weight loss is challenging, and innovative solutions are required. Digital technologies can support behavior change and, therefore, have the potential to be an effective tool for weight loss maintenance. However, to create meaningful and effective digital behavior change interventions that support end user values and needs, a combination of persuasive system design (PSD) principles and behavior change techniques (BCTs) might be needed. Objective: This study aimed to investigate how an evidence-informed digital behavior change intervention can be designed and developed by combining PSD principles and BCTs into design features to support end user values and needs for long-term weight loss maintenance. Methods: This study presents a concept for how PSD principles and BCTs can be translated into design features by combining design thinking and Agile methods to develop and deliver an evidence-informed digital behavior change intervention aimed at supporting weight maintenance. Overall, 45 stakeholders participated in the systematic and iterative development process comprising co-design workshops, prototyping, Agile development, and usability testing. This included prospective end users (n=17, 38%; ie, people with obesity who had lost ?8% of their weight), health care providers (n=9, 20%), healthy volunteers (n=4, 9%), a service designer (n=1, 2%), and stakeholders from the multidisciplinary research and development team (n=14, 31%; ie, software developers; digital designers; and eHealth, behavior change, and obesity experts). Stakeholder input on how to operationalize the design features and optimize the technology was examined through formative evaluation and qualitative analyses using rapid and in-depth analysis approaches. Results: A total of 17 design features combining PSD principles and BCTs were identified as important to support end user values and needs based on stakeholder input during the design and development of eCHANGE, a digital intervention to support long-term weight loss maintenance. The design features were combined into 4 main intervention components: Week Plan, My Overview, Knowledge and Skills, and Virtual Coach and Smart Feedback System. To support a healthy lifestyle and continued behavior change to maintain weight, PSD principles such as tailoring, personalization, self-monitoring, reminders, rewards, rehearsal, praise, and suggestions were combined and implemented into the design features together with BCTs from the clusters of goals and planning, feedback and monitoring, social support, repetition and substitution, shaping knowledge, natural consequences, associations, antecedents, identity, and self-belief. Conclusions: Combining and implementing PSD principles and BCTs in digital interventions aimed at supporting sustainable behavior change may contribute to the design of engaging and motivating interventions in line with end user values and needs. As such, the design and development of the eCHANGE intervention can provide valuable input for future design and tailoring of evidence-informed digital interventions, even beyond digital interventions in support of health behavior change and long-term weight loss maintenance. Trial Registration: ClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988 UR - https://humanfactors.jmir.org/2022/2/e37372 UR - http://dx.doi.org/10.2196/37372 UR - http://www.ncbi.nlm.nih.gov/pubmed/35622394 ID - info:doi/10.2196/37372 ER - TY - JOUR AU - Klein Schaarsberg, E. Renée AU - Popma, Arne AU - Lindauer, L. Ramón J. AU - van Dam, Levi PY - 2022/5/20 TI - The Effects of a Virtual Reality?Based Training Program for Adolescents With Disruptive Behavior Problems on Cognitive Distortions and Treatment Motivation: Protocol for a Multiple Baseline Single-Case Experimental Design JO - JMIR Res Protoc SP - e33555 VL - 11 IS - 5 KW - treatment motivation KW - cognitive distortions KW - reflective functioning KW - disruptive behavior problems KW - adolescence KW - virtual reality KW - single-case experimental design N2 - Background: Serious disruptive behavior among adolescents is a prevalent and often persistent problem. This highlights the importance of adequate and effective treatment to help adolescents with disruptive behavior problems react less hostile and aggressive. In order to create a treatment environment in which behavioral change can be enhanced, treatment motivation plays an essential role. Regarding treatment itself, a focus on challenging self-serving cognitive distortions in order to achieve behavioral change is important. Street Temptations (ST) is a new training program that was developed to address both treatment motivation and cognitive distortions in adolescents with disruptive behavior problems. One of the innovative aspects of ST is the use of virtual reality (VR) techniques to provide adolescents during treatment with visually presented daily social scenarios to activate emotional engagement and dysfunctional cognitions. By using the VR scenarios as an integral starting point of ST?s sessions and transferring the power of the VR experience into playful and dynamic exercises to practice social perspective?taking, adolescents are encouraged to reflect on both their own behavior and that of others. This focus on reflection is grounded in ST?s main treatment mechanism to influence treatment motivation and cognitive distortions, namely, mentalizing (ie, reflective functioning). Objective: The aim of this study is to describe the research protocol to evaluate the effects of ST on treatment motivation and cognitive distortions. We take a closer look at the use of ST and the methodology used, namely, the repeated single-case experimental design (SCED). Methods: The effects of ST are studied through a multiple baseline SCED, using both quantitative and qualitative data. In total, 18 adolescents from secure residential youth care facilities and secondary special education schools are randomly assigned to 1 of the 3 different baseline conditions. Throughout the baseline phase (1, 2, or 3 weeks), intervention phase (4 weeks), and follow-up phase (1, 2, or 3 weeks), daily measurements on treatment motivation and cognitive distortions are conducted. Secondary study parameters are assessed before baseline, after intervention, and after follow-up. Qualitative data are collected after intervention, as well as at 3 months and 6 months after the intervention. Results: Data collection for this study started in November 2021 and is planned to be completed by August 2023. The results will be published in peer-reviewed journals and presented at national and international conferences. Conclusions: ST aims to improve the disruptive behavior problems of adolescents. This study will be the first to gain insights into the effectiveness of ST. The strengths of this study include its thorough and individually focused design (SCED), the focus on a residential as well as a secondary special education setting, and the ecological validity. The implications for practice are discussed. Trial Registration: Central Committee on Research Involving Human Subjects NL75545.029.20. Netherlands Trial Register NL9639; https://www.trialregister.nl/trial/9639 International Registered Report Identifier (IRRID): PRR1-10.2196/33555 UR - https://www.researchprotocols.org/2022/5/e33555 UR - http://dx.doi.org/10.2196/33555 UR - http://www.ncbi.nlm.nih.gov/pubmed/35594071 ID - info:doi/10.2196/33555 ER - TY - JOUR AU - Feusner, D. Jamie AU - Farrell, R. Nicholas AU - Kreyling, Jeremy AU - McGrath, B. Patrick AU - Rhode, Andreas AU - Faneuff, Ted AU - Lonsway, Stephanie AU - Mohideen, Reza AU - Jurich, E. John AU - Trusky, Larry AU - Smith, M. Stephen PY - 2022/5/19 TI - Online Video Teletherapy Treatment of Obsessive-Compulsive Disorder Using Exposure and Response Prevention: Clinical Outcomes From a Retrospective Longitudinal Observational Study JO - J Med Internet Res SP - e36431 VL - 24 IS - 5 KW - digital behavioral health KW - cognitive-behavioral therapy KW - CBT KW - exposure and ritual prevention KW - ERP KW - EX/RP KW - digital health KW - telehealth KW - cognitive therapy KW - obsessive compulsive disorder KW - OCD KW - clinical outcomes KW - teletherapy KW - remote therapy KW - telemedicine KW - obsessive compulsive KW - symptom KW - comorbid symptom KW - comorbidity KW - comorbidities KW - video therapy KW - virtual therapy KW - clinical outcome KW - patient outcome KW - online therapy KW - mobile health KW - mHealth KW - app based KW - health app KW - technology assisted KW - messaging N2 - Background: Exposure and response prevention, a type of cognitive-behavioral therapy, is an effective first-line treatment for obsessive-compulsive disorder (OCD). Despite extensive evidence of the efficacy of exposure and response prevention (ERP) from clinical studies and in real-world samples, it is still underused as a treatment. This is likely due to the limits to access to care that include the availability of adequately trained therapists, as well as geographical location, time, and cost barriers. To address these, NOCD created a digital behavioral health treatment for OCD using ERP delivered via video teletherapy and with technology-assisted elements including app-based therapy tools and between-session therapist messaging. Objective: We examined treatment outcomes in a large naturalistic sample of 3552 adults with a primary OCD diagnosis who received NOCD treatment. Methods: The treatment model consisted of twice-weekly, live, face-to-face video teletherapy ERP for 3 weeks, followed by 6 weeks of once-weekly brief video teletherapy check-ins for 30 minutes. Assessments were conducted at baseline, at midpoint after completion of 3 weeks of twice-weekly sessions, and at the end of 6 weeks of brief check-ins (endpoint). Longitudinal assessments were also obtained at 3, 6, 9, and 12 months after endpoint. Results: Treatment resulted in clinically and statistically significant improvements, with a 43.4% mean reduction in obsessive-compulsive symptoms (g=1.0; 95% CI 0.93 to 1.03) and a 62.9% response rate. Treatment also resulted in a 44.2% mean reduction in depression, a 47.8% mean reduction in anxiety, and a 37.3% mean reduction in stress symptoms. Quality of life improved by a mean of 22.7%. Reduction in OCD symptoms and response rates were similar for those with mild, moderate, or severe symptoms. The mean duration of treatment was 11.5 (SD 4.0) weeks, and the mean total therapist time was 10.6 (SD 1.1) hours. Improvements were maintained at 3, 6, 9, and 12 months. Conclusions: In this sample, representing the largest reported treated cohort of patients with OCD to date, video teletherapy treatment demonstrated effectiveness in reducing obsessive-compulsive and comorbid symptoms and improved quality of life. Further, it achieved meaningful results in less than half the total therapist time compared with standard once-weekly outpatient treatment, an efficiency that represents substantial monetary and time savings. The effect size was large and similar to studies of in-person ERP. This technology-assisted remote treatment is readily accessible for patients, offering an advancement in the field in the dissemination of effective evidence-based care for OCD. UR - https://www.jmir.org/2022/5/e36431 UR - http://dx.doi.org/10.2196/36431 UR - http://www.ncbi.nlm.nih.gov/pubmed/35587365 ID - info:doi/10.2196/36431 ER - TY - JOUR AU - Wehbe, R. Rina AU - Whaley, Colin AU - Eskandari, Yasaman AU - Suarez, Ally AU - Nacke, E. Lennart AU - Hammer, Jessica AU - Lank, Edward PY - 2022/5/19 TI - Designing a Serious Game (Above Water) for Stigma Reduction Surrounding Mental Health: Semistructured Interview Study With Expert Participants JO - JMIR Serious Games SP - e21376 VL - 10 IS - 2 KW - human?computer interaction KW - games for change KW - games for mental health KW - sensitive topics KW - game design KW - empirical analysis KW - expert participants N2 - Background: Although in many contexts unsuccessful games targeting learning, social interaction, or behavioral change have few downsides, when covering a sensitive domain such as mental health (MH), care must be taken to avoid harm and stigmatization of people who live with MH conditions. As a result, evaluation of the game to identify benefits and risks is crucial in understanding the game?s success; however, assessment of these apps is often compared with the nongame control condition, resulting in findings specifically regarding entertainment value and user preferences. Research exploring the design process, integrating field experts, and guidelines for designing a successful serious game for sensitive topics is limited. Objective: The aim of this study is to understand which elements of game design can guide a designer when designing a game for sensitive topics. Methods: To carefully probe the design space of serious games for MH, we present Above Water (AbW), a game targeting the reduction of stigma surrounding MH, now in its second iteration. The game, AbW, serves as a consistent research probe to solicit expert feedback. Experts were recruited from a range of topic domains related to MH and wellness, game design, and user experience. Results: By using this deployment as a research probe, this study demonstrates how to synthesize gained insights from multiple expert perspectives and create actionable guidelines for successful design of serious games targeting sensitive topics. Conclusions: Our work contributes to a better understanding of how to design specialized games to address sensitive topics. We present a set of guidelines for designing games for sensitive subjects, and for each guideline, we present an example of how to apply the finding to the sample game (AbW). Furthermore, we demonstrate the generalizability to other sensitive topics by providing an additional example of a game that could be designed with the presented guidelines. UR - https://games.jmir.org/2022/2/e21376 UR - http://dx.doi.org/10.2196/21376 UR - http://www.ncbi.nlm.nih.gov/pubmed/35588056 ID - info:doi/10.2196/21376 ER - TY - JOUR AU - Friedman, J. Vanessa AU - Wright, C. Cassandra J. AU - Molenaar, Annika AU - McCaffrey, Tracy AU - Brennan, Linda AU - Lim, C. Megan S. PY - 2022/5/18 TI - The Use of Social Media as a Persuasive Platform to Facilitate Nutrition and Health Behavior Change in Young Adults: Web-Based Conversation Study JO - J Med Internet Res SP - e28063 VL - 24 IS - 5 KW - young adults KW - nutrition KW - physical activity KW - mental health KW - social media KW - qualitative methods KW - health promotion N2 - Background: Globally, suboptimal dietary choices are a leading cause of noncommunicable diseases. Evidence for effective interventions to address these behaviors, particularly in young adults, is limited. Given the substantial time young adults spend in using social media, there is interest in understanding the current and potential role of these platforms in shaping dietary behavior. Objective: This study aims to explore the influence of social media on young adults? dietary behaviors. Methods: We recruited 234 young adults aged 18-24 years and living in Australia, using market and social research panels. We applied a digital ethnography approach to collect data from web-based conversations in a series of forums, where participants responded to different health-themed questions related to health behavior change and persuasion on social media. We conducted a qualitative thematic analysis. Results: Participants described how social media influenced their decisions to change their health behaviors. Access to social support and health information through web-based communities was juxtaposed with exposure to highly persuasive fast-food advertisements. Some participants expressed that exposure to web-based health-focused content induced feelings of guilt about their behavior, which was more prominent among women. Fast-food advertisements were discussed as a contributor to poor health behaviors and indicated as a major barrier to change. Conclusions: Young adults reported that social media is highly persuasive toward dietary behavior through different pathways of social influence. This suggests that social norms on the web are an important aspect of changing young adults? health behaviors. The commercialization of social media also encourages poor health behaviors, largely through fast-food advertisements. Future social media?delivered dietary interventions should acknowledge the social and environmental factors that challenge the ability of young adults to make individual health behavior improvements. Care should also be taken to ensure that future interventions do not further elicit guilt in a way that contributes to poor mental health within this community. UR - https://www.jmir.org/2022/5/e28063 UR - http://dx.doi.org/10.2196/28063 UR - http://www.ncbi.nlm.nih.gov/pubmed/35583920 ID - info:doi/10.2196/28063 ER - TY - JOUR AU - Ramos, Raquel S. AU - Johnson, Constance AU - Melkus, Gail AU - Kershaw, Trace AU - Gwadz, Marya AU - Reynolds, Harmony AU - Vorderstrasse, Allison PY - 2022/5/17 TI - Cardiovascular Disease Prevention Education Using a Virtual Environment in Sexual-Minority Men of Color With HIV: Protocol for a Sequential, Mixed Method, Waitlist Randomized Controlled Trial JO - JMIR Res Protoc SP - e38348 VL - 11 IS - 5 KW - virtual environment KW - behavioral intervention KW - consumer health informatics KW - HIV KW - cardiovascular disease KW - sexual minority men KW - prevention education KW - gamification KW - health communication N2 - Background: It is estimated that 70% of all deaths each year in the United States are due to chronic conditions. Cardiovascular disease (CVD), a chronic condition, is the leading cause of death in ethnic and racial minority males. It has been identified as the second most common cause of death in persons with HIV. By the year 2030, it is estimated that 78% of persons with HIV will be diagnosed with CVD. Objective: We propose the first technology-based virtual environment intervention to address behavioral, modifiable risk factors associated with cardiovascular and metabolic comorbidities in sexual-minority men of color with HIV. Methods: This study will be guided using social cognitive theory and the Technology Acceptance Model. A sequential, mixed method, waitlist controlled randomized control feasibility trial will be conducted. Aim 1 is to qualitatively explore perceptions of cardiovascular risk in 15 participants. Aim 2 is to conduct a waitlist controlled comparison to test if a virtual environment is feasible and acceptable for CVD prevention, based on web-based, self-assessed, behavioral, and psychosocial outcomes in 80 sexual-minority men of color with HIV. Results: The study was approved by the New York University Institutional Review Board in 2019, University of Texas Health Science Center at Houston in 2020, and by the Yale University Institutional Review Board in February 2022. As of April 2022, aim 1 data collection is 87% completed. We expect to complete data collection for aim 1 by April 30, 2022. Recruitment for aim 2 will begin mid-May 2022. Conclusions: This study will be the first online virtual environment intervention for CVD prevention in sexual-minority men of color with HIV. We anticipate that the intervention will be beneficial for CVD prevention education and building peer social supports, resulting in change or modification over time in risk behaviors for CVD. Trial Registration: ClinicalTrials.gov NCT05242952; https://clinicaltrials.gov/ct2/show/NCT05242952 International Registered Report Identifier (IRRID): PRR1-10.2196/38348 UR - https://www.researchprotocols.org/2022/5/e38348 UR - http://dx.doi.org/10.2196/38348 UR - http://www.ncbi.nlm.nih.gov/pubmed/35579928 ID - info:doi/10.2196/38348 ER - TY - JOUR AU - Rajamani, Sripriya AU - Austin, Robin AU - Geiger-Simpson, Elena AU - Jantraporn, Ratchada AU - Park, Suhyun AU - Monsen, A. Karen PY - 2022/5/16 TI - Understanding Whole-Person Health and Resilience During the COVID-19 Pandemic and Beyond: A Cross-sectional and Descriptive Correlation Study JO - JMIR Nursing SP - e38063 VL - 5 IS - 1 KW - Omaha System KW - whole-person health KW - strengths KW - resilience KW - assessment KW - app KW - health information technology KW - health informatics KW - nursing KW - health care KW - mobile health KW - health application KW - mHealth KW - health data KW - health community KW - digital health N2 - Background: The COVID-19 pandemic has prompted an interest in whole-person health and emotional well-being. Informatics solutions through user-friendly tools such as mobile health apps offer immense value. Prior research developed a consumer-facing app MyStrengths + MyHealth using Simplified Omaha System Terms (SOST) to assess whole-person health. The MyStrengths + MyHealth app assesses strengths, challenges, and needs (SCN) for 42 concepts across four domains (My Living, My Mind and Networks, My Body, My Self-care; eg, Income, Emotions, Pain, and Nutrition, respectively). Given that emotional well-being was a predominant concern during the COVID-19 pandemic, we sought to understand whole-person health for participants with/without Emotions challenges. Objective: This study aims to use visualization techniques and data from attendees at a Midwest state fair to examine SCN overall and by groups with/without Emotions challenges, and to explore the resilience of participants. Methods: This cross-sectional and descriptive correlational study surveyed adult attendees at a 2021 Midwest state fair. Data were visualized using Excel and analyzed using descriptive and inferential statistics using SPSS. Results: The study participants (N=182) were primarily female (n=123, 67.6%), aged ?45 years (n=112, 61.5%), White (n=154, 84.6%), and non-Hispanic (n=177, 97.3%). Compared to those without Emotions challenges, those with Emotions challenges were aged 18-44 (P<.001) years, more often female (P=.02), and not married (P=.01). Overall, participants had more strengths (mean 28.6, SD 10.5) than challenges (mean 12, SD 7.5) and needs (mean 4.2, SD 7.5). The most frequent needs were in Emotions, Nutrition, Income, Sleeping, and Exercising. Compared to those without Emotions challenges, those with Emotions challenges had fewer strengths (P<.001), more challenges (P<.001), and more needs (P<.001), along with fewer strengths for Emotions (P<.001) and for the cluster of health-related behaviors domain concepts, Sleeping (P=.002), Nutrition (P<.001), and Exercising (P<.001). Resilience was operationalized as correlations among strengths for SOST concepts and visualized for participants with/without an Emotions challenge. Those without Emotions challenges had more positive strengths correlations across multiple concepts/domains. Conclusions: This survey study explored a large community-generated data set to understand whole-person health and showed between-group differences in SCN and resilience for participants with/without Emotions challenges. It contributes to the literature regarding an app-aided and data-driven approach to whole-person health and resilience. This research demonstrates the power of health informatics and provides researchers with a data-driven methodology for additional studies to build evidence on whole-person health and resilience. UR - https://nursing.jmir.org/2022/1/e38063 UR - http://dx.doi.org/10.2196/38063 UR - http://www.ncbi.nlm.nih.gov/pubmed/35576563 ID - info:doi/10.2196/38063 ER - TY - JOUR AU - Zapolski, Tamika AU - Whitener, MacKenzie AU - Khazvand, Shirin AU - Crichlow, Queenisha AU - Revilla, Rebecca AU - Salgado, F. Eduardo AU - Aalsma, Matthew AU - Cyders, Melissa AU - Salyers, Michelle AU - Wu, Wei PY - 2022/5/12 TI - Implementation of a Brief Dialectical Behavioral Therapy Skills Group in High Schools for At-Risk Youth: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e32490 VL - 11 IS - 5 KW - dialectical behavioral therapy KW - adolescents KW - high school KW - intervention KW - teenagers KW - risk-taking behavior KW - impulsivity KW - emotion dysregulation KW - social and emotional learning KW - youth N2 - Background: Adolescence is a developmental period marked by engagement in risk-taking behaviors, especially among impulsive or emotionally dysregulated youth. Thus, interventions that teach skills to reduce the risk of negative outcomes associated with emotional dysregulation are required. Social and emotional learning (SEL) programs have been developed to address both adolescent emotional dysregulation and risk-taking behaviors; however, current programs have mostly been implemented among younger youth and are used as a tier 1 universal intervention rather than a targeted tier 2 intervention for youth identified with emotional regulation difficulties. Objective: This study aimed to address the need for SEL programming that can be delivered in schools, particularly for older youth who have difficulties with emotional or behavioral dysregulation, to reduce the risk of health-risk behaviors among this population. Methods: Here, we outline the implementation of an SEL intervention titled Going 4 Goals, a 9-session adaptation of the Dialectical Behavioral Therapy for Adolescents (DBT-A) program delivered to at-risk high school students in a school setting. The primary objectives of the study are to test whether participating in the skills group intervention produces significant increases in the core DBT-A skills of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness, while also producing significant decreases in substance use and risky behaviors. These primary outcomes are based on changes in participant scores between baseline and after the intervention and follow-ups at 1, 3, and 6 months compared with a control group of youth participating in the school?s health curriculum at the same time points. Qualitative interviews will also be conducted with intervention participants and school staff to examine acceptability and facilitators of and barriers to the intervention. Results: A total of 171 participants across 13 groups had been enrolled in the intervention, with data collection ending December 2021. Data analysis will begin in the spring of 2022, with expected results to be published in the spring of 2023. Conclusions: This paper describes the protocol of the 9-session school-based adaptation of the DBT-A intervention and discusses the strengths and limitations of the study and future directions. International Registered Report Identifier (IRRID): DERR1-10.2196/32490 UR - https://www.researchprotocols.org/2022/5/e32490 UR - http://dx.doi.org/10.2196/32490 UR - http://www.ncbi.nlm.nih.gov/pubmed/35551054 ID - info:doi/10.2196/32490 ER - TY - JOUR AU - Serio, Catherine AU - Gabarda, Amanda AU - Uyar-Morency, Fatma AU - Silfee, Valerie AU - Ludwig, Justin AU - Szigethy, Eva AU - Butterworth, Susan PY - 2022/5/11 TI - Strengthening the Impact of Digital Cognitive Behavioral Interventions Through a Dual Intervention: Proficient Motivational Interviewing?Based Health Coaching Plus In-Application Techniques JO - JMIR Form Res SP - e34552 VL - 6 IS - 5 KW - digital health KW - mHealth KW - cognitive behavioral therapy KW - motivational interviewing KW - COVID-19 KW - mental health N2 - Background: The COVID-19 pandemic has accelerated the adoption of digital tools to support individuals struggling with their mental health. The use of a digital intervention plus human coaching (?dual? intervention) is gaining momentum in increasing overall engagement in digital cognitive behavioral interventions (dCBIs). However, there is limited insight into the methodologies and coaching models used by those deploying dual interventions. To achieve a deeper understanding, we need to identify and promote effective engagement that leads to clinical outcomes versus simply monitoring engagement metrics. Motivational interviewing (MI) is a collaborative, goal-oriented communication approach that pays particular attention to the language of change and is an effective engagement approach to help people manage mental health issues. However, this approach has been traditionally used for in-person or telephonic interventions, and less is known about the application of MI to digital interventions. Objective: We sought to provide a dual intervention approach and address multiple factors across two levels of engagement to operationalize a dCBI that combined cognitive behavioral therapy?based techniques and MI-based interactions between the digital health coach (DHC) and user. Methods: We reviewed hundreds of digital exchanges between DHCs and users to identify and improve training and quality assurance activities for digital interventions. Results: We tested five hypotheses and found that: (1) users of a dual digital behavioral health intervention had greater engagement levels than users of a noncoached intervention (P<.001); (2) DHCs with a demonstrated competency in applying MI to digital messages had more engaged users, as measured by the DHC-to-user message exchange ratio (P<.001); (3) the DHC-to-user message exchange ratio was correlated with more engagement in app activities (r=0.28, 95% CI 0.23-0.33); (4) DHCs with demonstrated MI proficiency elicited a greater amount of ?change talk? from users than did DHCs without MI proficiency (H=25.12, P<.001); and (5) users who were engaged by DHCs with MI proficiency had better clinical outcomes compared to users engaged by DHCs without MI proficiency (P=.02). Conclusions: To our knowledge, this pilot was the first of its kind to test the application of MI to digital coaching protocols, and it demonstrated the value of MI proficiency in digital health coaching for enhanced engagement and health improvement. Further research is needed to establish coaching models in dCBIs that incorporate MI to promote effective engagement and optimize positive behavioral outcomes. UR - https://formative.jmir.org/2022/5/e34552 UR - http://dx.doi.org/10.2196/34552 UR - http://www.ncbi.nlm.nih.gov/pubmed/35544323 ID - info:doi/10.2196/34552 ER - TY - JOUR AU - Scherer, A. Emily AU - Kim, Jung Sunny AU - Metcalf, A. Stephen AU - Sweeney, Ann Mary AU - Wu, Jialing AU - Xie, Haiyi AU - Mazza, L. Gina AU - Valente, J. Matthew AU - MacKinnon, P. David AU - Marsch, A. Lisa PY - 2022/5/10 TI - Momentary Self-regulation: Scale Development and Preliminary Validation JO - JMIR Ment Health SP - e35273 VL - 9 IS - 5 KW - self-regulation KW - momentary self-regulation KW - ecological momentary assessment KW - psychometric KW - health behavior change KW - health risk behaviors KW - mobile phone N2 - Background: Self-regulation refers to a person?s ability to manage their cognitive, emotional, and behavioral processes to achieve long-term goals. Most prior research has examined self-regulation at the individual level; however, individual-level assessments do not allow the examination of dynamic patterns of intraindividual variability in self-regulation and thus cannot aid in understanding potential malleable processes of self-regulation that may occur in response to the daily environment. Objective: This study aims to develop a brief, psychometrically sound momentary self-regulation scale that can be practically administered through participants? mobile devices at a momentary level. Methods: This study was conducted in 2 phases. In the first phase, in a sample of 522 adults collected as part of a larger self-regulation project, we examined 23 previously validated assessments of self-regulation containing 594 items in total to evaluate the underlying structure of self-regulation via exploratory and confirmatory factor analyses. We then selected 20 trait-level items to be carried forward to the second phase. In the second phase, we converted each item into a momentary question and piloted the momentary items in a sample of 53 adults over 14 days. Using the results from the momentary pilot study, we explored the psychometric properties of the items and assessed their underlying structure. We then proposed a set of subscale and total score calculations. Results: In the first phase, the selected individual-level items appeared to measure 4 factors of self-regulation. The factors identified were perseverance, sensation seeking, emotion regulation, and mindfulness. In the second phase of the ecological momentary assessment pilot, the selected items demonstrated strong construct validity as well as predictive validity for health risk behaviors. Conclusions: Our findings provide preliminary evidence for a 12-item momentary self-regulation scale comprising 4 subscales designed to capture self-regulatory dynamics at the momentary level. UR - https://mental.jmir.org/2022/5/e35273 UR - http://dx.doi.org/10.2196/35273 UR - http://www.ncbi.nlm.nih.gov/pubmed/35536605 ID - info:doi/10.2196/35273 ER - TY - JOUR AU - Buss, Helen Vera AU - Varnfield, Marlien AU - Harris, Mark AU - Barr, Margo PY - 2022/5/10 TI - A Mobile App for Prevention of Cardiovascular Disease and Type 2 Diabetes Mellitus: Development and Usability Study JO - JMIR Hum Factors SP - e35065 VL - 9 IS - 2 KW - mobile health KW - behavior change intervention KW - primary prevention KW - health promotion KW - cardiovascular disease KW - diabetes mellitus, type 2 KW - mobile phone N2 - Background: Cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) are posing a huge burden on health care systems worldwide. Mobile apps can deliver behavior change interventions for chronic disease prevention on a large scale, but current evidence for their effectiveness is limited. Objective: This paper reported on the development and user testing of a mobile app that aims at increasing risk awareness and engaging users in behavior change. It would form part of an intervention for primary prevention of CVD and T2DM. Methods: The theoretical framework of the app design was based on the Behaviour Change Wheel, combined with the capability, opportunity, and motivation for behavior change system and the behavior change techniques from the Behavior Change Technique Taxonomy (version 1). In addition, evidence from scientific literature has guided the development process. The prototype was tested for user-friendliness via an iterative approach. We conducted semistructured interviews with individuals in the target populations, which included the System Usability Scale. We transcribed and analyzed the interviews using descriptive statistics for the System Usability Scale and thematic analysis to identify app features that improved utility and usability. Results: The target population was Australians aged ?45 years. The app included 4 core modules (risk score, goal setting, health measures, and education). In these modules, users learned about their risk for CVD and T2DM; set goals for smoking, alcohol consumption, diet, and physical activity; and tracked them. In total, we included 12 behavior change techniques. We conducted 2 rounds of usability testing, each involving 5 participants. The average age of the participants was 58 (SD 8) years. Totally, 60% (6/10) of the participants owned iPhone Operating System phones, and 40% (4/10) of them owned Android phones. In the first round, we identified a technical issue that prevented 30% (3/10) of the participants from completing the registration process. Among the 70% (7/10) of participants who were able to complete the registration process, 71% (5/7) rated the app above average, based on the System Usability Scale. During the interviews, we identified some issues related to functionality, content, and language and clarity. We used the participants? feedback to improve these aspects. Conclusions: We developed the app using behavior change theory and scientific evidence. The user testing allowed us to identify and remove technical errors and integrate additional functions into the app, which the participants had requested. Next, we will evaluate the feasibility of the revised version of the app developed through this design process and usability testing. UR - https://humanfactors.jmir.org/2022/2/e35065 UR - http://dx.doi.org/10.2196/35065 UR - http://www.ncbi.nlm.nih.gov/pubmed/35536603 ID - info:doi/10.2196/35065 ER - TY - JOUR AU - Paul, Margot AU - Bullock, Kim AU - Bailenson, Jeremy PY - 2022/5/6 TI - Virtual Reality Behavioral Activation for Adults With Major Depressive Disorder: Feasibility Randomized Controlled Trial JO - JMIR Ment Health SP - e35526 VL - 9 IS - 5 KW - virtual reality KW - major depressive disorder KW - behavioral activation KW - depression N2 - Background: Major depressive disorder (MDD) is a global crisis with increasing incidence and prevalence. There are many established evidence-based psychotherapies (EBPs) for depression, but numerous barriers still exist; most notably, access and dissemination. Virtual reality (VR) may offer some solutions to existing constraints of EBPs for MDD. Objective: We aimed to examine the feasibility, acceptability, and tolerability of using VR as a method of delivering behavioral activation (BA) for adults diagnosed with MDD during a global pandemic and to explore for signs of clinical efficacy by comparing VR-enhanced BA (VR BA) to a standard BA treatment and a treatment as usual control group for individuals diagnosed with MDD. Methods: A feasibility trial using a 3-armed, unblinded, randomized controlled pilot design was conducted. The study took place remotely via Zoom telehealth visits between April 8, 2020, and January 15, 2021. This study used a 3-week, 4-session protocol in which VR BA participants used a VR headset to complete their BA homework. Feasibility was measured using dropout rates, serious adverse events, completion of homework, an adapted telepresence scale, the Simulator Sickness Questionnaire, the Brief Agitation Measure, and an adapted Technology Acceptance Model. Efficacy was assessed using the Patient Health Questionnaire?9. Results: Of the 35 participants assessed for eligibility, 13 (37%) were randomized into VR BA (n=5, 38%), traditional BA (n=4, 31%), or a treatment as usual control (n=4, 31%). The mean age of the 13 participants (5/13, 38% male; 7/13, 54% female; and 1/13, 8% nonbinary or third gender) was 35.4 (SD 12.3) years. This study demonstrated VR BA feasibility in participants with MDD through documented high levels of acceptability and tolerability while engaging in VR-induced pleasurable activities in conjunction with a brief BA protocol. No adverse events were reported. This study also illustrated that VR BA may have potential clinical utility for treating MDD, as the average VR BA participant?s clinical severity decreased by 5.67 points, signifying a clinically meaningful change in severity from a moderate to a mild level of depression as per the Patient Health Questionnaire?9 score. Conclusions: The findings of this study demonstrate that VR BA is safe and feasible to explore for the treatment of MDD. This study documented evidence that VR BA may be efficacious and justifies further examination in an adequately powered randomized controlled trial. This pilot study highlights the potential utility that VR technology may offer patients with MDD, especially those who have difficulty accessing real-world pleasant activities. In addition, for those having difficulty accessing care, VR BA could be adapted as a first step to help people improve their mood and increase their motivation while waiting to connect with a health care professional for other EBPs. Trial Registration: ClinicalTrials.gov NCT04268316; https://clinicaltrials.gov/ct2/show/NCT04268316 International Registered Report Identifier (IRRID): RR2-10.2196/24331 UR - https://mental.jmir.org/2022/5/e35526 UR - http://dx.doi.org/10.2196/35526 UR - http://www.ncbi.nlm.nih.gov/pubmed/35404830 ID - info:doi/10.2196/35526 ER - TY - JOUR AU - Espinosa-Curiel, Edrein Ismael AU - Pozas-Bogarin, Efrén Edgar AU - Hernández-Arvizu, Maryleidi AU - Navarro-Jiménez, Elena Maria AU - Delgado-Pérez, Emeth Edwin AU - Martínez-Miranda, Juan AU - Pérez-Espinosa, Humberto PY - 2022/5/6 TI - HelperFriend, a Serious Game for Promoting Healthy Lifestyle Behaviors in Children: Design and Pilot Study JO - JMIR Serious Games SP - e33412 VL - 10 IS - 2 KW - serious game KW - children KW - education and behavior change KW - healthy lifestyle behaviors KW - physical activity KW - healthy eating KW - socioemotional wellness N2 - Background: The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children. Objective: We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness. Methods: Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction. Results: Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (t14=2.01, P=.03), healthy eating (t14=3.14, P=.003), and socioemotional wellness (t14=2.75, P=.008). In addition, from T0 to T1, the intervention group improved their intention to perform physical activity (t14=2.82, P=.006), healthy eating (t14=3.44, P=.002), and socioemotional wellness (t14=2.65, P=.009); and there was a reduction in their intake of 13 unhealthy foods. HelperFriend was well received by intervention group. Conclusions: HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend. UR - https://games.jmir.org/2022/2/e33412 UR - http://dx.doi.org/10.2196/33412 UR - http://www.ncbi.nlm.nih.gov/pubmed/35522474 ID - info:doi/10.2196/33412 ER - TY - JOUR AU - Mazeas, Alexandre AU - Duclos, Martine AU - Pereira, Bruno AU - Chalabaev, Aïna PY - 2022/5/3 TI - Authors? Reply to: Learning More About the Effects of Gamification on Physical Activity. Comment on ?Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials? JO - J Med Internet Res SP - e38212 VL - 24 IS - 5 KW - behavior change KW - eHealth KW - gamification KW - health behavior KW - intervention KW - meta-analysis KW - mobile phone KW - physical activity KW - systematic review KW - elderly KW - old adults UR - https://www.jmir.org/2022/5/e38212 UR - http://dx.doi.org/10.2196/38212 UR - http://www.ncbi.nlm.nih.gov/pubmed/35503414 ID - info:doi/10.2196/38212 ER - TY - JOUR AU - Hung, Cheng-Hsien AU - Kao, Yung-Shuo PY - 2022/5/3 TI - Learning More About the Effects of Gamification on Physical Activity. Comment on ?Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials? JO - J Med Internet Res SP - e36396 VL - 24 IS - 5 KW - behavior change KW - eHealth KW - gamification KW - health behavior KW - intervention KW - meta-analysis KW - mobile phone KW - physical activity KW - systematic review KW - elderly KW - old adults UR - https://www.jmir.org/2022/5/e36396 UR - http://dx.doi.org/10.2196/36396 UR - http://www.ncbi.nlm.nih.gov/pubmed/35503654 ID - info:doi/10.2196/36396 ER - TY - JOUR AU - Kinouchi, Kaori AU - Ohashi, Kazutomo PY - 2022/5/3 TI - Assessing Engagement With Patient-Generated Health Data Recording and Its Impact on Health Behavior Changes in Multicomponent Interventions: Supplementary Analysis JO - JMIR Form Res SP - e35471 VL - 6 IS - 5 KW - patient-generated health data KW - engagement KW - health behavior change KW - postpartum women KW - health data KW - health informatics KW - pelvic health N2 - Background: The use and sharing of patient-generated health data (PGHD) by clinicians or researchers is expected to enhance the remote monitoring of specific behaviors that affect patient health. In addition, PGHD use could support patients? decision-making on preventive care management, resulting in reduced medical expenses. However, sufficient evidence on the use and sharing of PGHD is lacking, and the impact of PGHD recording on patients? health behavior changes remains unclear. Objective: This study aimed to assess patients? engagement with PGHD recording and to examine the impact of PGHD recording on their health behavior changes. Methods: This supplementary analysis used the data of 47 postpartum women who had been assigned to the intervention group of our previous study for managing urinary incontinence. To assess the patients? engagement with PGHD recording during the intervention period (8 weeks), the fluctuation in the number of patients who record their PGHD (ie, PGHD recorders) was evaluated by an approximate curve. In addition, to assess adherence to the pelvic floor muscle training (PFMT), the weekly mean number of pelvic floor muscle contractions performed per day among 17 PGHD recorders was examined by latent class growth modeling (LCGM). Results: The fluctuation in the number of PGHD recorders was evaluated using the sigmoid curve formula (R2=0.91). During the first week of the intervention, the percentage of PGHD recorders was around 64% (30/47) and then decreased rapidly from the second to the third week. After the fourth week, the percentage of PGHD recorders was 36% (17/47), which remained constant until the end of the intervention. When analyzing the data of these 17 PGHD recorders, PFMT adherence was categorized into 3 classes by LCGM: high (7/17, 41%), moderate (3/17, 18%), and low (7/17, 41%). Conclusions: The number of PGHD recorders declined over time in a sigmoid curve. A small number of users recorded PGHD continuously; therefore, patients? engagement with PGHD recording was low. In addition, more than half of the PGHD recorders (moderate- and low-level classes combined: 10/17, 59%) had poor PFMT adherence. These results suggest that PGHD recording does not always promote health behavior changes. UR - https://formative.jmir.org/2022/5/e35471 UR - http://dx.doi.org/10.2196/35471 UR - http://www.ncbi.nlm.nih.gov/pubmed/35503411 ID - info:doi/10.2196/35471 ER - TY - JOUR AU - Wiklund, Tobias AU - Molander, Peter AU - Lindner, Philip AU - Andersson, Gerhard AU - Gerdle, Björn AU - Dragioti, Elena PY - 2022/4/29 TI - Internet-Delivered Cognitive Behavioral Therapy for Insomnia Comorbid With Chronic Pain: Randomized Controlled Trial JO - J Med Internet Res SP - e29258 VL - 24 IS - 4 KW - insomnia KW - chronic pain KW - comorbid KW - CBT-i KW - RCT KW - web-based CBT KW - pain KW - online health KW - online treatment KW - digital health KW - mental health KW - rehabilitation N2 - Background: Patients with chronic pain often experience insomnia symptoms. Pain initiates, maintains, and exacerbates insomnia symptoms, and vice versa, indicating a complex situation with an additional burden for these patients. Hence, the evaluation of insomnia-related interventions for patients with chronic pain is important. Objective: This randomized controlled trial examined the effectiveness of internet-based cognitive behavioral therapy for insomnia (ICBT-i) for reducing insomnia severity and other sleep- and pain-related parameters in patients with chronic pain. Participants were recruited from the Swedish Quality Registry for Pain Rehabilitation. Methods: We included 54 patients (mean age 49.3, SD 12.3 years) who were randomly assigned to the ICBT-i condition and 24 to an active control condition (applied relaxation). Both treatment conditions were delivered via the internet. The Insomnia Severity Index (ISI), a sleep diary, and a battery of anxiety, depression, and pain-related parameter measurements were assessed at baseline, after treatment, and at a 6-month follow-up (only ISI, anxiety, depression, and pain-related parameters). For the ISI and sleep diary, we also recorded weekly measurements during the 5-week treatment. Negative effects were also monitored and reported. Results: Results showed a significant immediate interaction effect (time by treatment) on the ISI and other sleep parameters, namely, sleep efficiency, sleep onset latency, early morning awakenings, and wake time after sleep onset. Participants in the applied relaxation group reported no significant immediate improvements, but both groups exhibited a time effect for anxiety and depression at the 6-month follow-up. No significant improvements on pain-related parameters were found. At the 6-month follow-up, both the ICBT-i and applied relaxation groups had similar sleep parameters. For both treatment arms, increased stress was the most frequently reported negative effect. Conclusions: In patients with chronic pain, brief ICBT-i leads to a more rapid decline in insomnia symptoms than does applied relaxation. As these results are unique, further research is needed to investigate the effect of ICBT-i on a larger sample size of people with chronic pain. Using both treatments might lead to an even better outcome in patients with comorbid insomnia and chronic pain. Trial Registration: ClinicalTrials.gov NCT03425942; https://clinicaltrials.gov/ct2/show/NCT03425942 UR - https://www.jmir.org/2022/4/e29258 UR - http://dx.doi.org/10.2196/29258 UR - http://www.ncbi.nlm.nih.gov/pubmed/35486418 ID - info:doi/10.2196/29258 ER - TY - JOUR AU - Bartlett, Kiera Yvonne AU - Farmer, Andrew AU - Newhouse, Nikki AU - Miles, Lisa AU - Kenning, Cassandra AU - French, P. David PY - 2022/4/29 TI - Effects of Using a Text Message Intervention on Psychological Constructs and the Association Between Changes to Psychological Constructs and Medication Adherence in People With Type 2 Diabetes: Results From a Randomized Controlled Feasibility Study JO - JMIR Form Res SP - e30058 VL - 6 IS - 4 KW - medication adherence KW - type 2 diabetes mellitus KW - behavior change techniques KW - text messaging KW - feasibility studies KW - diabetes KW - medication KW - digital health N2 - Background: Poor adherence to oral medications is common in people with type 2 diabetes and can lead to an increased chance of health complications. Text messages may provide an effective delivery method for an intervention; however, thus far, the majority of these interventions do not specify either a theoretical basis or propose specific mechanisms of action. This makes it hard to determine how and whether an intervention is having an effect. The text messages included in the current intervention have been developed to deliver specific behavior change techniques. These techniques are the ?active ingredients? of the intervention and were selected to target psychological constructs identified as predictors of medication adherence. Objective: There are 2 aims of this study: (1) to assess whether a text message intervention with specified behavior change techniques can change the constructs that predict medication adherence behaviors in people with type 2 diabetes and (2) to assess whether changes to psychological constructs are associated with changes in self-reported medication adherence. Methods: We conducted a randomized controlled, 6-month feasibility trial. Adults prescribed oral medication for type 2 diabetes (N=209) were recruited from general practice and randomized to either receive a text message?based intervention or care as usual. Data were analyzed with repeated measures analysis of covariance and Spearman rho correlation coefficients. Results: For 8 of the 14 constructs that were measured, a significant time-by-condition interaction was found: necessity beliefs, intention, maintenance self-efficacy, recovery self-efficacy, action control, prompts and cues, social support, and satisfaction with experienced consequences all increased in the intervention group compared to the control group. Changes in action self-efficacy, intention, automaticity, maintenance self-efficacy, and satisfaction with experienced consequences were positively associated with changes in self-reported medication adherence. Conclusions: A relatively low-cost, scalable, text message?only intervention targeting medication adherence using behavior change techniques can influence psychological constructs that predict adherence. Not only do these constructs predict self-reported medication adherence, but changes in these constructs are correlated with changes in self-reported medication adherence. These findings support the promise of text message?based interventions for medication adherence in this population and suggest likely mechanisms of action. Trial Registration: ISRCTN Registry ISRCTN13404264; https://www.isrctn.com/ISRCTN13404264 UR - https://formative.jmir.org/2022/4/e30058 UR - http://dx.doi.org/10.2196/30058 UR - http://www.ncbi.nlm.nih.gov/pubmed/35486430 ID - info:doi/10.2196/30058 ER - TY - JOUR AU - Scott, Jodie AU - Oxlad, Melissa AU - Dodd, Jodie AU - Szabo, Claudia AU - Deussen, Andrea AU - Turnbull, Deborah PY - 2022/4/28 TI - Promoting Health Behavior Change in the Preconception Period: Combined Approach to Intervention Planning JO - JMIR Form Res SP - e35108 VL - 6 IS - 4 KW - intervention mapping KW - preconception KW - behavior change KW - healthy lifestyle KW - maternal health KW - weight management N2 - Background: Half of women begin pregnancy above the healthy weight range, increasing the risk of complications and adversely affecting the lifelong health of their babies. Maternal obesity remains the strongest risk factor for offspring obesity across childhood, adolescence, and adulthood. Previous research suggests that women should be encouraged to be within a healthy weight range before conception to improve health outcomes. Objective: We outlined the intervention planning and design process to develop an evidence-informed eHealth intervention to promote weight management. The intervention, based on psychological theories and behavior change techniques, has been developed for women affected by overweight or obesity who intend to become pregnant. The Begin Better web application is part of an integrated program being evaluated in a clinical trial to assess if weight management before pregnancy can influence clinical outcomes for mothers and babies. Methods: Our intervention development process was guided by intervention mapping and person-based methods. This study documents steps 2 to 4 of a 6-step iterative intervention mapping approach informed by the Information-Motivation-Behavioral Skills model and the findings of a previous interview study. We defined behavior change objectives for each of the Information-Motivation-Behavioral Skills behavioral determinants as well as theory-based behavior change techniques and practical strategies. We also used persuasive system design principles to assist in translating these strategies into a digital environment. Results: The resultant intervention comprises nutritional and physical activity content along with psychological strategies, which are notably absent from mainstream weight management programs. Strategies to increase motivation, garner social support, and promote self-care are integral to maintaining engagement with the intervention, which aims to improve lifestyle behaviors and enhance well-being. Important elements include tracking mechanisms for percentage progress toward goals to enable feedback on behaviors and outcomes; in-application messages of praise on entry of goals or habits; and strategies to prompt habit formation and action planning via small, easily achievable steps toward positive change. Conclusions: Design decisions and processes for idea generation about intervention content, format, and delivery are often not reported. In this study, we respond to this gap in the literature and outline a process that is potentially transferable to the development of other interventions. UR - https://formative.jmir.org/2022/4/e35108 UR - http://dx.doi.org/10.2196/35108 UR - http://www.ncbi.nlm.nih.gov/pubmed/35482370 ID - info:doi/10.2196/35108 ER - TY - JOUR AU - Crespi, Elizabeth AU - Hardesty, J. Jeffrey AU - Nian, Qinghua AU - Sinamo, Joshua AU - Welding, Kevin AU - Kennedy, David Ryan AU - Cohen, E. Joanna PY - 2022/4/27 TI - Agreement Between Self-reports and Photos to Assess e-Cigarette Device and Liquid Characteristics in Wave 1 of the Vaping and Patterns of e-Cigarette Use Research Study: Web-Based Longitudinal Cohort Study JO - J Med Internet Res SP - e33656 VL - 24 IS - 4 KW - tobacco KW - e-cigarette KW - methodology KW - internet KW - photo KW - survey KW - self-report N2 - Background: e-Cigarette device and liquid characteristics are highly customizable; these characteristics impact nicotine delivery and exposure to toxic constituents. It is critical to understand optimal methods for measuring these characteristics to accurately assess their impacts on user behavior and health. Objective: To inform future survey development, we assessed the agreement between responses from survey participants (self-reports) and photos uploaded by participants and the quantity of usable data derived from each approach. Methods: Adult regular e-cigarette users (?5 days per week) aged ?21 years (N=1209) were asked questions about and submitted photos of their most used e-cigarette device (1209/1209, 100%) and liquid (1132/1209, 93.63%). Device variables assessed included brand, model, reusability, refillability, display, and adjustable power. Liquid variables included brand, flavor, nicotine concentration, nicotine formulation, and bottle size. For each variable, percentage agreement was calculated where self-report and photo data were available. Krippendorff ? and intraclass correlation coefficient (ICC) were calculated for categorical and continuous variables, respectively. Results were stratified by device (disposable, reusable with disposable pods or cartridges, and reusable with refillable pods, cartridges, or tanks) and liquid (customized and noncustomized) type. The sample size for each calculation ranged from 3.89% (47/1209; model of disposable devices) to 95.12% (1150/1209; device reusability). Results: Percentage agreement between photos and self-reports was substantial to very high across device and liquid types for all variables except nicotine concentration. These results are consistent with Krippendorff ? calculations, except where prevalence bias was suspected. ICC results for nicotine concentration and bottle size were lower than percentage agreement, likely because ICC accounts for the level of disagreement between values. Agreement varied by device and liquid type. For example, percentage agreement for device brand was higher among users of reusable devices (94%) than among users of disposable devices (75%). Low percentage agreement may result from poor participant knowledge of characteristics, user modifications of devices inconsistent with manufacturer-intended use, inaccurate or incomplete information on websites, or photo submissions that are not a participant?s most used device or liquid. The number of excluded values (eg, self-report was ?don?t know? or no photo submitted) differed between self-reports and photos; for questions asked to participants, self-reports had more usable data than photos for all variables except device model and nicotine formulation. Conclusions: Photos and self-reports yield data of similar accuracy for most variables assessed in this study: device brand, device model, reusability, adjustable power, display, refillability, liquid brand, flavor, and bottle size. Self-reports provided more data for all variables except device model and nicotine formulation. Using these approaches simultaneously may optimize data quantity and quality. Future research should examine how to assess nicotine concentration and variables not included in this study (eg, wattage and resistance) and the resource requirements of these approaches. UR - https://www.jmir.org/2022/4/e33656 UR - http://dx.doi.org/10.2196/33656 UR - http://www.ncbi.nlm.nih.gov/pubmed/35475727 ID - info:doi/10.2196/33656 ER - TY - JOUR AU - Imai, Hissei AU - Tajika, Aran AU - Narita, Hisashi AU - Yoshinaga, Naoki AU - Kimura, Kenichi AU - Nakamura, Hideki AU - Takeshima, Nozomi AU - Hayasaka, Yu AU - Ogawa, Yusuke AU - Furukawa, Toshi PY - 2022/4/21 TI - Unguided Computer-Assisted Self-Help Interventions Without Human Contact in Patients With Obsessive-Compulsive Disorder: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e35940 VL - 24 IS - 4 KW - randomized controlled trial KW - RCT KW - information technology KW - psychotherapy KW - treatment adherence KW - anxiety disorder KW - anxiety KW - OCD KW - obsessive-compulsive disorder KW - systematic review KW - meta-analysis KW - mental health KW - computer-assisted KW - therapy KW - efficacy KW - acceptability KW - eHealth KW - mental illness N2 - Background: Computer-assisted treatment may reduce therapist contact and costs and promote client participation. This meta-analysis examined the efficacy and acceptability of an unguided computer-assisted therapy in patients with obsessive-compulsive disorder (OCD) compared with a waiting list or attention placebo. Objective: This study aimed to evaluate the effectiveness and adherence of computer-assisted self-help treatment without human contact in patients with OCD using a systematic review and meta-analysis approach. Methods: Randomized controlled trials with participants primarily diagnosed with OCD by health professionals with clinically significant OCD symptoms as measured with validated scales were included. The interventions included self-help treatment through the internet, computers, and smartphones. We excluded interventions that used human contact. We conducted a search on PubMed, Cochrane Central Register of Controlled Trials, EMBASE, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov, as well as the reference lists of the included studies. The risk of bias was evaluated using version 2 of the Cochrane risk-of-bias tool for randomized trials. We calculated the standardized mean differences for continuous outcomes and risk ratios for dichotomous outcomes. The primary outcomes were short-term improvement of OCD symptoms measured by validated scales and dropout for any reason. Results: We included 11 randomized controlled trials with a total of 983 participants. The results indicated that unguided computer-assisted self-help therapy was significantly more effective than a waiting list or psychological placebo (standard mean difference ?0.47, 95% CI ?0.73 to ?0.22). Unguided computer-assisted self-help therapy had more dropouts for any reason than waiting list or psychological placebo (risk ratio 1.98, 95% CI 1.21 to 3.23). However, the quality of evidence was very low because of the risk of bias and inconsistent results among the included studies. The subgroup analysis showed that exposure response and prevention and an intervention duration of more than 4 weeks strengthen the efficacy without worsening acceptability. Only a few studies have examined the interaction between participants and systems, and no study has used gamification. Most researchers only used text-based interventions, and no study has used a mobile device. The overall risk of bias of the included studies was high and the heterogeneity of results was moderate to considerable. Conclusions: Unguided computer-assisted self-help therapy for OCD is effective compared with waiting lists or psychological placebo. An exposure response and prevention component and intervention duration of more than 4 weeks may strengthen the efficacy without worsening the acceptability of the therapy. Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42021264644; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=264644 UR - https://www.jmir.org/2022/4/e35940 UR - http://dx.doi.org/10.2196/35940 UR - http://www.ncbi.nlm.nih.gov/pubmed/35451993 ID - info:doi/10.2196/35940 ER - TY - JOUR AU - Ahlers, Joachim AU - Baumgartner, Christian AU - Augsburger, Mareike AU - Wenger, Andreas AU - Malischnig, Doris AU - Boumparis, Nikolaos AU - Berger, Thomas AU - Stark, Lars AU - Ebert, D. David AU - Haug, Severin AU - Schaub, P. Michael PY - 2022/4/20 TI - Cannabis Use in Adults Who Screen Positive for Attention Deficit/Hyperactivity Disorder: CANreduce 2.0 Randomized Controlled Trial Subgroup Analysis JO - J Med Internet Res SP - e30138 VL - 24 IS - 4 KW - attention deficit/hyperactivity disorder KW - ADHD KW - cannabis KW - cannabis use disorder KW - CANreduce KW - web-based self-help tool KW - online tool KW - online health KW - mental health KW - digital health KW - anxiety KW - depression N2 - Background: Prevalence rates for lifetime cannabis use and cannabis use disorder are much higher in people with attention deficit/hyperactivity disorder than in those without. CANreduce 2.0 is an intervention that is generally effective at reducing cannabis use in cannabis misusers. This self-guided web-based intervention (6-week duration) consists of modules grounded in motivational interviewing and cognitive behavioral therapy. Objective: We aimed to evaluate whether the CANreduce 2.0 intervention affects cannabis use patterns and symptom severity in adults who screen positive for attention deficit/hyperactivity disorder more than in those who do not. Methods: We performed a secondary analysis of data from a previous study with the inclusion criterion of cannabis use at least once weekly over the last 30 days. Adults with and without attention deficit/hyperactivity disorder (based on the Adult Attention deficit/hyperactivity disorder Self-Report screener) who were enrolled to the active intervention arms of CANreduce 2.0 were compared regarding the number of days cannabis was used in the preceding 30 days, the cannabis use disorder identification test score (CUDIT) and the severity of dependence scale score (SDS) at baseline and the 3-month follow-up. Secondary outcomes were Generalized Anxiety Disorder score, Center for Epidemiological Studies Depression scale score, retention, intervention adherence, and safety. Results: Both adults with (n=94) and without (n=273) positive attention-deficit/hyperactivity disorder screening reported significantly reduced frequency (reduction in consumption days: with: mean 11.53, SD 9.28, P<.001; without: mean 8.53, SD 9.4, P<.001) and severity of cannabis use (SDS: with: mean 3.57, SD 3.65, P<.001; without: mean 2.47, SD 3.39, P<.001; CUDIT: with: mean 6.38, SD 5.96, P<.001; without: mean 5.33, SD 6.05, P<.001), as well as anxiety (with: mean 4.31, SD 4.71, P<.001; without: mean 1.84, SD 4.22, P<.001) and depression (with: mean 10.25, SD 10.54; without: mean 4.39, SD 10.22, P<.001). Those who screened positive for attention deficit/hyperactivity disorder also reported significantly decreased attention deficit/hyperactivity disorder scores (mean 4.65, SD 4.44, P<.001). There were no significant differences in change in use (P=.08), dependence (P=.95), use disorder (P=.85), attention deficit/hyperactivity disorder status (P=.84), depression (P=.84), or anxiety (P=.26) between baseline and final follow-up, dependent on positive attention-deficit/hyperactivity disorder screening. Attention deficit/hyperactivity disorder symptom severity at baseline was not associated with reduced cannabis use frequency or severity but was linked to greater reductions in depression (Spearman ?=.33) and anxiety (Spearman ?=.28). Individuals with positive attention deficit/hyperactivity disorder screening were significantly less likely to fill out the consumption diary (P=.02), but the association between continuous attention deficit/hyperactivity disorder symptom severity and retention (Spearman ?=?0.10, P=.13) was nonsignificant. There also was no significant intergroup difference in the number of completed modules (with: mean 2.10, SD 2.33; without: mean 2.36, SD 2.36, P=.34), and there was no association with attention deficit/hyperactivity disorder symptom severity (Spearman ?=?0.09; P=.43). The same was true for the rate of adverse effects (P=.33). Conclusions: Cannabis users screening positive for attention deficit/hyperactivity disorder may benefit from CANreduce 2.0 to decrease the frequency and severity of cannabis dependence and attenuate symptoms of depression and attention deficit/hyperactivity disorder-related symptoms. This web-based program?s advantages include its accessibility for remote users and a personalized counselling option that may contribute to increased adherence and motivation to change among program users. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 11086185; http://www.isrctn.com/ISRCTN11086185 UR - https://www.jmir.org/2022/4/e30138 UR - http://dx.doi.org/10.2196/30138 UR - http://www.ncbi.nlm.nih.gov/pubmed/35442196 ID - info:doi/10.2196/30138 ER - TY - JOUR AU - Kim, Heon Ho AU - Kim, Youngin AU - Michaelides, Andreas AU - Park, Rang Yu PY - 2022/4/15 TI - Weight Loss Trajectories and Related Factors in a 16-Week Mobile Obesity Intervention Program: Retrospective Observational Study JO - J Med Internet Res SP - e29380 VL - 24 IS - 4 KW - clustering KW - mobile health KW - weight loss KW - weight management KW - behavior management KW - time series analysis KW - mHealth KW - obesity KW - outcomes KW - machine learning KW - mobile app KW - adherence KW - prediction KW - mobile phone N2 - Background: In obesity management, whether patients lose ?5% of their initial weight is a critical factor in clinical outcomes. However, evaluations that take only this approach are unable to identify and distinguish between individuals whose weight changes vary and those who steadily lose weight. Evaluation of weight loss considering the volatility of weight changes through a mobile-based intervention for obesity can facilitate understanding of an individual?s behavior and weight changes from a longitudinal perspective. Objective: The aim of this study is to use a machine learning approach to examine weight loss trajectories and explore factors related to behavioral and app use characteristics that induce weight loss. Methods: We used the lifelog data of 13,140 individuals enrolled in a 16-week obesity management program on the health care app Noom in the United States from August 8, 2013, to August 8, 2019. We performed k-means clustering with dynamic time warping to cluster the weight loss time series and inspected the quality of clusters with the total sum of distance within the clusters. To identify use factors determining clustering assignment, we longitudinally compared weekly use statistics with effect size on a weekly basis. Results: The initial average BMI value for the participants was 33.6 (SD 5.9) kg/m2, and it ultimately reached 31.6 (SD 5.7) kg/m2. Using the weight log data, we identified five clusters: cluster 1 (sharp decrease) showed the highest proportion of participants who reduced their weight by >5% (7296/11,295, 64.59%), followed by cluster 2 (moderate decrease). In each comparison between clusters 1 and 3 (yo-yo) and clusters 2 and 3, although the effect size of the difference in average meal record adherence and average weight record adherence was not significant in the first week, it peaked within the initial 8 weeks (Cohen d>0.35) and decreased after that. Conclusions: Using a machine learning approach and clustering shape-based time series similarities, we identified 5 weight loss trajectories in a mobile weight management app. Overall adherence and early adherence related to self-monitoring emerged as potential predictors of these trajectories. UR - https://www.jmir.org/2022/4/e29380 UR - http://dx.doi.org/10.2196/29380 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436211 ID - info:doi/10.2196/29380 ER - TY - JOUR AU - Bonner, Carissa AU - Batcup, Carys AU - Ayre, Julie AU - Cvejic, Erin AU - Trevena, Lyndal AU - McCaffery, Kirsten AU - Doust, Jenny PY - 2022/4/15 TI - The Impact of Health Literacy?Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing JO - JMIR Cardio SP - e34142 VL - 6 IS - 1 KW - decision aids KW - shared decision-making KW - risk communication KW - heart age KW - cardiovascular disease prevention KW - behavior change KW - health literacy N2 - Background: Shared decision-making is an essential principle for the prevention of cardiovascular disease (CVD), where asymptomatic people consider lifelong medication and lifestyle changes. Objective: This study aims to develop and evaluate the first literacy-sensitive CVD prevention decision aid (DA) developed for people with low health literacy, and investigate the impact of literacy-sensitive design and heart age. Methods: We developed a standard DA based on international standards. The standard DA was based on our existing general practitioner DA. The literacy-sensitive DA included simple language, supporting images, white space, and a lifestyle action plan. The control DA used Heart Foundation materials. A randomized trial included 859 people aged 45-74 years using a 3 (DA: standard, literacy-sensitive, control) ×2 (heart age: heart age + percentage risk, percentage risk only) factorial design, with outcomes including prevention intentions and behaviors, gist and verbatim knowledge of risk, credibility, emotional response, and decisional conflict. We iteratively improved the literacy-sensitive version based on end-user testing interviews with 20 people with varying health literacy levels. Results: Immediately after the intervention (n=859), there were no differences in any outcome among the DA groups. The heart age group was less likely to have a positive emotional response, perceived the message as less credible, and had higher gist and verbatim knowledge of heart age risk but not percentage risk. After 4 weeks (n=596), the DA group had better gist knowledge of percentage risk than the control group. The literacy-sensitive DA group had higher fruit consumption, and the standard DA group had better verbatim knowledge of percentage risk. Verbatim knowledge was higher for heart age than for percentage risk among those who received both. Conclusions: The literacy-sensitive DA resulted in increased knowledge of CVD risk and increased fruit consumption in participants with varying health literacy levels and CVD risk results. Adding heart age did not increase lifestyle change intentions or behavior but did affect psychological outcomes, consistent with previous findings. This tool will be integrated with additional resources to improve other lifestyle outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000806965; https://tinyurl.com/226yhk8a UR - https://cardio.jmir.org/2022/1/e34142 UR - http://dx.doi.org/10.2196/34142 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436208 ID - info:doi/10.2196/34142 ER - TY - JOUR AU - Mattila, Elina AU - Horgan, Graham AU - Palmeira, L. António AU - O'Driscoll, Ruairi AU - Stubbs, James R. AU - Heitmann, L. Berit AU - Marques, M. Marta PY - 2022/4/14 TI - Evaluation of the Immediate Effects of Web-Based Intervention Modules for Goals, Planning, and Coping Planning on Physical Activity: Secondary Analysis of a Randomized Controlled Trial on Weight Loss Maintenance JO - J Med Internet Res SP - e35614 VL - 24 IS - 4 KW - digital intervention KW - Fitbit KW - weight KW - weight loss maintenance KW - physical activity KW - fitness KW - exercise KW - goal setting KW - action planning KW - coping planning KW - control trial KW - secondary analysis KW - RCT KW - randomized controlled trial KW - long-term effect KW - short-term effect KW - immediate effect KW - sustained effect N2 - Background: The use of digital interventions can be accurately monitored via log files. However, monitoring engagement with intervention goals or enactment of the actual behaviors targeted by the intervention is more difficult and is usually evaluated based on pre-post measurements in a controlled trial. Objective: The objective of this paper is to evaluate if engaging with 2 digital intervention modules focusing on (1) physical activity goals and action plans and (2) coping with barriers has immediate effects on the actual physical activity behavior. Methods: The NoHoW Toolkit (TK), a digital intervention developed to support long-term weight loss maintenance, was evaluated in a 2 x 2 factorial randomized controlled trial. The TK contained various modules based on behavioral self-regulation and motivation theories, as well as contextual emotion regulation approaches, and involved continuous tracking of weight and physical activity through connected commercial devices (Fitbit Aria and Charge 2). Of the 4 trial arms, 2 had access to 2 modules directly targeting physical activity: a module for goal setting and action planning (Goal) and a module for identifying barriers and coping planning (Barriers). Module visits and completion were determined based on TK log files and time spent in the module web page. Seven physical activity metrics (steps; activity; energy expenditure; fairly active, very active and total active minutes; and distance) were compared before and after visiting and completing the modules to examine whether the modules had immediate or sustained effects on physical activity. Immediate effect was determined based on 7-day windows before and after the visit, and sustained effects were evaluated for 1 to 8 weeks after module completion. Results: Out of the 811 participants, 498 (61.4%) visited the Goal module and 406 (50.1%) visited the Barriers module. The Barriers module had an immediate effect on very active and total active minutes (very active minutes: before median 24.2, IQR 10.4-43.0 vs after median 24.9, IQR 10.0-46.3; P=.047; total active minutes: before median 45.1, IQR 22.9-74.9 vs after median 46.9, IQR 22.4-78.4; P=.03). The differences were larger when only completed Barriers modules were considered. The Barriers module completion was also associated with sustained effects in fairly active and total active minutes for most of the 8 weeks following module completion and for 3 weeks in very active minutes. Conclusions: The Barriers module had small, significant, immediate, and sustained effects on active minutes measured by a wrist-worn activity tracker. Future interventions should pay attention to assessing barriers and planning coping mechanisms to overcome them. Trial Registration: ISRCTN Registry ISRCTN88405328; https://www.isrctn.com/ISRCTN88405328 UR - https://www.jmir.org/2022/4/e35614 UR - http://dx.doi.org/10.2196/35614 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436232 ID - info:doi/10.2196/35614 ER - TY - JOUR AU - Seiler, Jessie AU - Libby, E. Tanya AU - Jackson, Emahlea AU - Lingappa, JR AU - Evans, WD PY - 2022/4/14 TI - Social Media?Based Interventions for Health Behavior Change in Low- and Middle-Income Countries: Systematic Review JO - J Med Internet Res SP - e31889 VL - 24 IS - 4 KW - social media KW - behavior change KW - low- and middle-income countries KW - mobile phone N2 - Background: Despite the wealth of evidence regarding effective health behavior change techniques using digital interventions to focus on residents of high-income countries, there is limited information of a similar nature for low- and middle-income countries. Objective: The aim of this review is to identify and describe the available literature on effective social media?based behavior change interventions within low- and middle-income countries. Methods: This systematic review was conducted in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched PubMed, Embase, Elsevier, CINAHL, PsycInfo, and Global Index Medicus, and the final search was conducted on April 6, 2021. We excluded studies published before 2000 because of the subject matter. We included studies that evaluated interventions conducted at least partly on a social media platform. Results: We identified 1832 studies, of which 108 (5.89%) passed title-abstract review and were evaluated by full-text review. In all, 30.6% (33/108) were included in the final analysis. Although 22 studies concluded that the social media intervention was effective, only 13 quantified the level of social media engagement, of which, few used theory (n=8) or a conceptual model (n=5) of behavior change. Conclusions: We identified gaps in the settings of interventions, types and sectors of interventions, length of follow-up, evaluation techniques, use of theoretical and conceptual models, and discussions of the privacy implications of social media use. Trial Registration: PROSPERO CRD42020223572; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=223572 UR - https://www.jmir.org/2022/4/e31889 UR - http://dx.doi.org/10.2196/31889 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436220 ID - info:doi/10.2196/31889 ER - TY - JOUR AU - Robertson, C. Michael AU - Swartz, Chang Maria AU - Christopherson, Ursela AU - Bentley, R. Jason AU - Basen-Engquist, M. Karen AU - Thompson, Debbe AU - Volpi, Elena AU - Lyons, J. Elizabeth PY - 2022/4/14 TI - A Photography-based, Social Media Walking Intervention Targeting Autonomous Motivations for Physical Activity: Semistructured Interviews With Older Women JO - JMIR Serious Games SP - e35511 VL - 10 IS - 2 KW - physical activity KW - walking KW - exercise KW - fitness KW - social media KW - health KW - intervention KW - behavior KW - behavior mechanism KW - psychological theory KW - serious games KW - gamification KW - older women KW - older adults KW - behavior change KW - behavioral interventions KW - mobile phone KW - photography KW - patient perspective KW - patient attitude N2 - Background: Older adult women are at risk for negative health outcomes that engaging in sustained physical activity can help prevent. However, promoting long-term maintenance of physical activity in this population has proven to be a challenge. Increasing autonomous motivations (ie, intrinsic, integrated, and identified regulations) for physical activity may facilitate enduring behavior change. Digitally delivered games for health that take a celebratory technology approach, that is, using technology to create new ways to experience valued behaviors and express valued beliefs, may be a useful way to target autonomous motivations for physical activity. Formative research with the target population is needed to design compelling intervention content. Objective: The objective of this study is to investigate older adult women?s reactions to and thoughts about a photography-based, social media walking game targeting autonomous motivations for physical activity. Methods: During an individual semistructured interview, a moderator solicited feedback from 20 older adult women (age range 65-74 years) as part of formative research to develop a social media game featuring weekly walking challenges. The challenges were designed to target autonomous motivations for physical activity. Interviews were audio-recorded and transcribed verbatim. Two reviewers conducted thematic content analysis on interview transcripts. Results: We identified 3 overarching themes in qualitative data analysis. These reflected the playful experiences, value, and acceptability associated with the intervention challenges. Generally, participants understood what the challenges were asking them to do, proffered appropriate example responses, and indicated that the challenges would be enjoyable. Participants reported that the intervention content afforded many and varied playful experiences (eg, competition, discovery, exploration, expression, fellowship, humor, nurture, sensation). Further, participants indicated that the intervention increased their motivation for physical activity, occasioned meaningful shifts in perspective, increased their knowledge of various topics of interest, provided an opportunity to create valued connection with others, and provided health-related benefits. Participants suggested the intervention emphasize local history, nature, and cultural events. Conclusions: The photography-based, social media walking game with relatively simple game mechanics was well received and judged to be apt to bring about a wide variety of emotive experiences. A clear, geographically specific identity emerged as a key driver of interest for intervention content. Taking a celebratory technology approach holds promise for targeting autonomous motivations for physical activity in older adult women. UR - https://games.jmir.org/2022/2/e35511 UR - http://dx.doi.org/10.2196/35511 UR - http://www.ncbi.nlm.nih.gov/pubmed/35436205 ID - info:doi/10.2196/35511 ER - TY - JOUR AU - Odom, J. Krista AU - Ottosson, Amanda AU - Draru, Joyce AU - Komujuni, Harriet AU - Karamagi Nkolo, Karungi Esther AU - Faramand, Harb Taroub PY - 2022/4/13 TI - Improving Viral Load Suppression Among Men and Children Active in Care Through Community-Designed and Led Solutions: Protocol for Retrospective Closed Cohort Study in Eastern Uganda JO - JMIR Res Protoc SP - e32784 VL - 11 IS - 4 KW - HIV/AIDS KW - viral load suppression KW - Uganda KW - people living with HIV KW - 95-95-95 KW - social and behavior change KW - USAID KW - gender, youth, and social inclusion KW - virus KW - HIV KW - AIDS KW - antiretroviral therapy KW - behavioral science KW - implementation science KW - behavior change KW - men KW - children KW - community design KW - methodology N2 - Background: In collaboration with facilities, communities, district local government, and the United States Agency for International Development (USAID) implementing partners, the iDARE methodology was implemented at the community level to address root causes of low HIV antiretroviral therapy adherence among men and children actively enrolled in care, resulting in low viral load suppression (VLS) in two districts in the eastern region of Uganda. The methodology encourages the use of cocreated sustainable solutions addressing gender, youth, and social inclusion issues to reduce barriers to care and reach the 95-95-95 Joint United Nations Programme on HIV/AIDS target for HIV epidemic control. We aim to measure the impact of iDARE on VLS for men and children active in care and investigate the practical scale up of the solutions designed using the iDARE methodology. Objective: The primary objective of this study will be to measure the implementation impact of the iDARE methodology at the facility and community levels on VLS for people living with HIV. The secondary objective is to investigate the practical scale up of the iDARE methodology using evidence-based gender, youth, and social inclusion social behavior change packages to rapidly meet the Ugandan Ministry of Health targets for VLS. Methods: A retrospective cohort study design will be used to analyze program data that aims to increase the rates of VLS in men and children who are classified as active in care using community engagement and quality improvement techniques. We will examine 3 pilot health centers? data from a USAID-funded program aimed at social behavior change to increase health-seeking behavior in Uganda. Based on the iDARE process and results, change packages were developed to highlight lessons learned and best practices in order to share with subsequent implementation sites. Results: The USAID-funded Social and Behavior Change Activity began implementation of iDARE in September 2020, with baseline data collected in August 2020. Conclusions: Data on viral load suppression was collected from facilities on a monthly basis to record progress toward the 95-95-95 goal. The expected primary outcome is an increase in actively enrolled men and children reaching VLS in order to meet the Ugandan Ministry of Health target of 95% VLS among those active in care. International Registered Report Identifier (IRRID): DERR1-10.2196/32784 UR - https://www.researchprotocols.org/2022/4/e32784 UR - http://dx.doi.org/10.2196/32784 UR - http://www.ncbi.nlm.nih.gov/pubmed/35416790 ID - info:doi/10.2196/32784 ER - TY - JOUR AU - Bernstein, E. Emily AU - Weingarden, Hilary AU - Wolfe, C. Emma AU - Hall, D. Margaret AU - Snorrason, Ivar AU - Wilhelm, Sabine PY - 2022/4/8 TI - Human Support in App-Based Cognitive Behavioral Therapies for Emotional Disorders: Scoping Review JO - J Med Internet Res SP - e33307 VL - 24 IS - 4 KW - digital health KW - mental health KW - cognitive behavioral therapy KW - coaching KW - guided KW - mobile app KW - emotional disorder KW - mobile phone N2 - Background: Smartphone app?based therapies offer clear promise for reducing the gap in available mental health care for people at risk for or people with mental illness. To this end, as smartphone ownership has become widespread, app-based therapies have become increasingly common. However, the research on app-based therapies is lagging behind. In particular, although experts suggest that human support may be critical for increasing engagement and effectiveness, we have little systematic knowledge about the role that human support plays in app-based therapy. It is critical to address these open questions to optimally design and scale these interventions. Objective: The purpose of this study is to provide a scoping review of the use of human support or coaching in app-based cognitive behavioral therapy for emotional disorders, identify critical knowledge gaps, and offer recommendations for future research. Cognitive behavioral therapy is the most well-researched treatment for a wide range of concerns and is understood to be particularly well suited to digital implementations, given its structured, skill-based approach. Methods: We conducted systematic searches of 3 databases (PubMed, PsycINFO, and Embase). Broadly, eligible articles described a cognitive behavioral intervention delivered via smartphone app whose primary target was an emotional disorder or problem and included some level of human involvement or support (coaching). All records were reviewed by 2 authors. Information regarding the qualifications and training of coaches, stated purpose and content of the coaching, method and frequency of communication with users, and relationship between coaching and outcomes was recorded. Results: Of the 2940 titles returned by the searches, 64 (2.18%) were eligible for inclusion. This review found significant heterogeneity across all of the dimensions of coaching considered as well as considerable missing information in the published articles. Moreover, few studies had qualitatively or quantitatively evaluated how the level of coaching impacts treatment engagement or outcomes. Although users tend to self-report that coaching improves their engagement and outcomes, there is limited and mixed supporting quantitative evidence at present. Conclusions: Digital mental health is a young but rapidly expanding field with great potential to improve the reach of evidence-based care. Researchers across the reviewed articles offered numerous approaches to encouraging and guiding users. However, with the relative infancy of these treatment approaches, this review found that the field has yet to develop standards or consensus for implementing coaching protocols, let alone those for measuring and reporting on the impact. We conclude that coaching remains a significant hole in the growing digital mental health literature and lay out recommendations for future data collection, reporting, experimentation, and analysis. UR - https://www.jmir.org/2022/4/e33307 UR - http://dx.doi.org/10.2196/33307 UR - http://www.ncbi.nlm.nih.gov/pubmed/35394434 ID - info:doi/10.2196/33307 ER - TY - JOUR AU - Arroyo, Carmen Amber AU - Zawadzki, J. Matthew PY - 2022/4/4 TI - The Implementation of Behavior Change Techniques in mHealth Apps for Sleep: Systematic Review JO - JMIR Mhealth Uhealth SP - e33527 VL - 10 IS - 4 KW - behavior change techniques KW - sleep KW - mHealth KW - apps KW - digital health KW - mobile phone N2 - Background: Mobile health (mHealth) apps targeting health behaviors using behavior change techniques (BCTs) have been successful in promoting healthy behaviors; however, their efficacy with sleep is unclear. Some work has shown success in promoting sleep through mHealth, whereas there have been reports that sleep apps can be adverse and lead to unhealthy obsessions with achieving perfect sleep. Objective: This study aims to report and describe the use of BCTs in mHealth apps for sleep with the following research questions: How many BCTs are used on average in sleep apps, and does this relate to their effectiveness on sleep outcomes? Are there specific BCTs used more or less often in sleep apps, and does this relate to their effectiveness on sleep outcomes? Does the effect of mHealth app interventions on sleep change when distinguishing between dimension and measurement of sleep? Methods: We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to review articles on mHealth app interventions for sleep published between 2010 and 2020. Results: A total of 12 studies met the eligibility criteria. Most studies reported positive sleep outcomes, and there were no negative effects reported. Sleep quality was the most common dimension of sleep targeted. Subjective measures of sleep were used across all apps, whereas objective measures were often assessed but rarely reported as part of results. The average number of BCTs used was 7.67 (SD 2.32; range 3-11) of 16. Of the 12 studies, the most commonly used BCTs were feedback and monitoring (n=11, 92%), shaping knowledge (n=11, 92%), goals and planning (n=10, 83%), and antecedents (n=10, 83%), whereas the least common were scheduled consequences (n=0, 0%), self-belief (n=0, 0%), and covert learning (n=0, 0%). Most apps used a similar set of BCTs that unfortunately did not allow us to distinguish which BCTs were present when studies reported more positive outcomes. Conclusions: Our study describes the peer-reviewed literature on sleep apps and provides a foundation for further examination and optimization of BCTs used in mHealth apps for sleep. We found strong evidence that mHealth apps are effective in improving sleep, and the potential reasons for the lack of adverse sleep outcome reporting are discussed. We found evidence that the type of BCTs used in mHealth apps for sleep differed from other health outcomes, although more research is needed to understand how BCTs can be implemented effectively to improve sleep using mHealth and the mechanisms of action through which they are effective (eg, self-efficacy, social norms, and attitudes). UR - https://mhealth.jmir.org/2022/4/e33527 UR - http://dx.doi.org/10.2196/33527 UR - http://www.ncbi.nlm.nih.gov/pubmed/35377327 ID - info:doi/10.2196/33527 ER - TY - JOUR AU - Sourander, Andre AU - Ristkari, Terja AU - Kurki, Marjo AU - Gilbert, Sonja AU - Hinkka-Yli-Salomäki, Susanna AU - Kinnunen, Malin AU - Pulkki-Råback, Laura AU - McGrath, J. Patrick PY - 2022/4/4 TI - Effectiveness of an Internet-Based and Telephone-Assisted Training for Parents of 4-Year-Old Children With Disruptive Behavior: Implementation Research JO - J Med Internet Res SP - e27900 VL - 24 IS - 4 KW - parent training KW - early intervention KW - implementation KW - disruptive behavior KW - behavior problems KW - preschool children KW - internet-assisted KW - child mental health KW - mental health KW - behavior KW - intervention KW - children KW - parents N2 - Background: There is a lack of effectiveness studies when digital parent training programs are implemented in real-world practice. The efficacy of the internet-based and telephone-assisted Finnish Strongest Families Smart Website (SFSW) parent training intervention on the disruptive behavior of 4-year-old children was studied in a randomized controlled trial setting in Southwest Finland between 2011 and 2013. After that, the intervention was implemented nationwide in child health clinics from 2015 onwards. Objective: The main aim of this study was to compare the treatment characteristics and effectiveness of the SFSW parent training intervention between the families who received the intervention when it was implemented as a normal practice in child health clinics and the families who received the same intervention during the randomized controlled trial. Methods: The implementation group comprised 600 families who were recruited in the SFSW intervention between January 2015 and May 2017 in real-world implementation. The RCT intervention group comprised 232 families who were recruited between October 2011 and November 2013. The same demographic and child and parent measures were collected from both study groups and were compared using linear mixed-effect models for repeated measurements. The child psychopathology and functioning level were measured using the Child Behavior Checklist (CBCL) version 1.5-5 for preschool children, the Inventory of Callous-Unemotional Traits (ICU), and a modified version of the Barkley Home Situations Questionnaire. Parenting skills were measured using the 31-item Parenting Scale and the shorter 21-item Depression, Anxiety and Stress Scale (DASS-21). The estimated child and parent outcomes were adjusted for CBCL externalizing scores at baseline, maternal education, duration of the behavior problems, and paternal age. The baseline measurements of each outcome were used as covariates. Results: The implementation group was more likely to complete the intervention than the RCT intervention group (514/600, 85.7% vs 176/232, 75.9%, respectively; P<.001). There were no significant differences between the implementation and RCT intervention groups with regard to child measures, including CBCL externalizing score (?0.2, 95% CI ?1.3 to 1.6; P=.83), total score (?0.7, 95% CI ?3.0 to 4.5; P=.70), internalizing score (?0.3, 95% CI ?1.0 to 1.6; P=.64), and ICU total score (?0.4, 95% Cl ?1.9 to 1.2; P=.64). No significant difference was detected in the Parenting Scale total score (0.0, 95% Cl ?0.1 to 0.1; P=.50), while DASS-21 total score differed nearly significantly (2.5, 95% Cl 0.0-5.1; P=.05), indicating better improvement in the implementation group. Conclusions: The internet-based and telephone-assisted SFSW parent training intervention was effectively implemented in real-world settings. These findings have implications for addressing the unmet needs of children with disruptive behavior problems. Our initiative could also provide a quick socially distanced solution for the considerable mental health impact of the COVID-19 pandemic. Trial Registration: ClinicalTrials.gov NCT01750996; https://clinicaltrials.gov/ct2/show/NCT01750996 International Registered Report Identifier (IRRID): RR2-10.1186/1471-2458-13-985 UR - https://www.jmir.org/2022/4/e27900 UR - http://dx.doi.org/10.2196/27900 UR - http://www.ncbi.nlm.nih.gov/pubmed/35377332 ID - info:doi/10.2196/27900 ER - TY - JOUR AU - Menon, Rijuta AU - Meyer, Julien AU - Nippak, Pria AU - Begum, Housne PY - 2022/4/1 TI - Smartphone Alcohol Use Disorder Recovery Apps: Cross-sectional Survey of Behavioral Intention to Use JO - JMIR Hum Factors SP - e33493 VL - 9 IS - 2 KW - mobile health KW - alcohol use disorder KW - disease management KW - mobile apps KW - Unified Theory of Acceptance and Use of Technology N2 - Background: Alcohol use disorder (AUD) carries a huge health and economic cost to society. Effective interventions exist but numerous challenges limit their adoption, especially in a pandemic context. AUD recovery apps (AUDRA) have emerged as a potential complement to in-person interventions. They are easy to access and show promising results in terms of efficacy. However, they rely on individual adoption decisions and remain underused. Objective: The aim of this survey study is to explore the beliefs that determine the intention to use AUDRA. Methods: We conducted a cross-sectional survey study of people with AUD. We used the Unified Theory of Acceptance and Use of Technology, which predicts use and behavioral intention to use based on performance expectancy, effort expectancy, social influence, and facilitating conditions. Participants were recruited directly from 2 sources; first, respondents at addiction treatment facilities in Ontario, Canada, were contacted in person, and they filled a paper form; second, members from AUD recovery support groups on social media were contacted and invited to fill an internet-based survey. The survey was conducted between October 2019 and June 2020. Results: The final sample comprised 159 participants (124 involved in the web-based survey and 35 in the paper-based survey) self-identifying somewhat or very much with AUD. Most participants (n=136, 85.5%) were aware of AUDRA and those participants scored higher on performance expectancy, effort expectancy, and social influence. Overall, the model explains 35.4% of the variance in the behavioral intention to use AUDRA and 11.1% of the variance in use. Social influence (P=.31), especially for women (P=.23), and effort expectancy (P=.25) were key antecedents of behavioral intention. Facilitating conditions were not significant overall but were moderated by age (P=.23), suggesting that it matters for older participants. Performance expectancy did not predict behavioral intention, which is unlike many other technologies but confirms other findings associated with mobile health (mHealth). Open-ended questions suggest that privacy concerns may significantly influence the use of AUDRA. Conclusions: This study suggests that unlike many other technologies, the adoption of AUDRA is not mainly determined by utilitarian factors such as performance expectancy. Rather, effort expectancy and social influence play a key role in determining the intention to use AUDRA. UR - https://humanfactors.jmir.org/2022/2/e33493 UR - http://dx.doi.org/10.2196/33493 UR - http://www.ncbi.nlm.nih.gov/pubmed/35363145 ID - info:doi/10.2196/33493 ER - TY - JOUR AU - Ögmundsdóttir Michelsen, Halldóra AU - Sjölin, Ingela AU - Bäck, Maria AU - Gonzalez Garcia, Manuel AU - Olsson, Anneli AU - Sandberg, Camilla AU - Schiopu, Alexandru AU - Leósdóttir, Margrét PY - 2022/3/31 TI - Effect of a Lifestyle-Focused Web-Based Application on Risk Factor Management in Patients Who Have Had a Myocardial Infarction: Randomized Controlled Trial JO - J Med Internet Res SP - e25224 VL - 24 IS - 3 KW - eHealth KW - cardiac rehabilitation KW - cardiovascular KW - mobile device app KW - risk factors KW - web-based application KW - mobile phone N2 - Background: Cardiac rehabilitation is central in reducing mortality and morbidity after myocardial infarction. However, the fulfillment of guideline-recommended cardiac rehabilitation targets is unsatisfactory. eHealth offers new possibilities to improve clinical care. Objective: This study aims to assess the effect of a web-based application designed to support adherence to lifestyle advice and self-control of risk factors (intervention) in addition to center-based cardiac rehabilitation, compared with cardiac rehabilitation only (usual care). Methods: All 150 patients participated in cardiac rehabilitation. Patients randomized to the intervention group (n=101) received access to the application for 25 weeks where information about lifestyle (eg, diet and physical activity), risk factors (eg, weight and blood pressure [BP]), and symptoms could be registered. The software provided feedback and lifestyle advice. The primary outcome was a change in submaximal exercise capacity (Watts [W]) between follow-up visits. Secondary outcomes included changes in modifiable risk factors between baseline and follow-up visits and uptake and adherence to the application. Regression analysis was used, adjusting for relevant baseline variables. Results: There was a nonsignificant trend toward a larger change in exercise capacity in the intervention group (n=66) compared with the usual care group (n=40; +14.4, SD 19.0 W, vs +10.3, SD 16.1 W; P=.22). Patients in the intervention group achieved significantly larger BP reduction compared with usual care patients at 2 weeks (systolic ?27.7 vs ?16.4 mm Hg; P=.006) and at 6 to 10 weeks (systolic ?25.3 vs ?16.4 mm Hg; P=.02, and diastolic ?13.4 vs ?9.1 mm Hg; P=.05). A healthy diet index score improved significantly more between baseline and the 2-week follow-up in the intervention group (+2.3 vs +1.4 points; P=.05), mostly owing to an increase in the consumption of fish and fruit. At 6 to 10 weeks, 64% (14/22) versus 46% (5/11) of smokers in the intervention versus usual care groups had quit smoking, and at 12 to 14 months, the respective percentages were 55% (12/22) versus 36% (4/11). However, the number of smokers in the study was low (33/149, 21.9%), and the differences were nonsignificant. Attendance in cardiac rehabilitation was high, with 96% (96/100) of patients in the intervention group and 98% (48/49) of patients receiving usual care only attending 12- to 14-month follow-up. Uptake (logging data in the application at least once) was 86.1% (87/101). Adherence (logging data at least twice weekly) was 91% (79/87) in week 1 and 56% (49/87) in week 25. Conclusions: Complementing cardiac rehabilitation with a web-based application improved BP and dietary habits during the first months after myocardial infarction. A nonsignificant tendency toward better exercise capacity and higher smoking cessation rates was observed. Although the study group was small, these positive trends support further development of eHealth in cardiac rehabilitation. Trial Registration: ClinicalTrials.gov NCT03260582; https://clinicaltrials.gov/ct2/show/NCT03260582 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-018-3118-1 UR - https://www.jmir.org/2022/3/e25224 UR - http://dx.doi.org/10.2196/25224 UR - http://www.ncbi.nlm.nih.gov/pubmed/35357316 ID - info:doi/10.2196/25224 ER - TY - JOUR AU - Marcu, Gabriela AU - Ondersma, J. Steven AU - Spiller, N. Allison AU - Broderick, M. Brianna AU - Kadri, Reema AU - Buis, R. Lorraine PY - 2022/3/30 TI - Barriers and Considerations in the Design and Implementation of Digital Behavioral Interventions: Qualitative Analysis JO - J Med Internet Res SP - e34301 VL - 24 IS - 3 KW - computers KW - mobile apps KW - screening KW - brief interventions KW - diagnosis KW - computer-assisted/methods KW - surveys and questionnaires KW - motivational interviewing KW - therapy KW - implementation KW - qualitative KW - mobile phone N2 - Background: Digital behavioral interventions have become increasingly popular for their ability to support patient diagnosis and treatment, chronic disease self-management, behavior change, and adherence to recommended care. However, digital intervention development is impeded by challenges such as limited technical skills, limited access to developers, and cost. The purpose of this study is to elicit in-depth qualitative feedback from intervention developers who have interest in digital behavioral interventions but lack programming skills regarding the barriers they experience and key considerations in the design and implementation of digital interventions. Objective: This study aims to understand barriers in the design and implementation of digital behavioral interventions, as well as to identify key considerations for researchers who are developing these interventions. Methods: We conducted semistructured qualitative interviews with 18 researchers who had experience either designing (but not coding) digital behavioral interventions or running research studies with them. Participants were a convenience sample of users of the Computerized Intervention Authoring System platform, an existing no-code development platform for building digital intervention content, and were recruited through either direct email solicitation or snowball sampling. All interviews were conducted and recorded over videoconference between February and April 2020. Recordings from interviews were transcribed and thematically analyzed by multiple coders. Results: Interviews were completed with 18 participants and lasted between 24 and 65 (mean 46.9, SD 11.3) minutes. Interviewees were predominantly female (17/18, 94%) and represented different job roles, ranging from researcher to project/study staff. Three key barriers in the development of digital behavior interventions were identified during interviews: lack of cross-disciplinary understanding; variability in recipients? technology access, infrastructure, and literacy; and the idea that evidence-based in-person interactions do not translate directly to digital interactions. Interviewees identified several key considerations that interventionists learned to prioritize, which have the potential to overcome these barriers and lead to successful interventions. Conclusions: Barriers in the development of digital behavioral interventions are often created by a lack of cross-disciplinary understanding, which can lead to difficulties conceptualizing interventions, unrealistic expectations in terms of cost, and confusion about the development process. Moreover, concerns about research study participant characteristics and access to technology, as well as the translation of in-person interventions to digital, are apparent. Appropriate training in how to work with software development teams may help future digital behavior intervention creators overcome these barriers and may lead to new, exciting innovations in this space. UR - https://www.jmir.org/2022/3/e34301 UR - http://dx.doi.org/10.2196/34301 UR - http://www.ncbi.nlm.nih.gov/pubmed/35353043 ID - info:doi/10.2196/34301 ER - TY - JOUR AU - Marcu, Gabriela AU - Ondersma, J. Steven AU - Spiller, N. Allison AU - Broderick, M. Brianna AU - Kadri, Reema AU - Buis, R. Lorraine PY - 2022/3/30 TI - The Perceived Benefits of Digital Interventions for Behavioral Health: Qualitative Interview Study JO - J Med Internet Res SP - e34300 VL - 24 IS - 3 KW - computers KW - mobile apps KW - screening KW - brief interventions KW - diagnosis KW - computer-assisted/methods KW - surveys and questionnaires KW - motivational interviewing KW - therapy KW - implementation KW - qualitative KW - mobile phone N2 - Background: Digital interventions have gained momentum in terms of behavioral health. However, owing to lacking standard approaches or tools for creating digital behavioral interventions, clinical researchers follow widely varying conceptions of how best to go about digital intervention development. Researchers also face significant cost-, time-, and expertise-related challenges in digital intervention development. Improving the availability of tools and guidance for researchers will require a thorough understanding of the motivations and needs of researchers seeking to create digital interventions. Objective: This study aims to understand the perceptions of behavioral researchers toward digital interventions, and inform the use of these interventions, by documenting the reasons why researchers are increasingly focusing their efforts on digital interventions and their perspectives on the perceived benefits that digital approaches can provide for researchers and intervention recipients. Methods: We conducted semistructured qualitative interviews with 18 researchers who had experience designing digital behavioral interventions or running studies with them. A convenience sample of interviewees was recruited from among users of the Computerized Intervention Authoring System platform, a web-based tool that facilitates the process of creating and deploying digital interventions in behavioral research. Interviews were conducted over teleconference between February and April 2020. Recordings from the interviews were transcribed and thematically analyzed by multiple coders. Results: Interviews were completed with 18 individuals and lasted between 24 and 65 (mean 46.9, SD 11.3) minutes. Interviewees were predominantly female (17/18, 94%) and represented different job roles, ranging from researcher to project or study staff. Four major themes came out of the interviews concerning the benefits of digital interventions for behavioral health: convenience and flexibility for interventionists and recipients, support for implementing evidence-based interventions with fidelity, scaling and improving access to interventions, and getting a foot in the door despite stigma and disenfranchisement. Conclusions: Interviewees described a number of important potential benefits of digital interventions, particularly with respect to scientific rigor, scalability, and overcoming barriers to reaching more people. There are complex considerations with regard to translating behavior change strategies into digital forms of delivery, and interventionists make individual, sometimes unexpected, choices with minimal evidence of their relative effectiveness. Future research should investigate how behavioral researchers can be supported in making these choices toward usability, ease of access, and approachability of digital interventions. Our study underscores the need for authoring platforms that can facilitate the process of creating and deploying digital interventions to reach their full potential for interventionists and recipients alike. UR - https://www.jmir.org/2022/3/e34300 UR - http://dx.doi.org/10.2196/34300 UR - http://www.ncbi.nlm.nih.gov/pubmed/35353045 ID - info:doi/10.2196/34300 ER - TY - JOUR AU - Milne-Ives, Madison AU - Homer, Sophie AU - Andrade, Jackie AU - Meinert, Edward PY - 2022/3/29 TI - Associations Between Behavior Change Techniques and Engagement With Mobile Health Apps: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e35172 VL - 11 IS - 3 KW - engagement KW - behavior change techniques KW - telemedicine KW - mobile apps N2 - Background: Digitally enabled care along with an emphasis on self-management of health is steadily growing. Mobile health apps provide a promising means of supporting health behavior change; however, engagement with them is often poor and evidence of their impact on health outcomes is lacking. As engagement is a key prerequisite to health behavior change, it is essential to understand how engagement with mobile health apps and their target health behaviors can be better supported. Although the importance of engagement is emphasized strongly in the literature, the understanding of how different components of engagement are associated with specific techniques that aim to change behaviors is lacking. Objective: The purpose of this systematic review protocol is to provide a synthesis of the associations between various behavior change techniques (BCTs) and the different components and measures of engagement with mobile health apps. Methods: The review protocol was structured using the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) and the PICOS (Population, Intervention, Comparator, Outcome, and Study type) frameworks. The following seven databases will be systematically searched: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, ScienceDirect, Cochrane Library, and Web of Science. Title and abstract screening, full-text review, and data extraction will be conducted by 2 independent reviewers. Data will be extracted into a predetermined form, any disagreements in screening or data extraction will be discussed, and a third reviewer will be consulted if consensus cannot be reached. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias 2 and the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tools; descriptive and thematic analyses will be conducted to summarize the relationships between BCTs and the different components of engagement. Results: The systematic review has not yet started. It is expected to be completed and submitted for publication by May 2022. Conclusions: This systematic review will summarize the associations between different BCTs and various components and measures of engagement with mobile health apps. This will help identify areas where further research is needed to examine BCTs that could potentially support effective engagement and help inform the design and evaluation of future mobile health apps. Trial Registration: PROSPERO CRD42022312596; https://tinyurl.com/nhzp8223 International Registered Report Identifier (IRRID): PRR1-10.2196/35172 UR - https://www.researchprotocols.org/2022/3/e35172 UR - http://dx.doi.org/10.2196/35172 UR - http://www.ncbi.nlm.nih.gov/pubmed/35348460 ID - info:doi/10.2196/35172 ER - TY - JOUR AU - Hanano, Maria AU - Rith-Najarian, Leslie AU - Boyd, Meredith AU - Chavira, Denise PY - 2022/3/28 TI - Measuring Adherence Within a Self-Guided Online Intervention for Depression and Anxiety: Secondary Analyses of a Randomized Controlled Trial JO - JMIR Ment Health SP - e30754 VL - 9 IS - 3 KW - self-guided KW - adherence KW - depression KW - anxiety KW - online intervention N2 - Background: Self-guided online interventions offer users the ability to participate in an intervention at their own pace and address some traditional service barriers (eg, attending in-person appointments, cost). However, these interventions suffer from high dropout rates, and current literature provides little guidance for defining and measuring online intervention adherence as it relates to clinical outcomes. Objective: This study aims to develop and test multiple measures of adherence to a specific self-guided online intervention, as guided by best practices from the literature. Methods: We conducted secondary analyses on data from a randomized controlled trial of an 8-week online cognitive behavioral program that targets depression and anxiety in college students. We defined multiple behavioral and attitudinal adherence measures at varying levels of effort (ie, low, moderate, and high). Linear regressions were run with adherence terms predicting improvement in the primary outcome measure, the 21-item Depression, Anxiety, and Stress Scale (DASS-21). Results: Of the 947 participants, 747 initiated any activity and 449 provided posttest data. Results from the intent-to-treat sample indicated that high level of effort for behavioral adherence significantly predicted symptom change (F4,746=17.18, P<.001; and ?=?.26, P=.04). Moderate level of effort for attitudinal adherence also significantly predicted symptom change (F4,746=17.25, P<.001; and ?=?.36, P=.03). Results differed in the initiators-only sample, such that none of the adherence measures significantly predicted symptom change (P=.09-.27). Conclusions: Our findings highlight the differential results of dose-response models testing adherence measures in predicting clinical outcomes. We summarize recommendations that might provide helpful guidance to future researchers and intervention developers aiming to investigate online intervention adherence. Trial Registration: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/ct2/show/NCT04361045 UR - https://mental.jmir.org/2022/3/e30754 UR - http://dx.doi.org/10.2196/30754 UR - http://www.ncbi.nlm.nih.gov/pubmed/35343901 ID - info:doi/10.2196/30754 ER - TY - JOUR AU - Yau, W. Kiana AU - Tang, S. Tricia AU - Görges, Matthias AU - Pinkney, Susan AU - Kim, D. Annie AU - Kalia, Angela AU - Amed, Shazhan PY - 2022/3/28 TI - Effectiveness of Mobile Apps in Promoting Healthy Behavior Changes and Preventing Obesity in Children: Systematic Review JO - JMIR Pediatr Parent SP - e34967 VL - 5 IS - 1 KW - childhood obesity KW - mobile health KW - health behaviors KW - prevention KW - study design KW - systematic review KW - mobile phone N2 - Background: Mobile apps have been increasingly incorporated into healthy behavior promotion interventions targeting childhood obesity. However, their effectiveness remains unclear. Objective: This paper aims to conduct a systematic review examining the effectiveness of mobile apps aimed at preventing childhood obesity by promoting health behavior changes in diet, physical activity, or sedentary behavior in children aged 8 to 12 years. Methods: MEDLINE, Embase, PsycINFO, CINAHL, and ERIC were systematically searched for peer-reviewed primary studies from January 2008 to July 2021, which included children aged 8 to 12 years; involved mobile app use; and targeted at least one obesity-related factor, including diet, physical activity, or sedentary behavior. Data extraction and risk of bias assessments were conducted by 2 authors. Results: Of the 13 studies identified, most used a quasi-experimental design (n=8, 62%). Significant improvements in physical activity (4/8, 50% studies), dietary outcomes (5/6, 83% studies), and BMI (2/6, 33% studies) were reported. All 6 multicomponent interventions and 57% (4/7) of standalone interventions reported significant outcomes in ?1 behavioral change outcome measured (anthropometric, physical activity, dietary, and screen time outcomes). Gamification, behavioral monitoring, and goal setting were common features of the mobile apps used in these studies. Conclusions: Apps for health behavior promotion interventions have the potential to increase the adoption of healthy behaviors among children; however, their effectiveness in improving anthropometric measures remains unclear. Further investigation of studies that use more rigorous study designs, as well as mobile apps as a standalone intervention, is needed. UR - https://pediatrics.jmir.org/2022/1/e34967 UR - http://dx.doi.org/10.2196/34967 UR - http://www.ncbi.nlm.nih.gov/pubmed/35343908 ID - info:doi/10.2196/34967 ER - TY - JOUR AU - Humphrey, Gayl AU - Chu, Ting Joanna AU - Ruwhiu-Collins, Rebecca AU - Erick-Peleti, Stephanie AU - Dowling, Nicki AU - Merkouris, Stephanie AU - Newcombe, David AU - Rodda, Simone AU - Ho, Elsie AU - Nosa, Vili AU - Parag, Varsha AU - Bullen, Christopher PY - 2022/3/25 TI - Adapting an Evidence-Based e-Learning Cognitive Behavioral Therapy Program Into a Mobile App for People Experiencing Gambling-Related Problems: Formative Study JO - JMIR Form Res SP - e32940 VL - 6 IS - 3 KW - gambling KW - CBT KW - mHealth KW - co-design KW - smartphone KW - self-directed KW - behavior change KW - engagement KW - mobile phone N2 - Background: Many people who experience harm and problems from gambling do not seek treatment from gambling treatment services because of personal and resource barriers. Mobile health (mHealth) interventions are widely used across diverse health care areas and populations. However, there are few in the gambling harm field, despite their potential as an additional modality for delivering treatment and support. Objective: This study aims to understand the needs, preferences, and priorities of people experiencing gambling harms and who are potential end users of a cognitive behavioral therapy mHealth intervention to inform design, features, and functions. Methods: Drawing on a mixed methods approach, we used creators and domain experts to review the GAMBLINGLESS web-based program and convert it into an mHealth prototype. Each module was reviewed against the original evidence base to maintain its intended fidelity and conceptual integrity. Early wireframes, design ideas (look, feel, and function), and content examples were developed to initiate discussions with end users. Using a cocreation process with a young adult, a M?ori, and a Pasifika peoples group, all with experiences of problem or harmful gambling, we undertook 6 focus groups: 2 cycles per group. In each focus group, participants identified preferences, features, and functions for inclusion in the final design and content of the mHealth intervention. Results: Over 3 months, the GAMBLINGLESS web-based intervention was reviewed and remapped from 4 modules to 6. This revised program is based on the principles underpinning the transtheoretical model, in which it is recognized that some end users will be more ready to change than others. Change is a process that unfolds over time, and a nonlinear progression is common. Different intervention pathways were identified to reflect the end users? stage of change. In all, 2 cycles of focus groups were then conducted, with 30 unique participants (13 M?ori, 9 Pasifika, and 8 young adults) in the first session and 18 participants (7 M?ori, 6 Pasifika, and 5 young adults) in the second session. Prototype examples demonstrably reflected the focus group discussions and ideas, and the features, functions, and designs of the Manaaki app were finalized. Attributes such as personalization, cultural relevance, and positive framing were identified as the key. Congruence of the final app attributes with the conceptual frameworks of the original program was also confirmed. Conclusions: Those who experience gambling harms may not seek help. Developing and demonstrating the effectiveness of new modalities to provide treatment and support are required. mHealth has the potential to deliver interventions directly to the end user. Weaving the underpinning theory and existing evidence of effective treatment with end-user input into the design and development of mHealth interventions does not guarantee success. However, it provides a foundation for framing the intervention?s mechanism, context, and content, and arguably provides a greater chance of demonstrating effectiveness. UR - https://formative.jmir.org/2022/3/e32940 UR - http://dx.doi.org/10.2196/32940 UR - http://www.ncbi.nlm.nih.gov/pubmed/35108213 ID - info:doi/10.2196/32940 ER - TY - JOUR AU - Ritola, Ville AU - Lipsanen, Olavi Jari AU - Pihlaja, Satu AU - Gummerus, Eero-Matti AU - Stenberg, Jan-Henry AU - Saarni, Suoma AU - Joffe, Grigori PY - 2022/3/24 TI - Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Nationwide Routine Care: Effectiveness Study JO - J Med Internet Res SP - e29384 VL - 24 IS - 3 KW - CBT KW - iCBT KW - cognitive behavioral therapy KW - routine care KW - generalized anxiety disorder KW - internet KW - web-based KW - digital health KW - mental health N2 - Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficacious for generalized anxiety disorder (GAD), but few studies are yet to report its effectiveness in routine care. Objective: In this study, we aim to examine whether a new 12-session iCBT program for GAD is effective in nationwide routine care. Methods: We administered a specialized, clinic-delivered, therapist-supported iCBT for GAD in 1099 physician-referred patients. The program was free of charge for patients, and the completion time was not predetermined. We measured symptoms with web-based questionnaires. The primary measure of anxiety was the GAD 7-item scale (GAD-7); secondary measures were, for pathological worry, the Penn State Worry Questionnaire and, for anxiety and impairment, the Overall Anxiety Severity and Impairment Scale. Results: Patients completed a mean 7.8 (SD 4.2; 65.1%) of 12 sessions, and 44.1% (485/1099) of patients completed all sessions. The effect size in the whole sample for GAD-7 was large (Cohen d=0.97, 95% CI 0.88-1.06). For completers, effect sizes were very large (Cohen d=1.34, 95% CI 1.25-1.53 for GAD-7; Cohen d=1.14, 95% CI 1.00-1.27 for Penn State Worry Questionnaire; and Cohen d=1.23, 95% CI 1.09-1.37 for Overall Anxiety Severity and Impairment Scale). Noncompleters also benefited from the treatment. Greater symptomatic GAD-7?measured relief was associated with more completed sessions, older age, and being referred from private or occupational care. Of the 894 patients with a baseline GAD-7 score ?10, approximately 421 (47.1%) achieved reliable recovery. Conclusions: This nationwide, free-of-charge, therapist-supported HUS Helsinki University Hospital?iCBT for GAD was effective in routine care, but further research must establish effectiveness against other treatments and optimize the design of iCBT for GAD for different patient groups and individual patients. UR - https://www.jmir.org/2022/3/e29384 UR - http://dx.doi.org/10.2196/29384 UR - http://www.ncbi.nlm.nih.gov/pubmed/35323119 ID - info:doi/10.2196/29384 ER - TY - JOUR AU - Castela Forte, José AU - Gannamani, Rahul AU - Folkertsma, Pytrik AU - Kumaraswamy, Sridhar AU - Mount, Sarah AU - van Dam, Sipko AU - Hoogsteen, Jan PY - 2022/3/23 TI - Changes in Blood Lipid Levels After a Digitally Enabled Cardiometabolic Preventive Health Program: Pre-Post Study in an Adult Dutch General Population Cohort JO - JMIR Cardio SP - e34946 VL - 6 IS - 1 KW - cholesterol KW - lifestyle intervention KW - prevention KW - hypercholesterolemia KW - digital health N2 - Background: Despite widespread education, many individuals fail to follow basic health behaviors such as consuming a healthy diet and exercising. Positive changes in lifestyle habits are associated with improvements in multiple cardiometabolic health risk factors, including lipid levels. Digital lifestyle interventions have been suggested as a viable complement or potential alternative to conventional health behavior change strategies. However, the benefit of digital preventive interventions for lipid levels in a preventive health context remains unclear. Objective: This observational study aimed to determine how the levels of lipids, namely total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, non-HDL cholesterol, and triglycerides, changed over time in a Dutch general population cohort undergoing a digital preventive health program. Moreover, we looked to establish associations between lifestyle factors at baseline and lipid levels. Methods: We included 348 adults from the Dutch general population who underwent a digitally enabled preventive health program at Ancora Health between January 2020 and October 2021. Upon enrollment, participants underwent a baseline assessment involving a comprehensive lifestyle questionnaire, a blood biochemistry panel, physical measurements, and cardiopulmonary fitness measurements. Thereafter, users underwent a lifestyle coaching program and could access the digital application to register and track health behaviors, weight, and anthropometric data at any time. Lipid levels were categorized as normal, elevated, high, and clinical dyslipidemia according to accepted international standards. If at least one lipid marker was high or HDL was low, participants received specific coaching and advice for cardiometabolic health. We retrospectively analyzed the mean and percentage changes in lipid markers in users who were remeasured after a cardiometabolic health?focused intervention, and studied the association between baseline user lifestyle characteristics and having normal lipid levels. Results: In our cohort, 199 (57.2%) participants had dyslipidemia at baseline, of which 104 participants were advised to follow a cardiometabolic health?focused intervention. Eating more amounts of favorable food groups and being more active were associated with normal lipid profiles. Among the participants who underwent remeasurement 9 months after intervention completion, 57% (17/30), 61% (19/31), 56% (15/27), 82% (9/11), and 100% (8/8) showed improvements at remeasurement for total, LDL, HDL, and non-HDL cholesterol, and triglycerides, respectively. Moreover, between 35.3% and 77.8% showed a return to normal levels. In those with high lipid levels at baseline, total cholesterol decreased by 0.5 mmol/L (7.5%), LDL cholesterol decreased by 0.39 mmol/L (10.0%), non-HDL cholesterol decreased by 0.44 mmol/L (8.3%), triglycerides decreased by 0.97 mmol/L (32.0%), and HDL increased by 0.17 mmol/L (15.6%), after the intervention. Conclusions: A cardiometabolic screening program in a general population cohort identified a significant portion of individuals with subclinical and clinical lipid levels. Individuals who, after screening, actively engaged in a cardiometabolic health?focused lifestyle program improved their lipid levels. UR - https://cardio.jmir.org/2022/1/e34946 UR - http://dx.doi.org/10.2196/34946 UR - http://www.ncbi.nlm.nih.gov/pubmed/35319473 ID - info:doi/10.2196/34946 ER - TY - JOUR AU - Jensen, Skov Esben AU - Ladegaard, Nicolai AU - Mellentin, Isabella Angelina AU - Ebert, Daniel David AU - Titzler, Ingrid AU - Araya, Ricardo AU - Cerga Pashoja, Arlinda AU - Hazo, Jean-Baptiste AU - Holtzmann, Jérôme AU - Cieslak, Roman AU - Smoktunowicz, Ewelina AU - Baños, Rosa AU - Herrero, Rocio AU - García-Palacios, Azucena AU - Botella, Cristina AU - Berger, Thomas AU - Krieger, Tobias AU - Holmberg, Theresa Trine AU - Topooco, Naira AU - Andersson, Gerhard AU - van Straten, Annemieke AU - Kemmeren, Lise AU - Kleiboer, Annet AU - Riper, Heleen AU - Mathiasen, Kim PY - 2022/3/21 TI - Effect of Sleep Disturbance Symptoms on Treatment Outcome in Blended Cognitive Behavioral Therapy for Depression (E-COMPARED Study): Secondary Analysis JO - J Med Internet Res SP - e30231 VL - 24 IS - 3 KW - blended care KW - bCBT KW - cognitive behavioral therapy KW - digital intervention KW - major depressive disorder KW - sleep disturbance KW - sleep disorder KW - mental health KW - digital health KW - mobile phone N2 - Background: Sleep disturbance symptoms are common in major depressive disorder (MDD) and have been found to hamper the treatment effect of conventional face-to-face psychological treatments such as cognitive behavioral therapy. To increase the dissemination of evidence-based treatment, blended cognitive behavioral therapy (bCBT) consisting of web-based and face-to-face treatment is on the rise for patients with MDD. To date, no study has examined whether sleep disturbance symptoms have an impact on bCBT treatment outcomes and whether it affects bCBT and treatment-as-usual (TAU) equally. Objective: The objectives of this study are to investigate whether baseline sleep disturbance symptoms have an impact on treatment outcomes independent of treatment modality and whether sleep disturbance symptoms impact bCBT and TAU in routine care equally. Methods: The study was based on data from the E-COMPARED (European Comparative Effectiveness Research on Blended Depression Treatment Versus Treatment-as-Usual) study, a 2-arm, multisite, parallel randomized controlled, noninferiority trial. A total of 943 outpatients with MDD were randomized to either bCBT (476/943, 50.5%) or TAU consisting of routine clinical MDD treatment (467/943, 49.5%). The primary outcome of this study was the change in depression symptom severity at the 12-month follow-up. The secondary outcomes were the change in depression symptom severity at the 3- and 6-month follow-up and MDD diagnoses at the 12-month follow-up, assessed using the Patient Health Questionnaire-9 and Mini-International Neuropsychiatric Interview, respectively. Mixed effects models were used to examine the association of sleep disturbance symptoms with treatment outcome and treatment modality over time. Results: Of the 943 patients recruited for the study, 558 (59.2%) completed the 12-month follow-up assessment. In the total sample, baseline sleep disturbance symptoms did not significantly affect change in depressive symptom severity at the 12-month follow-up (?=.16, 95% CI ?0.04 to 0.36). However, baseline sleep disturbance symptoms were negatively associated with treatment outcome for bCBT (?=.49, 95% CI 0.22-0.76) but not for TAU (?=?.23, 95% CI ?0.50 to 0.05) at the 12-month follow-up, even when adjusting for baseline depression symptom severity. The same result was seen for the effect of sleep disturbance symptoms on the presence of depression measured with Mini-International Neuropsychiatric Interview at the 12-month follow-up. However, for both treatment formats, baseline sleep disturbance symptoms were not associated with depression symptom severity at either the 3- (?=.06, 95% CI ?0.11 to 0.23) or 6-month (?=.09, 95% CI ?0.10 to 0.28) follow-up. Conclusions: Baseline sleep disturbance symptoms may have a negative impact on long-term treatment outcomes in bCBT for MDD. This effect was not observed for TAU. These findings suggest that special attention to sleep disturbance symptoms might be warranted when MDD is treated with bCBT. Future studies should investigate the effect of implementing modules specifically targeting sleep disturbance symptoms in bCBT for MDD to improve long-term prognosis. UR - https://www.jmir.org/2022/3/e30231 UR - http://dx.doi.org/10.2196/30231 UR - http://www.ncbi.nlm.nih.gov/pubmed/35311687 ID - info:doi/10.2196/30231 ER - TY - JOUR AU - Idris, Y. Muhammed AU - Alema-Mensah, Ernest AU - Olorundare, Elizabeth AU - Mohammad, Mohammad AU - Brown, Michelle AU - Ofili, Elizabeth AU - Pemu, Priscilla PY - 2022/3/18 TI - Exploring the Discursive Emphasis on Patients and Coaches Who Participated in Technology-Assisted Diabetes Self-management Education: Clinical Implementation Study of Health360x JO - J Med Internet Res SP - e23535 VL - 24 IS - 3 KW - self-management KW - structural topic modeling KW - coaching KW - diabetes KW - minority populations KW - mobile phone N2 - Background: A critical unmet need for underserved patients with diabetes is regular access to sufficient support for diabetes self-management. Although advances in digital technologies have made way for eHealth applications that provide a scalable path for tailored interventions for self-management of chronic conditions, health and digital literacy has remained an obstacle to leveraging these technologies for effective diabetes self-management education. Studies have shown that the availability of coaches helps to maintain engagement in internet-based studies and improves self-efficacy for behavior change. However, little is known about the substances involved in these interactions. Objective: This study aims to compare the content of conversations between patient?coach pairs that achieved their self-management goals and those that did not. The context is a clinical implementation study of diabetes self-management behavior change using Health360x within the practices of the Morehouse Choice Accountable Care Organization in the Atlanta metro area. Health360x is a coach-assisted consumer health information technology designed to support self-management skills acquisition and behavior among underserved, high-risk patients with diabetes. Methods: We provide a novel analysis of the discursive emphasis on patients and coaches. We examined transcripts of visits using a structural topic model to estimate topic content and prevalence as a function of patient and coach characteristics. We compared topics between patient?coach pairs that achieved diabetes-related self-management goals and those who did not. We also estimated a regression in which utterances are the units, the dependent variable is the proportion of an utterance that is about a given topic, and the independent variables are speaker types and explored other themes. Results: Transcripts from 50 patients who were recruited and consented, starting in February 2015, were analyzed. A total of 44 topics were estimated for patient?coach pairs that achieved their intended health goals and 50 topics for those who did not. Analysis of the structural topic model results indicated that coaches in patient?coach pairs that were able to achieve self-management goals provided more contextual feedback and probed into patients? experience with technology and trust in consumer information technologies. We also found that discussions around problem areas and stress, support (?Coach=.015; P<.001), initial visits (?Coach=.02; P<.001), problems with technology (?Coach=.01; P<.001), health eating goals (?Coach=.01; P=.04), diabetes knowledge (?Coach=.02; P<.001), managing blood sugar (?Coach=.03; P<.001), and using Health360x (?Coach=.003; P=.03) were dominated by coaches. Conclusions: Coach-facilitated, technology-based diabetes self-management education can help underserved patients with diabetes. Our use of topic modeling in this application sheds light on the actual dynamics in conversations between patients and coaches. Knowledge of the key elements for successful coach?patient interactions based on the analysis of transcripts could be applied to understanding everyday patient?provider encounters, given the recent paradigm shift around the use of telehealth. UR - https://www.jmir.org/2022/3/e23535 UR - http://dx.doi.org/10.2196/23535 UR - http://www.ncbi.nlm.nih.gov/pubmed/35302506 ID - info:doi/10.2196/23535 ER - TY - JOUR AU - Denecke, Kerstin AU - Schmid, Nicole AU - Nüssli, Stephan PY - 2022/3/10 TI - Implementation of Cognitive Behavioral Therapy in e?Mental Health Apps: Literature Review JO - J Med Internet Res SP - e27791 VL - 24 IS - 3 KW - cognitive behavioral therapy KW - mHealth KW - e?mental health KW - chatbot KW - mobile phone N2 - Background: To address the matter of limited resources for treating individuals with mental disorders, e?mental health has gained interest in recent years. More specifically, mobile health (mHealth) apps have been suggested as electronic mental health interventions accompanied by cognitive behavioral therapy (CBT). Objective: This study aims to identify the therapeutic aspects of CBT that have been implemented in existing mHealth apps and the technologies used. From these, we aim to derive research gaps that should be addressed in the future. Methods: Three databases were screened for studies on mHealth apps in the context of mental disorders that implement techniques of CBT: PubMed, IEEE Xplore, and ACM Digital Library. The studies were independently selected by 2 reviewers, who then extracted data from the included studies. Data on CBT techniques and their technical implementation in mHealth apps were synthesized narratively. Results: Of the 530 retrieved citations, 34 (6.4%) studies were included in this review. mHealth apps for CBT exploit two groups of technologies: technologies that implement CBT techniques for cognitive restructuring, behavioral activation, and problem solving (exposure is not yet realized in mHealth apps) and technologies that aim to increase user experience, adherence, and engagement. The synergy of these technologies enables patients to self-manage and self-monitor their mental state and access relevant information on their mental illness, which helps them cope with mental health problems and allows self-treatment. Conclusions: There are CBT techniques that can be implemented in mHealth apps. Additional research is needed on the efficacy of the mHealth interventions and their side effects, including inequalities because of the digital divide, addictive internet behavior, lack of trust in mHealth, anonymity issues, risks and biases for user groups and social contexts, and ethical implications. Further research is also required to integrate and test psychological theories to improve the impact of mHealth and adherence to the e?mental health interventions. UR - https://www.jmir.org/2022/3/e27791 UR - http://dx.doi.org/10.2196/27791 UR - http://www.ncbi.nlm.nih.gov/pubmed/35266875 ID - info:doi/10.2196/27791 ER - TY - JOUR AU - Berry, Alice AU - McClellan, Carey AU - Wanless, Ben AU - Walsh, Nicola PY - 2022/3/8 TI - A Tailored App for the Self-management of Musculoskeletal Conditions: Evidencing a Logic Model of Behavior Change JO - JMIR Form Res SP - e32669 VL - 6 IS - 3 KW - musculoskeletal KW - supported self-management KW - behavior change KW - digital health intervention KW - behavior change wheel N2 - Background: Musculoskeletal conditions such as joint pain are a growing problem, affecting 18.8 million people in the United Kingdom. Digital health interventions (DHIs) are a potentially effective way of delivering information and supporting self-management. It is vital that the development of such interventions is transparent and can illustrate how individual components work, how they link back to the theoretical constructs they are attempting to change, and how this might influence outcomes. getUBetter is a DHI developed to address the lack of personalized, supported self-management tools available to patients with musculoskeletal conditions by providing knowledge, skills, and confidence to navigate through a self-management journey. Objective: The aim of this study was to map a logic model of behavior change for getUBetter to illustrate how the content and functionality of the DHI are aligned with recognized behavioral theory, effective behavior change techniques, and clinical guidelines. Methods: A range of behavior change models and frameworks were used, including the behavior change wheel and persuasive systems design framework, to map the logic model of behavior change underpinning getUBetter. The three main stages included understanding the behavior the intervention is attempting to change, identifying which elements of the intervention might bring about the desired change in behavior, and describing intervention content and how this can be optimally implemented. Results: The content was mapped to 25 behavior change techniques, including information about health consequences, instruction on how to perform a behavior, reducing negative emotions, and verbal persuasion about capability. Mapping to the persuasive system design framework illustrated the use of a number of persuasive design principles, including tailoring, personalization, simulation, and reminders. Conclusions: This process enabled the proposed mechanisms of action and theoretical foundations of getUBetter to be comprehensively described, highlighting the key techniques used to support patients to self-manage their condition. These findings provide guidance for the ongoing evaluation of the effectiveness (including quality of engagement) of the intervention and highlight areas that might be strengthened in future iterations. UR - https://formative.jmir.org/2022/3/e32669 UR - http://dx.doi.org/10.2196/32669 UR - http://www.ncbi.nlm.nih.gov/pubmed/35258462 ID - info:doi/10.2196/32669 ER - TY - JOUR AU - Haladay, Douglas AU - Ditwiler, Edgeworth Rebecca AU - Klein, B. Aimee AU - Miro, Rebecca AU - Lazinski, Matthew AU - Swisher, Lee Laura AU - Beckstead, Jason AU - Wolfson, Jay AU - Hardwick, Dustin PY - 2022/3/7 TI - Goal Attainment Scaling in Outpatient Physical Therapy for Chronic Low Back Pain: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e32457 VL - 11 IS - 3 KW - goal attainment scaling KW - goal setting KW - low back pain KW - chronic pain KW - physical therapy KW - patient engagement KW - adherence KW - rehabilitation KW - physical therapist N2 - Background: Patient engagement in decisions regarding their health care may lead to improved outcomes and improved adherence to treatment plans. While there are several options for involving patients in their health care, goal setting is a readily accessible method for physical therapists to increase the involvement of patients in health care decisions. Physical therapy goals are often generated by health care providers based on subjective information or standardized, fixed-item, patient-reported outcome measures. However, these outcome measures may not fully reveal the activity and participation limitations of individual patients. Goal attainment scaling (GAS) is a patient-centered approach that allows patients to set meaningful goals. While GAS has been shown to be reliable, valid, and sensitive to change in various populations, there is limited evidence in the United States on utilizing GAS in physical therapy for patients with chronic low back pain (LBP). Objective: The purpose of this paper is to describe the protocol for a study to (1) develop a way to apply GAS procedures for physical therapists treating patients with chronic LBP in the United States and (2) test the feasibility of applying GAS procedures for chronic LBP in an outpatient physical therapy setting. Methods: This study used a mixed methods design with 2 phases: qualitative and quantitative. The qualitative phase of the study employed focus groups of patients with chronic LBP to identify an inventory of goals that were important and measurable. A series of prompts was developed from this inventory to assist physical therapists in collaboratively establishing goals with patients in a clinical setting. The quantitative phase of the study pilot-tested the inventory developed in the qualitative phase in patients with chronic LBP to determine feasibility, reliability, validity, and responsiveness. We also plan to compare how well GAS reveals change over time relative to traditional, fixed-item, patient-reported measures. Results: Phase 1 data collection was completed in June 2020, while data collection for phase 2 was performed between March 2021 and December 2021. We anticipate that this study will demonstrate that GAS can be implemented successfully by outpatient physical therapists, and that it will demonstrate clinically important changes in patients with chronic LBP. Conclusions: GAS represents an opportunity for patient-centered care in the physical therapy management of chronic LBP. While GAS is not new, it has never been studied in real-world physical therapy for chronic LBP in a clinical setting. Due to unique time and productivity constraints, for GAS to be successfully implemented in this environment, we must demonstrate that clinicians can be trained efficiently and reliably, that GAS can be implemented in a clinical setting in under 15 minutes, and that GAS is able to detect clinically meaningful changes in patient outcomes. International Registered Report Identifier (IRRID): DERR1-10.2196/32457 UR - https://www.researchprotocols.org/2022/3/e32457 UR - http://dx.doi.org/10.2196/32457 UR - http://www.ncbi.nlm.nih.gov/pubmed/35254282 ID - info:doi/10.2196/32457 ER - TY - JOUR AU - Robinson, Anna AU - Husband, Andrew AU - Slight, Robert AU - Slight, P. Sarah PY - 2022/3/4 TI - Designing Digital Health Technology to Support Patients Before and After Bariatric Surgery: Qualitative Study Exploring Patient Desires, Suggestions, and Reflections to Support Lifestyle Behavior Change JO - JMIR Hum Factors SP - e29782 VL - 9 IS - 1 KW - digital technology KW - eHealth KW - mHealth KW - bariatric surgery KW - behavior change KW - qualitative research KW - co-design KW - perioperative care KW - mobile phone N2 - Background: A patient?s capability, motivation, and opportunity to change their lifestyle are determinants of successful outcomes following bariatric surgery. Lifestyle changes before and after surgery, including improved dietary intake and physical activity levels, have been associated with greater postsurgical weight loss and improved long-term health. Integrating patient-centered digital technologies within the bariatric surgical pathway could form part of an innovative strategy to promote and sustain healthier behaviors, and provide holistic patient support, to improve surgical success. Previous research focused on implementing digital technologies and measuring effectiveness in surgical cohorts. However, there is limited work concerning the desires, suggestions, and reflections of patients undergoing bariatric surgery. This qualitative investigation explores patients? perspectives on technology features that would support behavior changes during the pre- and postoperative periods, to potentially maintain long-term healthy lifestyles following surgery. Objective: This study aims to understand how digital technologies can be used to support patient care during the perioperative journey to improve weight loss outcomes and surgical success, focusing on what patients want from digital technologies, how they want to use them, and when they would be of most benefit during their surgical journey. Methods: Patients attending bariatric surgery clinics in one hospital in the North of England were invited to participate. Semistructured interviews were conducted with purposively sampled pre- and postoperative patients to discuss lifestyle changes and the use of digital technologies to complement their care. The interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data. Ethical approval was obtained from the National Health Service Health Research Authority. Results: A total of 20 patients were interviewed (preoperative phase: 40% (8/20); postoperative phase: 60% (12/20). A total of 4 overarching themes were developed and related to the optimization of technology functionality. These centered on providing tailored content and support; facilitating self-monitoring and goal setting; delivering information in an accessible, trusted, and usable manner; and meeting patient information-seeking and engagement needs during the surgical pathway. Functionalities that delivered personalized feedback and postoperative follow-up were considered beneficial. Individualized goal setting functionality could support a generation of digitally engaged patients with bariatric conditions as working toward achievable targets was deemed an effective strategy for motivating behavior change. The creation of digital package of care checklists between patients and clinicians was a novel finding from this study. Conclusions: Perceptions of patients undergoing bariatric surgery validated the integration of digital technologies within the surgical pathway, offering enhanced connectedness and support. Recommendations are made relating to the design, content, and functionality of digital interventions to best address the needs of this cohort. These findings have the potential to influence the co-design and integration of person-centered, perioperative technologies. UR - https://humanfactors.jmir.org/2022/1/e29782 UR - http://dx.doi.org/10.2196/29782 UR - http://www.ncbi.nlm.nih.gov/pubmed/35254271 ID - info:doi/10.2196/29782 ER - TY - JOUR AU - Simon, L. Stacey AU - Kaar, L. Jill AU - Talker, Ishaah AU - Reich, Jennifer PY - 2022/3/3 TI - Evidence-Based Behavioral Strategies in Smartphone Apps for Children?s Sleep: Content Analysis JO - JMIR Pediatr Parent SP - e32129 VL - 5 IS - 1 KW - pediatrics KW - technology KW - smartphones KW - health behavior KW - sleep applications KW - children KW - mobile health KW - mHealth KW - smartphone applications KW - health applications KW - sleep disorders KW - sleep problems KW - developer descriptions KW - apps N2 - Background: Empirically supported treatments for pediatric sleep problems exist, but many families turn to other sources for help with their children?s sleep, such as smartphone apps. Sleep apps are easy for families to access, but little evidence exists regarding the validity of the services and information provided in the developer descriptions of the apps. Objective: The goal of this study was to examine the features and claims of developer descriptions of sleep apps for children. Methods: A search of the Apple iTunes store and Google Play was conducted using the terms ?kids sleep,? ?child sleep,? and ?baby sleep.? Data on the type of app, price, user rating, and number of users were collected. Apps were analyzed in comparison with evidence-based behavioral strategies and were thematically coded on the basis of claims provided in developer descriptions. Results: A total of 83 app descriptions were examined, of which only 2 (2.4%) offered sleep improvement strategies. The majority were sound and light apps (78%) and 19% were bedtime games or stories. Only 18 of 83 (21.6%) apps were identified as containing empirically supported behavioral sleep strategies. Despite this, many apps asserted claims that they will help children ?fall asleep instantly,? ?cry less and sleep better,? or improve child development. Conclusions: A large variety of sleep apps exist for use among children, but few include evidence-based behavioral strategies according to the developer descriptions of the apps. Addressing sleep difficulties in children is important to promote physical, cognitive, and emotional development. Collaboration between sleep researchers and technology developers may be beneficial for creating evidence-supported apps to help with children?s sleep in the future. UR - https://pediatrics.jmir.org/2022/1/e32129 UR - http://dx.doi.org/10.2196/32129 UR - http://www.ncbi.nlm.nih.gov/pubmed/35238787 ID - info:doi/10.2196/32129 ER - TY - JOUR AU - Skvortsova, Aleksandrina AU - Cohen Rodrigues, Talia AU - de Buisonjé, David AU - Kowatsch, Tobias AU - Santhanam, Prabhakaran AU - Veldhuijzen, S. Dieuwke AU - van Middendorp, Henriët AU - Evers, Andrea PY - 2022/3/1 TI - Increasing the Effectiveness of a Physical Activity Smartphone Intervention With Positive Suggestions: Randomized Controlled Trial JO - J Med Internet Res SP - e32130 VL - 24 IS - 3 KW - eHealth KW - mobile health KW - physical activity KW - walking KW - positive suggestions KW - outcome expectations KW - mobile phone N2 - Background: eHealth interventions have the potential to increase the physical activity of users. However, their effectiveness varies, and they often have only short-term effects. A possible way of enhancing their effectiveness is to increase the positive outcome expectations of users by giving them positive suggestions regarding the effectiveness of the intervention. It has been shown that when individuals have positive expectations regarding various types of interventions, they tend to benefit from these interventions more. Objective: The main objective of this web-based study is to investigate whether positive suggestions can change the expectations of participants regarding the effectiveness of a smartphone physical activity intervention and subsequently enhance the number of steps the participants take during the intervention. In addition, we study whether suggestions affect perceived app effectiveness, engagement with the app, self-reported vitality, and fatigue of the participants. Methods: This study involved a 21-day fully automated physical activity intervention aimed at helping participants to walk more steps. The intervention was delivered via a smartphone-based app that delivered specific tasks to participants (eg, setting activity goals or looking for social support) and recorded their daily step count. Participants were randomized to either a positive suggestions group (69/133, 51.9%) or a control group (64/133, 48.1%). Positive suggestions emphasizing the effectiveness of the intervention were implemented in a web-based flyer sent to the participants before the intervention. Suggestions were repeated on days 8 and 15 of the intervention via the app. Results: Participants significantly increased their daily step count from baseline compared with 21 days of the intervention (t107=?8.62; P<.001) regardless of the suggestions. Participants in the positive suggestions group had more positive expectations regarding the app (B=?1.61, SE 0.47; P<.001) and higher expected engagement with the app (B=3.80, SE 0.63; P<.001) than the participants in the control group. No effects of suggestions on the step count (B=?22.05, SE 334.90; P=.95), perceived effectiveness of the app (B=0.78, SE 0.69; P=.26), engagement with the app (B=0.78, SE 0.75; P=.29), and vitality (B=0.01, SE 0.11; P=.95) were found. Positive suggestions decreased the fatigue of the participants during the 3 weeks of the intervention (B=0.11, SE 0.02; P<.001). Conclusions: Although the suggestions did not affect the number of daily steps, they increased the positive expectations of the participants and decreased their fatigue. These results indicate that adding positive suggestions to eHealth physical activity interventions might be a promising way of influencing subjective but not objective outcomes of interventions. Future research should focus on finding ways of strengthening the suggestions, as they have the potential to boost the effectiveness of eHealth interventions. Trial Registration: Open Science Framework 10.17605/OSF.IO/CWJES; https://osf.io/cwjes UR - https://www.jmir.org/2022/3/e32130 UR - http://dx.doi.org/10.2196/32130 UR - http://www.ncbi.nlm.nih.gov/pubmed/35230245 ID - info:doi/10.2196/32130 ER - TY - JOUR AU - Struik, Laura AU - Rodberg, Danielle AU - Sharma, H. Ramona PY - 2022/3/1 TI - The Behavior Change Techniques Used in Canadian Online Smoking Cessation Programs: Content Analysis JO - JMIR Ment Health SP - e35234 VL - 9 IS - 3 KW - content analysis KW - smoking cessation KW - internet KW - behavior change technique KW - mental health KW - smoking KW - online program KW - website KW - government KW - federal KW - provincial N2 - Background: Smoking rates in Canada remain unacceptably high, and cessation rates have stalled in recent years. Online cessation programs, touted for their ability to reach many different populations anytime, have shown promise in their efficacy. The Government of Canada has therefore funded provincial and national smoking cessation websites countrywide. However, little is known about the behavior change techniques (BCTs) that underpin the content of these websites, which is key to establishing the quality of the websites, as well as a way forward for evaluation. Objective: The purpose of this study, therefore, is to apply the BCTTv1 taxonomy to Canadian provincial and federal websites, and to determine which BCTs they use. Methods: A total of 12 government-funded websites across Canada were included for analysis. Using deductive content analysis and through training in applying the BCTTv1 taxonomy, the website content was coded according to the 93 BCTs across the 16 BCT categories. Results: Of the 16 BCT categories, 14 were present within the websites. The most widely represented BCT categories (used in all 12 websites) included goals and planning, social support, natural consequences, and regulation. Implementation of BCTs within these categories varied across the sites. Conclusions: Analyzing the content of online smoking cessation websites using the BCTTv1 taxonomy is an appropriate method for identifying the behavior change content of these programs. The findings offer programmers and researchers tangible directions for prioritizing and enhancing provincial and national smoking cessation programs, and an evaluation framework to assess smoking cessation outcomes in relation to the web-based content. UR - https://mental.jmir.org/2022/3/e35234 UR - http://dx.doi.org/10.2196/35234 UR - http://www.ncbi.nlm.nih.gov/pubmed/35230253 ID - info:doi/10.2196/35234 ER - TY - JOUR AU - Bartlett, Larissa AU - Doherty, Kathleen AU - Farrow, Maree AU - Kim, Sarang AU - Hill, Edward AU - King, Anna AU - Alty, Jane AU - Eccleston, Claire AU - Kitsos, Alex AU - Bindoff, Aidan AU - Vickers, C. James PY - 2022/3/1 TI - Island Study Linking Aging and Neurodegenerative Disease (ISLAND) Targeting Dementia Risk Reduction: Protocol for a Prospective Web-Based Cohort Study JO - JMIR Res Protoc SP - e34688 VL - 11 IS - 3 KW - public health KW - online KW - prospective research cohort KW - dementia KW - aging KW - older adult KW - neurodegenerative KW - modifiable risk factors KW - risk reduction KW - prevention KW - lifestyle and behaviors KW - lifestyle KW - behavior change KW - intervention KW - risk KW - cognition KW - blood-based dementia biomarkers KW - research translation N2 - Background: Up to 40% of incident dementia is considered attributable to behavioral and lifestyle factors. Given the current lack of medical treatments and the projected increase in dementia prevalence, a focus on prevention through risk reduction is needed. Objective: We aim to increase dementia risk knowledge and promote changes in dementia risk behaviors at individual and population levels. Methods: The Island Study Linking Aging and Neurodegenerative Disease (ISLAND) is a long-term prospective, web-based cohort study with nested interventions that will be conducted over a 10-year period. Target participants (n=10,000) reside in Tasmania and are aged 50 years or over. Survey data on knowledge, attitudes, and behaviors related to modifiable dementia risk factors will be collected annually. After each survey wave, participants will be provided with a personalized dementia risk profile containing guidelines for reducing risk across 9 behavioral and lifestyle domains and with opportunities to engage in educational and behavioral interventions targeting risk reduction. Survey data will be modeled longitudinally with intervention engagement indices, cognitive function indices, and blood-based biomarkers, to measure change in risk over time. Results: In the initial 12 months (October 2019 to October 2020), 6410 participants have provided baseline data. The study is ongoing. Conclusions: Recruitment targets are feasible and efforts are ongoing to achieve a representative sample. Findings will inform future public health dementia risk reduction initiatives by showing whether, when, and how dementia risk can be lowered through educational and behavioral interventions, delivered in an uncontrolled real-world context. International Registered Report Identifier (IRRID): DERR1-10.2196/34688 UR - https://www.researchprotocols.org/2022/3/e34688 UR - http://dx.doi.org/10.2196/34688 UR - http://www.ncbi.nlm.nih.gov/pubmed/35230251 ID - info:doi/10.2196/34688 ER - TY - JOUR AU - Wan Mohd Yunus, Azam Wan Mohd AU - Matinolli, Hanna-Maria AU - Waris, Otto AU - Upadhyaya, Subina AU - Vuori, Miika AU - Korpilahti-Leino, Tarja AU - Ristkari, Terja AU - Koffert, Tarja AU - Sourander, Andre PY - 2022/2/23 TI - Digitalized Cognitive Behavioral Interventions for Depressive Symptoms During Pregnancy: Systematic Review JO - J Med Internet Res SP - e33337 VL - 24 IS - 2 KW - pregnancy KW - antenatal depression KW - systematic review KW - cognitive behavior therapy KW - digital interventions KW - COVID-19 N2 - Background: Studies have shown a high prevalence of depression during pregnancy, and there is also evidence that cognitive behavioral therapy (CBT) is one of the most effective psychosocial interventions. Emerging evidence from randomized controlled trials (RCTs) has shown that technology has been successfully harnessed to provide CBT interventions for other populations. However, very few studies have focused on their use during pregnancy. This approach has become increasingly important in many clinical areas due to the COVID-19 pandemic, and our study aimed to expand the knowledge in this particular clinical area. Objective: Our systematic review aimed to bring together the available research-based evidence on digitalized CBT interventions for depression symptoms during pregnancy. Methods: A systematic review of the Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, MEDLINE, Embase, PsycINFO, Scopus, ClinicalTrials.gov, and EBSCO Open Dissertations databases was carried out from the earliest available evidence to October 27, 2021. Only RCT studies published in English were considered. The PRISMA (Preferred Reporting Items of Systematic Reviews and Meta-analyses) guidelines were followed, and the protocol was registered on the Prospective Register of Systematic Reviews. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomized trials. Results: The review identified 7 studies from 5 countries (the United States, China, Australia, Norway, and Sweden) published from 2015 to 2021. The sample sizes ranged from 25 to 1342 participants. The interventions used various technological elements, including text, images, videos, games, interactive features, and peer group discussions. They comprised 2 guided and 5 unguided approaches. Using digitalized CBT interventions for depression during pregnancy showed promising efficacy, with guided intervention showing higher effect sizes (Hedges g=1.21) than the unguided interventions (Hedges g=0.14-0.99). The acceptability of the digitalized CBT interventions was highly encouraging, based on user feedback. Attrition rates were low for the guided intervention (4.5%) but high for the unguided interventions (22.1%-46.5%). A high overall risk of bias was present for 6 of the 7 studies. Conclusions: Our search only identified a small number of digitalized CBT interventions for pregnant women, despite the potential of this approach. These showed promising evidence when it came to efficacy and positive outcomes for depression symptoms, and user feedback was positive. However, the overall risk of bias suggests that the efficacy of the interventions needs to be interpreted with caution. Future studies need to consider how to mitigate these sources of biases. Digitalized CBT interventions can provide prompt, effective, evidence-based interventions for pregnant women. This review increases our understanding of the importance of digitalized interventions during pregnancy, including during the COVID-19 pandemic. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42020216159; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=216159 UR - https://www.jmir.org/2022/2/e33337 UR - http://dx.doi.org/10.2196/33337 UR - http://www.ncbi.nlm.nih.gov/pubmed/35195532 ID - info:doi/10.2196/33337 ER - TY - JOUR AU - Marcolin, Barb AU - Saunders, Chad AU - Aubert, Benoit PY - 2022/2/23 TI - Persuasive Technologies and Social Interactions in Professional Environments: Embedded Qualitative Case Study JO - JMIR Form Res SP - e32613 VL - 6 IS - 2 KW - persuasive technology KW - patient experience platforms KW - group effects KW - professional work management KW - services co-design KW - self-management KW - health and wellness outcomes KW - social environments KW - work influence N2 - Background: Although previous studies have highlighted the impact of interactions on the web in the context of patient?health care professional (HCP) dyads, this paper extends that context to a triad that includes the role of employers and associated settings with social groups. Objective: This study aims to evaluate how the interactions between individuals and the social use of the platform affect individuals? use of persuasive technology and, in turn, their work environment actions and responses, by implementing a persuasive technology health and wellness platform in a work environment. Methods: For 8 months, we deployed a persuasive technology platform with different combinations of health-related features and content in 1 embedded case design with 8 fire stations for a small Canadian city (total number of participant firefighters, n=141) assigned to 1 of 2 treatments?interactive or static webpages. We used text-based content analysis techniques for outcome measures, drawn from a total of 29 participant exit interviews. In addition, medical assessments were conducted at baseline, midpoint, and end point by 7 HCPs and 1 researcher (BM), who also served as the data steward and managed the study. Results: Our results reveal that group, social, and work influences introduce new elements to the use of persuasive technology, which interact to foster higher levels of individual success. The platform in our study served as part of a larger social system, providing information that facilitated new behaviors at work and home. The 8-month group programs centered on exercise, nutrition, and smoking cessation. Groups of participants coached by certified professionals showed significant increases in sodium awareness, levels of actual exercise, and consistency of activities. As a result of the study, of 141 people, 15 (10.6%) were notified of serious medical health issues and 29 (20.6%) underwent blood work assessments and a privacy shield (protected by federal law) was enacted to protect employees from losing their employment based on any health concerns disclosed. Conclusions: The persuasive technology platform, in combination with self-management and professional management and social interactions, significantly altered work management behaviors. Interactions among individual outcomes, group influences, and social situations strongly influenced individuals? behaviors in their work and home environments. Three things further improved the positive results that we observed: privacy shields (which allowed employees to reveal health concerns without fear of professional consequences), individual private activities aligned with group activities, and integration between HCP work with localized, organizational work roles. UR - https://formative.jmir.org/2022/2/e32613 UR - http://dx.doi.org/10.2196/32613 UR - http://www.ncbi.nlm.nih.gov/pubmed/35195527 ID - info:doi/10.2196/32613 ER - TY - JOUR AU - Silang, A. Katherine AU - Sohal, R. Pooja AU - Bright, S. Katherine AU - Leason, Jennifer AU - Roos, Leslie AU - Lebel, Catherine AU - Giesbrecht, F. Gerald AU - Tomfohr-Madsen, M. Lianne PY - 2022/2/21 TI - eHealth Interventions for Treatment and Prevention of Depression, Anxiety, and Insomnia During Pregnancy: Systematic Review and Meta-analysis JO - JMIR Ment Health SP - e31116 VL - 9 IS - 2 KW - eHealth KW - pregnancy KW - depression KW - anxiety KW - insomnia KW - mobile phone N2 - Background: Pregnancy is associated with an increased risk for depression, anxiety, and insomnia. eHealth interventions provide a promising and accessible treatment alternative to face-to-face interventions. Objective: The objective of this systematic review and meta-analysis is to determine the effectiveness of eHealth interventions in preventing and treating depression, anxiety, and insomnia during pregnancy. Secondary aims are to identify demographic and intervention moderators of effectiveness. Methods: A total of 5 databases (PsycINFO, Medline, CINAHL, Embase, and Cochrane) were searched from inception to May 2021. Terms related to eHealth, pregnancy, randomized controlled trials (RCTs), depression, anxiety, and insomnia were included. RCTs and pilot RCTs were included if they reported an eHealth intervention for the prevention or treatment of depression, anxiety, or insomnia in pregnant women. Study screening, data extractions, and quality assessment were conducted independently by 2 reviewers from an 8-member research team (KAS, PRS, Hangsel Sanguino, Roshni Sohail, Jasleen Kaur, Songyang (Mark) Jin, Makayla Freeman, and Beatrice Valmana). Random-effects meta-analyses of pooled effect sizes were conducted to determine the effect of eHealth interventions on prenatal mental health. Meta-regression analyses were conducted to identify potential moderators. Results: In total, 17 studies were included in this review that assessed changes in depression (11/17, 65%), anxiety (10/17, 59%), and insomnia (3/17, 18%). Several studies included both depression and anxiety symptoms as outcomes (7/17, 41%). The results indicated that during pregnancy, eHealth interventions showed small effect sizes for preventing and treating symptoms of anxiety and depression and a moderate effect size for treating symptoms of insomnia. With the exception of intervention type for the outcome of depressive symptoms, where mindfulness interventions outperformed other intervention types, no significant moderators were detected. Conclusions: eHealth interventions are an accessible and promising resource for treating symptoms of anxiety, depression, and insomnia during pregnancy. However, more research is necessary to identify ways to increase the efficacy of eHealth interventions for this population. Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42020205954; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=205954 UR - https://mental.jmir.org/2022/2/e31116 UR - http://dx.doi.org/10.2196/31116 UR - http://www.ncbi.nlm.nih.gov/pubmed/35188471 ID - info:doi/10.2196/31116 ER - TY - JOUR AU - Egashira, Mahiro AU - Son, Daisuke AU - Ema, Arisa PY - 2022/2/21 TI - Serious Game for Change in Behavioral Intention Toward Lifestyle-Related Diseases: Experimental Study With Structural Equation Modeling Using the Theory of Planned Behavior JO - JMIR Serious Games SP - e28982 VL - 10 IS - 1 KW - lifestyle-related disease KW - mechanism of behavior change KW - serious game KW - theory of planned behavior N2 - Background: Health activities should be tailored to individual lifestyles and values. To raise awareness of health behaviors, various practices related to health education, such as interactive activities among individuals with different backgrounds, have been developed. Moreover, serious games have been used as a tool for facilitating communication. However, there have been few investigations that are based on the framework of the theory of planned behavior on the mechanisms of health-related behavioral intention change from playing serious games. Objective: We aimed to investigate the mechanisms of behavioral intention change among various age groups after an intervention using a serious game to increase awareness of lifestyle-related diseases. Methods: Adults, undergraduates, and high school students played a serious game, called Negotiation Battle, and answered a questionnaire?Gaming Event Assessment Form for Lifestyle-related Diseases?before, immediately after, and 2-4 weeks after the game. The questionnaire was composed of 16 items based on the theory of planned behavior. We used structural equation modeling to compare responses from the 3 groups. Results: For all 3 age groups (adults: mean 43.4 years, range 23-67 years; undergraduates: mean 20.9 years, range 19-34 years; high school students: mean 17.9 years, 17-18 years), perceived behavior control was the key factor of behavioral intention change. Immediately after the game, causal relationships between perceived behavioral control and behavioral intention were enhanced or maintained for all groups?adults (before: path coefficient 1.030, P<.001; after: path coefficient 2.045, P=.01), undergraduates (before: path coefficient 0.568, P=.004; after: path coefficient 0.737, P=.001), and high school students (before: path coefficient 14.543, P=.97; after: path coefficient 0.791, P<.001). Analysis of free descriptions after intervention suggested that experiencing dilemma is related to learning and behavioral intention. Conclusions: The study revealed that the serious game changed the behavioral intention of adolescents and adults regarding lifestyle-related diseases, and changes in perceived behavioral control mediated the alteration mechanism. UR - https://games.jmir.org/2022/1/e28982 UR - http://dx.doi.org/10.2196/28982 UR - http://www.ncbi.nlm.nih.gov/pubmed/35188465 ID - info:doi/10.2196/28982 ER - TY - JOUR AU - Pouls, PH Bart AU - Bekker, L. Charlotte AU - van Dulmen, Sandra AU - Vriezekolk, E. Johanna AU - van den Bemt, JF Bart PY - 2022/2/18 TI - A Serious Puzzle Game to Enhance Adherence to Antirheumatic Drugs in Patients With Rheumatoid Arthritis: Systematic Development Using Intervention Mapping JO - JMIR Serious Games SP - e31570 VL - 10 IS - 1 KW - medication adherence KW - serious game KW - eHealth KW - rheumatoid arthritis KW - intervention mapping KW - intervention development N2 - Background: Patients? implicit attitudes toward medication need and concerns may influence their adherence. Targeting these implicit attitudes by combining game-entertainment with medication-related triggers might improve medication adherence in patients with rheumatoid arthritis (RA). Objective: The aim of this study was to describe the systematic development of a serious game to enhance adherence to antirheumatic drugs by using intervention mapping. Methods: A serious game was developed using the intervention mapping framework guided by a multidisciplinary expert group, which proceeded along 6 steps: (1) exploring the problem by assessing the relationship between medication adherence and implicit attitudes, (2) defining change objectives, (3) selecting evidence-based behavior change techniques that focused on adjusting implicit attitudes, (4) designing the intervention, (5) guaranteeing implementation by focusing on intrinsic motivation, and (6) planning a scientific evaluation. Results: Based on the problem assessment and guided by the Dual-Attitude Model, implicit negative and illness-related attitudes of patients with RA were defined as the main target for the intervention. Consequently, the change objective was ?after the intervention, participants have a more positive attitude toward antirheumatic drugs.? Attention bias modification, evaluative conditioning, and goal priming were the techniques chosen to implicitly target medication needs. These techniques were redesigned into medication-related triggers and built in the serious puzzle game. Thirty-seven patients with RA tested the game at several stages. Intrinsic motivation was led by the self-determination theory and addressed the 3 needs, that is, competence, autonomy, and relatedness. The intervention will be evaluated in a randomized clinical trial that assesses the effect of playing the serious game on antirheumatic drug adherence. Conclusions: We systematically developed a serious game app to enhance adherence to antirheumatic drugs among patients with RA by using the intervention mapping framework. This paper could serve as a guideline for other health care providers when developing similar interventions. UR - https://games.jmir.org/2022/1/e31570 UR - http://dx.doi.org/10.2196/31570 UR - http://www.ncbi.nlm.nih.gov/pubmed/35179510 ID - info:doi/10.2196/31570 ER - TY - JOUR AU - Williams, Christopher AU - McClay, Carrie-Anne AU - Martinez, Rebeca AU - Morrison, Jill AU - Haig, Caroline AU - Jones, Ray AU - Farrand, Paul PY - 2022/2/17 TI - Online Cognitive Behavioral Therapy (CBT) Life Skills Program for Depression: Pilot Randomized Controlled Trial JO - JMIR Form Res SP - e30489 VL - 6 IS - 2 KW - pilot study KW - depression KW - low mood KW - iCBT KW - guided self-help KW - online KW - psychotherapy KW - LLTTF KW - RCT KW - treatment gap KW - bibliotherapy KW - life skills KW - anxiety N2 - Background: Depression is a common mental health problem with significant personal and social consequences. Studies have suggested that cognitive behavioral therapy (CBT) is an effective treatment for depression and anxiety when delivered one-to-one by an expert practitioner, but access to this talking therapy is often limited, and waiting lists can be long. However, a range of low-intensity interventions that can increase access to services are available including guided CBT self-help materials delivered via books, classes, and online packages. Objective: This project aimed to pilot a randomized controlled trial (RCT) of an online CBT-based life skills course with community-based individuals experiencing depression. Methods: Individuals with symptoms of depression were recruited directly from the community via newspaper advertisements. Participants were remotely randomized to receive either immediate access (IA) or delayed access (DA) to a research version of the Living Life to the Full online CBT-based life skills package (3rd edition) with telephone support provided by nonspecialist, charity-based workers while they used the online intervention. The primary end point was at 3 months postrandomization, at which point, the DA group were offered the intervention. Levels of depression, anxiety, social functioning, and satisfaction were assessed. Results: There were effective recruitment, randomization, and uptake, with 19 IA and 17 DA control participants entering the pilot study via newspaper advertisements and 13 of the 19 participants taking up the intervention. Overall, 72% (26/36) were not currently under the care of their general practitioner. The online package was acceptable to participants; the mean satisfaction score on the Client Satisfaction Questionnaire was 21 out of 32 (SD 8.89). At 3 months, data collection was achieved from 78% (28/36) of the participants. The efficacy and retention data were used for a power calculation indicating that 72 participants in total will be required for a future substantive RCT. Conclusions: The research design successfully tested the recruitment, data collection, and intervention delivery. The pilot study has provided data for the required sample size for the full RCT. Trial Registration: ISRCTN registry ISRCTN12890709; https://doi.org/10.1186/ISRCTN12890709 International Registered Report Identifier (IRRID): RR2-10.1186/s13063-016-1336-y UR - https://formative.jmir.org/2022/2/e30489 UR - http://dx.doi.org/10.2196/30489 UR - http://www.ncbi.nlm.nih.gov/pubmed/35175203 ID - info:doi/10.2196/30489 ER - TY - JOUR AU - Liu, Weichen AU - Andrade, Gianna AU - Schulze, Jurgen AU - Doran, Neal AU - Courtney, E. Kelly PY - 2022/2/15 TI - Using Virtual Reality to Induce and Assess Objective Correlates of Nicotine Craving: Paradigm Development Study JO - JMIR Serious Games SP - e32243 VL - 10 IS - 1 KW - nicotine KW - craving KW - cue-exposure KW - virtual reality KW - attentional bias KW - pupillometry KW - development KW - smoking KW - addiction KW - eye-tracking N2 - Background: Craving is a clinically important phenotype for the development and maintenance of nicotine addiction. Virtual reality (VR) paradigms are successful in eliciting cue-induced subjective craving and may even elicit stronger craving than traditional picture-cue methods. However, few studies have leveraged the advances of this technology to improve the assessment of craving. Objective: This report details the development of a novel, translatable VR paradigm designed to both elicit nicotine craving and assess multiple eye-related characteristics as potential objective correlates of craving. Methods: A VR paradigm was developed, which includes three Active scenes with nicotine and tobacco product (NTP) cues present, and three Neutral scenes devoid of NTP cues. A pilot sample (N=31) of NTP users underwent the paradigm and completed subjective measures of nicotine craving, sense of presence in the VR paradigm, and VR-related sickness. Eye-gaze fixation time (?attentional bias?) and pupil diameter toward Active versus Neutral cues, as well as spontaneous blink rate during the Active and Neutral scenes, were recorded. Results: The NTP Cue VR paradigm was found to elicit a moderate sense of presence (mean Igroup Presence Questionnaire score 60.05, SD 9.66) and low VR-related sickness (mean Virtual Reality Sickness Questionnaire score 16.25, SD 13.94). Scene-specific effects on attentional bias and pupil diameter were observed, with two of the three Active scenes eliciting greater NTP versus control cue attentional bias and pupil diameter (Cohen d=0.30-0.92). The spontaneous blink rate metrics did not differ across Active and Neutral scenes. Conclusions: This report outlines the development of the NTP Cue VR paradigm. Our results support the potential of this paradigm as an effective laboratory-based cue-exposure task and provide early evidence of the utility of attentional bias and pupillometry, as measured during VR, as useful markers for nicotine addiction. UR - https://games.jmir.org/2022/1/e32243 UR - http://dx.doi.org/10.2196/32243 UR - http://www.ncbi.nlm.nih.gov/pubmed/35166685 ID - info:doi/10.2196/32243 ER - TY - JOUR AU - Kouvari, Matina AU - Karipidou, Melina AU - Tsiampalis, Thomas AU - Mamalaki, Eirini AU - Poulimeneas, Dimitrios AU - Bathrellou, Eirini AU - Panagiotakos, Demosthenes AU - Yannakoulia, Mary PY - 2022/2/14 TI - Digital Health Interventions for Weight Management in Children and Adolescents: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e30675 VL - 24 IS - 2 KW - childhood obesity KW - eHealth KW - mHealth KW - digital health KW - youth KW - mobile phone N2 - Background: Recent meta-analyses suggest the use of technology-based interventions as a treatment option for obesity in adulthood. Similar meta-analytic approaches for children are scarce. Objective: The aim of this meta-analysis is to examine the effect of technology-based interventions on overweight and obesity treatment in children and adolescents. Methods: A systematic literature search was performed using MEDLINE (PubMed), Scopus, and Cochrane Library for randomized clinical trials to identify interventional studies published between January 2000 and February 2021. Results: In total, 9 manuscripts from 8 clinical trials of 582 children or adolescents were considered eligible. BMI, BMI z-score, and other BMI-related baseline metrics during and after intervention were considered as primary outcomes. In 7 of 8 studies, a technology-based intervention was applied in addition to conventional care. Of the 8 studies, 6 studies were conducted in the United States, 1 in Australia, and 1 in northwestern Europe. In total, 5 studies included adolescents, whereas the rest addressed children aged 9 to 12 years. Intervention duration ranged from 3 to 24 months. Significant differences between groups in BMI metric changes were reported by 5 of the 8 studies. Pooled analysis revealed an overall significant decrease in BMI metrics in the intervention group (standardized mean difference ?0.61, 95% CI ?1.10 to ?0.13; P=.01). Subgroup analysis revealed that significance was lost in case of no parental involvement (standardized mean difference ?0.36, 95% CI ?0.83 to 0.11; P=.14). The small number of clinical trials found, the varying study quality, and the study heterogeneity are some limitations of this review. Conclusions: The studies reported herein describe functional and acceptable technology-based approaches, in addition to conventional treatments, to enhance weight loss in young populations. UR - https://www.jmir.org/2022/2/e30675 UR - http://dx.doi.org/10.2196/30675 UR - http://www.ncbi.nlm.nih.gov/pubmed/35156934 ID - info:doi/10.2196/30675 ER - TY - JOUR AU - W Beukes, Eldré AU - Andersson, Gerhard AU - Fagelson, Marc AU - Manchaiah, Vinaya PY - 2022/2/14 TI - Internet-Based Audiologist-Guided Cognitive Behavioral Therapy for Tinnitus: Randomized Controlled Trial JO - J Med Internet Res SP - e27584 VL - 24 IS - 2 KW - tinnitus KW - cognitive behavioral therapy KW - internet intervention KW - web-based intervention KW - randomized controlled trial KW - telehealth KW - teleaudiology KW - eHealth N2 - Background: Tinnitus is a symptom that can be very distressing owing to hearing sounds not related to any external sound source. Managing tinnitus is notoriously difficult, and access to evidence-based care is limited. Cognitive behavioral therapy (CBT) is a tinnitus management strategy with the most evidence of effectiveness but is rarely offered to those distressed by tinnitus. The provision of internet-based CBT for tinnitus overcomes accessibility barriers; however, it is not currently readily available in the United States. Objective: The aim of this study is to investigate the efficacy of internet-based CBT compared with that of weekly monitoring for the management of tinnitus in reducing tinnitus distress; reducing tinnitus-related comorbidities, including tinnitus cognitions, insomnia, anxiety, and depression; and assessing the stability of the intervention effects 2 months after the intervention. Methods: A 2-arm randomized clinical trial comparing audiologist-guided internet-based CBT (n=79) to a weekly monitoring group (n=79) with a 2-month follow-up assessed the efficacy of internet-based CBT. Eligible participants included adults seeking help for tinnitus. Recruitment was conducted on the web using an open-access website. Participants were randomized via 1:1 allocation, but blinding was not possible. The study was undertaken by English or Spanish speakers on the web. The primary outcome was a change in tinnitus distress as measured using the Tinnitus Functional Index. Secondary outcome measures included anxiety, depression, insomnia, tinnitus cognition, hearing-related difficulties, and quality of life. Results: Internet-based CBT led to a greater reduction in tinnitus distress (mean 36.57, SD 22) compared with that in weekly monitoring (mean 46.31, SD 20.63; effect size: Cohen d=0.46, 95% CI 0.14-0.77) using an intention-to-treat analysis. For the secondary outcomes, there was a greater reduction in negative tinnitus cognition and insomnia. The results remained stable over the 2-month follow-up period. No important adverse events were observed. Further, 16% (10/158) of participants withdrew, with low overall compliance rates for questionnaire completion of 72.3% (107/148) at T1, 61% (91/148) at T2, and 42% (62/148) at T3. Conclusions: This study is the first to evaluate and indicate the efficacy of audiologist-delivered internet-based CBT in reducing tinnitus distress in a US population. It was also the first study to offer internet-based CBT in Spanish to accommodate the large Hispanic population in the United States. The results have been encouraging, and further work is indicated in view of making such an intervention applicable to a wider population. Further work is required to improve compliance and attract more Spanish speakers. Trial Registration: ClinicalTrials.gov NCT04004260; https://clinicaltrials.gov/ct2/show/NCT04004260 UR - https://www.jmir.org/2022/2/e27584 UR - http://dx.doi.org/10.2196/27584 UR - http://www.ncbi.nlm.nih.gov/pubmed/35156936 ID - info:doi/10.2196/27584 ER - TY - JOUR AU - Abd-alrazaq, Alaa AU - Alajlani, Mohannad AU - Alhuwail, Dari AU - Schneider, Jens AU - Akhu-Zaheya, Laila AU - Ahmed, Arfan AU - Househ, Mowafa PY - 2022/2/14 TI - The Effectiveness of Serious Games in Alleviating Anxiety: Systematic Review and Meta-analysis JO - JMIR Serious Games SP - e29137 VL - 10 IS - 1 KW - serious games KW - exergames KW - anxiety KW - computerized cognitive behavioral therapy games KW - biofeedback games KW - systematic reviews KW - meta-analysis KW - mobile phone N2 - Background: Anxiety is a mental disorder characterized by apprehension, tension, uneasiness, and other related behavioral disturbances. One of the nonpharmacological treatments used for reducing anxiety is serious games, which are games that have a purpose other than entertainment. The effectiveness of serious games in alleviating anxiety has been investigated by several systematic reviews; however, they were limited by design and methodological weaknesses. Objective: This study aims to assess the effectiveness of serious games in alleviating anxiety by summarizing the results of previous studies and providing an up-to-date review. Methods: We conducted a systematic review of randomized controlled trials (RCTs). The following seven databases were searched: MEDLINE, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also conducted backward and forward reference list checking for the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies. Results: Of the 935 citations retrieved, 33 studies were included in this review. Of these, 22 RCTs were eventually included in the meta-analysis. Very low?quality evidence from 9 RCTs and 5 RCTs showed no statistically significant effect of exergames (games entailing physical exercises) on anxiety levels when compared with conventional exercises (P=.70) and no intervention (P=.27), respectively. Although 6 RCTs demonstrated a statistically and clinically significant effect of computerized cognitive behavioral therapy games on anxiety levels when compared with no intervention (P=.01), the quality of the evidence reported was low. Similarly, low-quality evidence from 3 RCTs showed a statistically and clinically significant effect of biofeedback games on anxiety levels when compared with conventional video games (P=.03). Conclusions: This review shows that exergames can be as effective as conventional exercises in alleviating anxiety; computerized cognitive behavioral therapy games and exergames can be more effective than no intervention, and biofeedback games can be more effective than conventional video games. However, our findings remain inconclusive, mainly because there was a high risk of bias in the individual studies included, the quality of meta-analyzed evidence was low, few studies were included in some meta-analyses, patients without anxiety were recruited in most studies, and purpose-shifted serious games were used in most studies. Therefore, serious games should be considered complementary to existing interventions. Researchers should use serious games that are designed specifically to alleviate depression, deliver other therapeutic modalities, and recruit a diverse population of patients with anxiety. UR - https://games.jmir.org/2022/1/e29137 UR - http://dx.doi.org/10.2196/29137 UR - http://www.ncbi.nlm.nih.gov/pubmed/35156932 ID - info:doi/10.2196/29137 ER - TY - JOUR AU - Scott-Andrews, Q. Katherine AU - Lane, Annalise AU - Rock, Sarah AU - Robinson, E. Leah PY - 2022/2/14 TI - Considerations for a Social Media Physical Activity Program: Exploratory Study JO - JMIR Pediatr Parent SP - e26008 VL - 5 IS - 1 KW - physical activity KW - motor skills KW - programs and interventions KW - social media N2 - Background: Social media may be a powerful platform to combat parents? and children?s low physical activity levels. Objective: This study surveyed parents? beliefs about physical activity in order to expand the extant literature concerning the interest in and the design of an effective and feasible social media physical activity (SMPA) program. Methods: Primary caregivers (n=250; 215 [86%] mothers, 164 [65.6%] White) of children aged 6-12 years completed an online questionnaire. Interest was examined through responses on the questionnaire; beliefs (ie, perceptions, knowledge, and support) about physical activity were examined using Spearman correlations; and to support the SMPA program design, researchers examined a combination of multiple-choice and free-response questions. For the free-response questions, the researchers performed open coding related to perceived benefits, barriers, and motivators. Results: Parent respondents (n=215, 86%) were interested in a SMPA program tailored for families. Regarding beliefs, parents exhibited a monotonic relationship between 2 questions related to perceptions of physical activity levels in their children (rs(250)=.310, P<.001), knowledge about physical activity and motor skills (rs(250)=.328, P<.001), and support of physical activity and motor skills (rs(250)=.385, P<.001). Parents perceived benefits of a SMPA program, highlighting family time and health. Barriers included time constraints, a lack of motivation, and environmental factors. Conclusions: Parents are interested in supporting healthy family behaviors using a SMPA program. An effective program should emphasize motor skill activities, be fun and family oriented, and incorporate incentives, goal setting, and advice and tips. SMPA also needs to address identified barriers, such as those regarding time and environment. UR - https://pediatrics.jmir.org/2022/1/e26008 UR - http://dx.doi.org/10.2196/26008 UR - http://www.ncbi.nlm.nih.gov/pubmed/35156926 ID - info:doi/10.2196/26008 ER - TY - JOUR AU - van Loenen, Inge AU - Scholten, Willemijn AU - Muntingh, Anna AU - Smit, Johannes AU - Batelaan, Neeltje PY - 2022/2/10 TI - The Effectiveness of Virtual Reality Exposure?Based Cognitive Behavioral Therapy for Severe Anxiety Disorders, Obsessive-Compulsive Disorder, and Posttraumatic Stress Disorder: Meta-analysis JO - J Med Internet Res SP - e26736 VL - 24 IS - 2 KW - anxiety disorders KW - virtual reality KW - virtual reality exposure therapy KW - cognitive behavioral therapy KW - meta-analysis KW - mobile phone N2 - Background: In recent years, virtual reality exposure?based cognitive behavioral therapy (VRE-CBT) has shown good treatment results in (subclinical) anxiety disorders and seems to be a good alternative to exposure in vivo in regular cognitive behavioral therapy (CBT). However, previous meta-analyses on the efficacy of VRE-CBT on anxiety disorders have included studies on specific phobias and subthreshold anxiety; therefore, these results may not be generalizable to patients with more severe and disabling anxiety disorders. Objective: The objective of our study is to determine the efficacy of VRE-CBT on more severe anxiety disorders, excluding specific phobias and subthreshold anxiety disorders. Meta-analyses will be conducted to examine the efficacy of VRE-CBT versus waitlist and regular CBT. Our secondary objectives are to examine whether the efficacy differs according to the type of anxiety disorder, type of recruitment, and type of VRE-CBT (virtual reality exposure either with or without regular CBT). Furthermore, attrition in VRE-CBT and CBT will be compared. Methods: Studies published until August 20, 2020, were retrieved through systematic literature searches in PubMed, PsycINFO, and Embase. We calculated the effect sizes (Hedges g) for the difference between the conditions and their 95% CIs for posttest and follow-up measurements in a random effects model. A separate meta-analysis was performed to compare attrition between the VRE-CBT and CBT conditions. Results: A total of 16 trials with 817 participants were included. We identified 10 comparisons between VRE-CBT and a waitlist condition and 13 comparisons between VRE-CBT and a CBT condition. With regard to risk of bias, information on random sequence generation, allocation concealment, and risk of bias for selective outcome reporting was often absent or unclear. The mean effect size of VRE-CBT compared with waitlist (nco=10) was medium and significant, favoring VRE-CBT (Hedges g=?0.490, 95% CI ?0.82 to ?0.16; P=.003). The mean effect size of VRE-CBT compared with CBT (nco=13) was small and nonsignificant, favoring CBT (Hedges g=0.083, 95% CI ?0.13 to 0.30; P=.45). The dropout rates between VRE-CBT and CBT (nco=10) showed no significant difference (odds ratio 0.79, 95% CI 0.49-1.27; P=.32). There were no indications of small study effects or publication bias. Conclusions: The results of our study show that VRE-CBT is more effective than waitlist and as effective as CBT in the treatment of more severe anxiety disorders. Therefore, VRE-CBT may be considered a promising alternative to CBT for patients with more severe anxiety disorders. Higher-quality randomized controlled trials are needed to verify the robustness of these findings. UR - https://www.jmir.org/2022/2/e26736 UR - http://dx.doi.org/10.2196/26736 UR - http://www.ncbi.nlm.nih.gov/pubmed/35142632 ID - info:doi/10.2196/26736 ER - TY - JOUR AU - Sato, Daisuke AU - Sekizawa, Yoichi AU - Sutoh, Chihiro AU - Hirano, Yoshiyuki AU - Okawa, Sho AU - Hirose, Motohisa AU - Takemura, Ryo AU - Shimizu, Eiji PY - 2022/2/9 TI - Effectiveness of Unguided Internet-Based Cognitive Behavioral Therapy and the Three Good Things Exercise for Insomnia: 3-Arm Randomized Controlled Trial JO - J Med Internet Res SP - e28747 VL - 24 IS - 2 KW - insomnia KW - internet-based treatment KW - cognitive behavioral therapy KW - positive psychology KW - randomized controlled trial KW - mobile phone N2 - Background: The treatment of insomnia with sleep medication causes problems such as long-term use, dependence, and significant economic losses, including medical expenses. Evidence-based lifestyle guidance is required to improve insomnia symptoms not only in person but also in easy-to-use web-based formats. Objective: This study aims to clarify whether unguided internet-based cognitive behavioral therapy (ICBT) or the Three Good Things (TGT) exercise, both administered as self-help internet interventions without email support, could improve insomnia symptoms compared with a waiting list control (WLC) group. Methods: A 4-week program was implemented, and participants were randomly allocated to 1 of the 3 groups. The primary outcome measure was the Pittsburgh Sleep Questionnaire (PSQI) score at 4 weeks compared with baseline. Results: Of the 21,394 individuals invited to participate, 312 (1.46%) met the eligibility criteria and were randomly assigned to 1 of the 3 groups. Of these 312 individuals, 270 (86.5%; ICBT 79/270, 29.3%; TGT 88/270, 32.6%; and WLC 103/270, 38.1%) completed a postintervention survey at 4 and 8 weeks. The adjusted mean changes of the primary outcome measure (PSQI) in the ICBT (?1.56, 95% CI ?2.52 to ?0.59; P<.001) and TGT (?1.15, 95% CI ?2.08 to ?0.23; P=.002) groups at 4 weeks from baseline showed a significant improvement compared with the WLC group. The adjusted mean changes in the secondary outcome measures of sleep onset latency, total sleep time, Athens Insomnia Scale score, and Patient Health Questionnaire-9 score at 4 weeks from baseline, as well as in the PSQI at 8 weeks from baseline, showed significant improvement for ICBT. Moreover, total sleep time, Athens Insomnia Scale, and Patient Health Questionnaire-9 scores at 4 weeks from baseline showed a significant improvement in the TGT group compared with the WLC group. Conclusions: A total of 4 weeks of unguided ICBT and TGT exercises improved insomnia. Trial Registration: University Hospital Medical Information Network Clinical Trial Registry UMIN000034927; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000039814 UR - https://www.jmir.org/2022/2/e28747 UR - http://dx.doi.org/10.2196/28747 UR - http://www.ncbi.nlm.nih.gov/pubmed/35138259 ID - info:doi/10.2196/28747 ER - TY - JOUR AU - Tang, Hao AU - Kim, Sungwoo AU - Laforet, E. Priscila AU - Tettey, Naa-Solo AU - Basch, H. Corey PY - 2022/2/9 TI - Loss of Weight Gained During the COVID-19 Pandemic: Content Analysis of YouTube Videos JO - JMIR Form Res SP - e35164 VL - 6 IS - 2 KW - COVID-19 KW - quarantine KW - weight loss KW - weight gain KW - social media KW - YouTube N2 - Background: Many people experienced unintended weight gain during the COVID-19 pandemic, which has been discussed widely on social media. Objective: This study aims to describe the content of weight loss videos on YouTube (Google LLC) during the COVID-19 pandemic. Methods: By using the keywords weight loss during quarantine, the 100 most viewed English-language videos were identified and coded for content related to losing weight gained during the COVID-19 pandemic. Results: In total, 9 videos were excluded due to having non-English content or posting data before the COVID-19 pandemic. The 91 videos included in the study sample acquired 407,326 views at the time of study and were roughly 14 minutes long. A total of 48% (44/91) of the sample videos included graphic comparisons to illustrate weight change. Videos that included a graphic comparison were more likely to have content related to trigger warnings (?21=6.05; P=.01), weight loss (?21=13.39; P<.001), negative feelings during quarantine (?21=4.75; P=.03), instructions for losing weight (?21=9.17; P=.002), self-love (?21=6.01; P=.01), body shaming (?21=4.36; P=.04), and special dietary practices (?21=11.10; P<.001) but were less likely to include food recipes (?21=5.05; P=.03). Our regression analysis results suggested that mentioning quarantine (P=.05), fat-gaining food (P=.04), self-care and self-love (P=.05), and body shaming (P=.008) and having presenters from both sexes (P<.001) are significant predictors for a higher number of views. Our adjusted regression model suggested that videos with content about routine change have significantly lower view counts (P=.03) than those of videos without such content. Conclusions: The findings of this study indicate the ways in which YouTube is being used to showcase COVID-19?related weight loss in a pre-post fashion. The use of graphic comparisons garnered a great deal of attention. Additional studies are needed to understand the role of graphic comparisons in social media posts. Further studies that focus on people?s attitudes and behaviors toward weight change during the COVID-19 pandemic and the implications of social media on these attitudes and behaviors are warranted. UR - https://formative.jmir.org/2022/2/e35164 UR - http://dx.doi.org/10.2196/35164 UR - http://www.ncbi.nlm.nih.gov/pubmed/34978534 ID - info:doi/10.2196/35164 ER - TY - JOUR AU - Ponnada, Aditya AU - Wang, Shirlene AU - Chu, Daniel AU - Do, Bridgette AU - Dunton, Genevieve AU - Intille, Stephen PY - 2022/2/9 TI - Intensive Longitudinal Data Collection Using Microinteraction Ecological Momentary Assessment: Pilot and Preliminary Results JO - JMIR Form Res SP - e32772 VL - 6 IS - 2 KW - intensive longitudinal data KW - ecological momentary assessment KW - experience sampling KW - microinteractions KW - smartwatch KW - health behavior research KW - mobile phone N2 - Background: Ecological momentary assessment (EMA) uses mobile technology to enable in situ self-report data collection on behaviors and states. In a typical EMA study, participants are prompted several times a day to answer sets of multiple-choice questions. Although the repeated nature of EMA reduces recall bias, it may induce participation burden. There is a need to explore complementary approaches to collecting in situ self-report data that are less burdensome yet provide comprehensive information on an individual?s behaviors and states. A new approach, microinteraction EMA (?EMA), restricts EMA items to single, cognitively simple questions answered on a smartwatch with single-tap assessments using a quick, glanceable microinteraction. However, the viability of using ?EMA to capture behaviors and states in a large-scale longitudinal study has not yet been demonstrated. Objective: This paper describes the ?EMA protocol currently used in the Temporal Influences on Movement & Exercise (TIME) Study conducted with young adults, the interface of the ?EMA app used to gather self-report responses on a smartwatch, qualitative feedback from participants after a pilot study of the ?EMA app, changes made to the main TIME Study ?EMA protocol and app based on the pilot feedback, and preliminary ?EMA results from a subset of active participants in the TIME Study. Methods: The TIME Study involves data collection on behaviors and states from 246 individuals; measurements include passive sensing from a smartwatch and smartphone and intensive smartphone-based hourly EMA, with 4-day EMA bursts every 2 weeks. Every day, participants also answer a nightly EMA survey. On non?EMA burst days, participants answer ?EMA questions on the smartwatch, assessing momentary states such as physical activity, sedentary behavior, and affect. At the end of the study, participants describe their experience with EMA and ?EMA in a semistructured interview. A pilot study was used to test and refine the ?EMA protocol before the main study. Results: Changes made to the ?EMA study protocol based on pilot feedback included adjusting the single-question selection method and smartwatch vibrotactile prompting. We also added sensor-triggered questions for physical activity and sedentary behavior. As of June 2021, a total of 81 participants had completed at least 6 months of data collection in the main study. For 662,397 ?EMA questions delivered, the compliance rate was 67.6% (SD 24.4%) and the completion rate was 79% (SD 22.2%). Conclusions: The TIME Study provides opportunities to explore a novel approach for collecting temporally dense intensive longitudinal self-report data in a sustainable manner. Data suggest that ?EMA may be valuable for understanding behaviors and states at the individual level, thus possibly supporting future longitudinal interventions that require within-day, temporally dense self-report data as people go about their lives. UR - https://formative.jmir.org/2022/2/e32772 UR - http://dx.doi.org/10.2196/32772 UR - http://www.ncbi.nlm.nih.gov/pubmed/35138253 ID - info:doi/10.2196/32772 ER - TY - JOUR AU - Kaiser, Julia AU - Nagl, Michaela AU - Hoffmann, Rahel AU - Linde, Katja AU - Kersting, Anette PY - 2022/2/8 TI - Therapist-Assisted Web-Based Intervention for Prolonged Grief Disorder After Cancer Bereavement: Randomized Controlled Trial JO - JMIR Ment Health SP - e27642 VL - 9 IS - 2 KW - digital interventions KW - grief KW - traumatic loss KW - treatment effectiveness evaluation KW - cognitive behavioral therapy KW - neoplasms N2 - Background: Bereavement due to cancer increases the risk of prolonged grief disorder. However, specialized treatment options for prolonged grief after a loss due to illness are still scarce. Objective: The aim of this study is to extend previous findings by evaluating a web-based cognitive behavioral intervention with asynchronous therapist support, consisting of structured writing tasks adapted specifically for prolonged grief after cancer bereavement. Methods: The intervention was evaluated in a purely web-based randomized waitlist-controlled trial. Open-access recruitment of participants was conducted on the web. Prolonged grief (Inventory of Complicated Grief), depression, anxiety, posttraumatic stress, posttraumatic growth, somatization, sleep quality, and mental and physical health were assessed on the web via validated self-report measures. Results: A total of 87 participants were randomized into the intervention group (IG; 44/87, 51%) or the waitlist control group (43/87, 49%). Of the participants, 7% (6/87) dropped out of the study (5/44, 11%, in the IG). Of the 39 completers in the IG, 37 (95%) completed all intervention tasks. The intervention reduced symptoms of prolonged grief (intention-to-treat: P<.001; ?2=0.34; Cohen d=0.80) to a clinically significant extent. It had favorable effects on depression, anxiety, posttraumatic stress, posttraumatic growth, and overall mental health but not on somatization, sleep quality, or physical health. Conclusions: The web-based intervention for prolonged grief after cancer bereavement is effective in reducing symptoms of prolonged grief disorder and accompanying syndromes in a timely, easily realizable manner and addresses specific challenges of bereavement to illness. Considering web-based approaches in future mental health care policy and practice can reduce health care gaps for those who are bereaved to cancer. Trial Registration: German?Clinical?Trial?Register?U1111?1186-6255;?https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011001 UR - https://mental.jmir.org/2022/2/e27642 UR - http://dx.doi.org/10.2196/27642 UR - http://www.ncbi.nlm.nih.gov/pubmed/35133286 ID - info:doi/10.2196/27642 ER - TY - JOUR AU - Pit, Winona Sabrina AU - Tan, H. Aaron J. AU - Ramsden, Robyn AU - Payne, Kristy AU - Freihaut, Winona AU - Hayes, Oliver AU - Eames, Benjamin AU - Edwards, Mike AU - Colbran, Richard PY - 2022/2/7 TI - Persuasive Design Solutions for a Sustainable Workforce: Review of Persuasive Apps for Real-Time Capability Support for Rural Health Care Professionals JO - JMIR Mhealth Uhealth SP - e33413 VL - 10 IS - 2 KW - health KW - wellness KW - mobile apps KW - persuasive strategies KW - behavior change KW - review KW - health workforce KW - capability KW - career KW - employment KW - rural KW - workforce planning N2 - Background: There is a need to further investigate how persuasive design principles can change rural health professionals? behaviors to look after their own health workforce capability. Several theories are used when developing apps to persuade people to change behavior, including the Persuasive System Design Model, consisting of primary task, dialogue, system credibility, and social support categories, and Cialdini?s principles of persuasion. These have not been analyzed yet in the field of health workforce capability. Objective: This study aims to determine the persuasive design techniques used in capability building?related apps and to provide recommendations for designing a health workforce app to increase their persuasiveness. Methods: A Python script was used to extract a total of 3060 apps from Google Play. Keywords centered around health workforce capability elements. App inclusion criteria were as follows: been updated since 2019, rated by users on average 4 and above, and more than 100,000 downloads. Next, 2 experts reviewed whether 32 persuasive strategies were used in the selected apps, and these were further analyzed by capability categories: competencies and skills, health and personal qualities, values and attitudes, and work organization. Results: In all, 53 mobile apps were systematically reviewed to identify the persuasive design techniques. The most common were surface credibility (n=48, 90.6%) and liking (n=48), followed by trustworthiness (n=43, 81.1%), reminders (n=38, 71.7%), and suggestion (n=30, 56.6%). The techniques in the social support domain were the least used across the different apps analyzed for health workforce capability, whereas those in the primary task support domain were used most frequently. The recommendations reflect learnings from our analysis. These findings provided insight into mobile app design principles relevant to apps used in improving health workforce capability. Conclusions: Our review showed that there are many persuasive design techniques that can assist in building health workforce capability. Additionally, several apps are available in the market that can assist in improving health workforce capability. There is, however, a specific lack of digital, real-time support to improve health workforce capability. Social support strategies through using social support persuasive design techniques will need to be integrated more prominently into a health workforce capability app. An app to measure and monitor health workforce capability scores can be used in conjunction with direct real-world person and real-time support to discuss and identify solutions to improve health workforce capability for rural and remote health professionals who are at high risk of burnout or leaving the rural health workforce. UR - https://mhealth.jmir.org/2022/2/e33413 UR - http://dx.doi.org/10.2196/33413 UR - http://www.ncbi.nlm.nih.gov/pubmed/35129447 ID - info:doi/10.2196/33413 ER - TY - JOUR AU - Gray, Michelle AU - Madero, N. Erica AU - Gills, L. Joshua AU - Paulson, Sally AU - Jones, D. Megan AU - Campitelli, Anthony AU - Myers, Jennifer AU - Bott, T. Nicholas AU - Glenn, M. Jordan PY - 2022/2/4 TI - Intervention for a Digital, Cognitive, Multi-Domain Alzheimer Risk Velocity Study: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e31841 VL - 11 IS - 2 KW - health coaching KW - Alzheimer risk KW - digital health KW - mobile phone N2 - Background: In the United States, more than 6 million adults live with Alzheimer disease (AD) that affects 1 out of every 3 older adults. Although there is no cure for AD currently, lifestyle-based interventions aimed at slowing the rate of cognitive decline or delaying the onset of AD have shown promising results. However, most studies primarily focus on older adults (>55 years) and use in-person interventions. Objective: The aim of this study is to determine the effects of a 2-year digital lifestyle intervention on AD risk among at-risk middle-aged and older adults (45-75 years) compared with a health education control. Methods: The lifestyle intervention consists of a digitally delivered, personalized health coaching program that directly targets the modifiable risk factors for AD. The primary outcome measure is AD risk as determined by the Australian National University-Alzheimer Disease Risk Index; secondary outcome measures are functional fitness, blood biomarkers (inflammation, glucose, cholesterol, and triglycerides), and cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status and Neurotrack Cognitive Battery). Screening commenced in January 2021 and was completed in June 2021. Results: Baseline characteristics indicate no difference between the intervention and control groups for AD risk (mean ?1.68, SD 7.31; P=.90). Conclusions: The intervention in the Digital, Cognitive, Multi-domain Alzheimer Risk Velocity is uniquely designed to reduce the risk of AD through a web-based health coaching experience that addresses the modifiable lifestyle-based risk factors. Trial Registration: ClinicalTrials.gov NCT04559789; https://clinicaltrials.gov/show/NCT04559789 International Registered Report Identifier (IRRID): DERR1-10.2196/31841 UR - https://www.researchprotocols.org/2022/2/e31841 UR - http://dx.doi.org/10.2196/31841 UR - http://www.ncbi.nlm.nih.gov/pubmed/35119374 ID - info:doi/10.2196/31841 ER - TY - JOUR AU - Collins, Tracie AU - Geana, Mugur AU - Overton, Kathryn AU - Benton, Mary AU - Lu, Liuqiang AU - Khan, Faarina AU - Rohleder, Mason AU - Ahluwalia, Jasjit AU - Resnicow, Ken AU - Zhu, Yiliang PY - 2022/2/3 TI - Use of a Smartphone App Versus Motivational Interviewing to Increase Walking Distance and Weight Loss in Overweight/Obese Adults With Peripheral Artery Disease: Pilot Randomized Trial JO - JMIR Form Res SP - e30295 VL - 6 IS - 2 KW - mobile health KW - smartphone app KW - peripheral artery disease KW - motivational interviewing N2 - Background: Walking therapy improves functional outcomes in patients with peripheral artery disease (PAD). Less is known about the additive benefit of a dietary intervention. Objective: Our objectives were to develop a smartphone app and, as a pilot, explore its potential efficacy as compared to motivational interviewing (MI) to increase walking distance and promote weight loss in overweight/obese adults with PAD. Methods: We conducted a 3-month, 2-arm randomized pilot study at the University of Kansas. Inclusion criteria were BMI >27 kg/m2 and symptomatic PAD, defined by an ankle-brachial index <0.9. Patients were randomized into 2 groups: MI, delivered through in-person and telephone counseling, and app, a mobile smartphone app. Both interventions encouraged walking for exercise and healthy dietary habits (increasing fruits and vegetables and whole grains while reducing fat and sugary drinks). We assessed medical history at baseline. At baseline and 3 months, participants completed an assessment of 6-minute walking distance, weight, quality of life, exercise behaviors, and dietary habits. The primary outcome was 3-month change in walking distance. Secondary outcomes were changes in weight, quality of life, exercise behaviors, and dietary habits. We used a Wilcoxon rank-sum test to analyze the primary and secondary outcomes at 3 months within the MI and app groups and to compare the changes between the groups with adjustment for baseline. Results: We randomized 29 participants with a mean age of 66.03 (SD 8.12) years; 25 participants completed the trial. At baseline, mean walking distance among completers was 260.40 (SD 94.32) meters and 326.15 (SD 69.28) meters for MI and app participants, respectively. At 3 months, the mean walking distance was 298.67 (SD 101.20) meters and 331.19 (SD 58.63) meters for MI and app participants, respectively (group difference P=.03, adjusting for baseline). Increase in walking distance at 3 months was 40.5 meters (95% CI 6.77 to 61.34; P=.02) in MI group. At baseline, mean body weight was 253.10 (SD 59.45) lbs and 225.13 (SD 58.93) lbs for MI and app participants, respectively. At 3 months, mean body weight was 242.14 (SD 58.54) lbs and 223.44 (SD 59.54) lbs for MI and app, respectively (group difference P=.006, adjusting for baseline). Pre-post study decrease in weight was 10.1 lbs (95% CI ?17.9 to ?3.0) and 2.3 lbs (95% CI ?3.4 to ?0.7) in MI and app group, respectively. Comparing baseline to 3 months, there were no statistically significant differences in quality of life, exercise behaviors, or dietary habits. Conclusions: Our study demonstrates that MI can promote walking and weight loss in overweight/obese adults with PAD. The smartphone app showed a small weight loss but no statistically significant increase in walking distance. As this was a pilot study, future large-scale studies are needed to replicate the efficacy of MI to promote weight loss in overweight or obese adults with PAD. Trial Registration: ClinicalTrials.gov NCT03694652; https://clinicaltrials.gov/ct2/show/NCT03694652 UR - https://formative.jmir.org/2022/2/e30295 UR - http://dx.doi.org/10.2196/30295 UR - http://www.ncbi.nlm.nih.gov/pubmed/35113020 ID - info:doi/10.2196/30295 ER - TY - JOUR AU - Xu, Linqi AU - Shi, Hongyu AU - Shen, Meidi AU - Ni, Yuanyuan AU - Zhang, Xin AU - Pang, Yue AU - Yu, Tianzhuo AU - Lian, Xiaoqian AU - Yu, Tianyue AU - Yang, Xige AU - Li, Feng PY - 2022/2/3 TI - The Effects of mHealth-Based Gamification Interventions on Participation in Physical Activity: Systematic Review JO - JMIR Mhealth Uhealth SP - e27794 VL - 10 IS - 2 KW - mobile health KW - gamification KW - physical activity KW - systematic review KW - mobile phone N2 - Background: It is well known that regular physical exercise has associated benefits; yet, participation remains suboptimal. Mobile health (mHealth) has become an indispensable medium to deliver behavior change interventions, and there is a growing interest in the gamification apps in mHealth to promote physical activity (PA) participation. Gamification could use game design elements (such as points, leaderboards, and progress bars), and it has the potential to increase motivation for PA and engagement. However, mHealth-based gamification interventions are still emerging, and little is known about the application status and efficacy of such interventions. Objective: This systematic review aims to investigate gamification apps in mHealth for improving PA levels and simultaneously summarize the impact of gamification interventions on PA participation. Methods: We searched PubMed, Scopus, Web of Science, Embase, CINAHL (EBSCO host), and IEEE Xplore from inception to December 20, 2020. Original empirical research exploring the effects of gamification interventions on PA participation was included. The papers described at least one outcome regarding exercise or PA participation, which could be subjective self-report or objective indicator measurement. Of note, we excluded studies about serious games or full-fledged games. Results: Of 2944 studies identified from the database search, 50 (1.69%) were included, and the information was synthesized. The review revealed that gamification of PA had been applied to various population groups and broadly distributed among young people but less distributed among older adults and patients with a disease. Most of the studies (30/50, 60%) combined gamification with wearable devices to improve PA behavior change, and 50% (25/50) of the studies used theories or principles for designing gamified PA interventions. The most frequently used game elements were goal-setting, followed by progress bars, rewards, points, and feedback. This review demonstrated that gamification interventions could increase PA participation; however, the results were mixed, and modest changes were attained, which could be attributed to the heterogeneity across studies. Conclusions: Overall, this study provides an overview of the existing empirical research in PA gamification interventions and provides evidence for the efficacy of gamification in enhancing PA participation. High-quality empirical studies are needed in the future to assess the efficacy of a combination of gamification and wearable activity devices to promote PA, and further exploration is needed to investigate the optimal implementation of these features of game elements and theories to enhance PA participation. UR - https://mhealth.jmir.org/2022/2/e27794 UR - http://dx.doi.org/10.2196/27794 UR - http://www.ncbi.nlm.nih.gov/pubmed/35113034 ID - info:doi/10.2196/27794 ER - TY - JOUR AU - Liu, Yunxin AU - Stamos, Angelos AU - Dewitte, Siegfried AU - van Berlo, C. Zeph M. AU - van der Laan, N. Laura PY - 2022/2/3 TI - Development and Evaluation of a Virtual Reality Puzzle Game to Decrease Food Intake: Randomized Controlled Trial JO - JMIR Serious Games SP - e31747 VL - 10 IS - 1 KW - virtual reality KW - pre-exposure KW - self-control KW - hedonic consumption KW - food cravings N2 - Background: Virtual reality (VR) has gained popularity in daily life, and VR food cues seem to elicit food cravings, similar to real food cues. However, little is known about the impact of VR food cues on actual food intake. Objective: In real life (RL), exposure to food cues in a situation in which the desire to eat food interferes with the completion of a food-related task reduces the subsequent food intake (ie, the pre-exposure effect). In this study, we examine, on the one hand, whether the pre-exposure effect could be replicated in RL and, on the other hand, whether this effect could be extended to VR contexts. Methods: The study used a 2 (stimulus type: food vs nonfood) × 2 (mode: VR vs RL) between-subject design (n=175). Participants were randomly assigned to 1 of the 4 conditions. Results: We found the main effect of mode on food intake, with a higher food intake after both VR conditions than after RL conditions (P=.02). In addition, among female participants, we found that exposure to both food cues (ie, VR and RL) resulted in lower food intake than exposure to both nonfood cues (P=.05). In contrast, this effect was not observed among male participants (P=.34). Additionally, VR and RL cues generated similar emotional and behavioral responses (eg, arousal and game difficulty). Conclusions: We were unable to replicate the exposure effect in our complete sample. Subgroup analyses, however, showed that for women, exposure to food cues (either in VR or in RL) reduces food intake, indicating that a VR pre-exposure procedure may effectively be applied exclusively for women. Trial Registration: ClinicalTrials.gov NCT05169996; https://clinicaltrials.gov/ct2/show/NCT05169996 UR - https://games.jmir.org/2022/1/e31747 UR - http://dx.doi.org/10.2196/31747 UR - http://www.ncbi.nlm.nih.gov/pubmed/35113028 ID - info:doi/10.2196/31747 ER - TY - JOUR AU - Ilskens, Karina AU - Wrona, J. Kamil AU - Dockweiler, Christoph AU - Fischer, Florian PY - 2022/2/2 TI - An Evidence Map on Serious Games in Preventing Sexually Transmitted Infections Among Adolescents: Systematic Review About Outcome Categories Investigated in Primary Studies JO - JMIR Serious Games SP - e30526 VL - 10 IS - 1 KW - serious games KW - entertainment education KW - STI KW - STD KW - sexual health KW - effect KW - impact KW - sexually transmitted infections KW - adolescents KW - adolescent sexual health N2 - Background: Sexually transmitted infections (STIs) represent a global health risk. Adolescents are at increased risk of infection for several reasons such as lack of knowledge, risky sexual behaviors, and lack of behavioral sills (eg, to negotiate safer sex). Given the fact that adolescents often use digital media and that serious games are considered to have the potential to change knowledge, attitudes and behavior, serious games represent an opportunity for the prevention of STIs. Objective: The aim of this systematic review was to identify and systematically summarize the dimensions that have been investigated in primary studies on serious games targeting STI prevention among adolescents. Methods: A systematic review was conducted in PubMed and Web of Science. Studies published from 2009 to 2021 were included that assessed the effectiveness of serious games on adolescent sexual health. A total of 18 studies met the inclusion criteria and were categorized according to dimensions of effectiveness and user experience. Results: Various dimensions of effectiveness and aspects of user experience were investigated in the primary studies. In total, 9 dimensions of effectiveness were observed: sexual behavior, behavioral intentions, knowledge, attitudes and beliefs, self-efficacy and personal limitations, character traits and future orientation, environmental and individual risk factors, risk perception and risk assessment, as well as normative beliefs and (social) norms. Furthermore, several dimensions related to user experience were investigated in primary studies, that is, motivation, acceptability, trustworthiness, comprehensibility, handling and control, perceived effectiveness, as well as satisfaction. Conclusions: This review provides an overview of serious games interventions that are vastly different in approach, content, and even platform. In previous studies, knowledge has already been comprehensively assessed, and a positive influence of serious games on knowledge about sexual topics is evident. The results clearly show that adolescents? sexual knowledge has been increased by the serious games interventions. However, methodological and content differences in the surveys make it difficult to draw conclusions about the effectiveness related to changes in attitudes and behavior. UR - https://games.jmir.org/2022/1/e30526 UR - http://dx.doi.org/10.2196/30526 UR - http://www.ncbi.nlm.nih.gov/pubmed/35107438 ID - info:doi/10.2196/30526 ER - TY - JOUR AU - Lugones-Sanchez, Cristina AU - Recio-Rodriguez, I. Jose AU - Agudo-Conde, Cristina AU - Repiso-Gento, Irene AU - G Adalia, Esther AU - Ramirez-Manent, Ignacio José AU - Sanchez-Calavera, Antonia Maria AU - Rodriguez-Sanchez, Emiliano AU - Gomez-Marcos, A. Manuel AU - Garcia-Ortiz, Luis AU - PY - 2022/2/1 TI - Long-term Effectiveness of a Smartphone App Combined With a Smart Band on Weight Loss, Physical Activity, and Caloric Intake in a Population With Overweight and Obesity (Evident 3 Study): Randomized Controlled Trial JO - J Med Internet Res SP - e30416 VL - 24 IS - 2 KW - mobile app KW - telemedicine KW - eHealth KW - weight control KW - exercise KW - obesity KW - mobile phone N2 - Background: Multicomponent mobile health approaches can improve lifestyle intervention results, although little is known about their long-term effectiveness. Objective: This study aims to evaluate the long-term effectiveness (12 months) of a multicomponent mobile health intervention?combining a smartphone app, an activity tracker wristband, and brief counseling, compared with a brief counseling group only?on weight loss and improving body composition, physical activity, and caloric intake in Spanish sedentary adults with overweight or obesity. Methods: We conducted a randomized controlled, multicenter clinical trial (Evident 3). A total of 650 participants were recruited from 5 primary care centers, with 318 participants in the intervention group (IG) and 332 in the control group (CG). All participants were briefly counseled about a healthy diet and physical activity at the baseline visit. For the 3-month intervention period, the IG received training to use the app to promote healthy lifestyles and the smart band (Mi Band 2, Xiaomi). All measurements were performed at baseline and at 3 and 12 months. Physical activity was measured using the International Physical Activity Questionnaire?Short Form. Nutritional habits were assessed using the Food Frequency Questionnaire and Adherence to Mediterranean diet questionnaire. Results: Of the 650 participants included, 563 (86.6%) completed the 3-month visit and 443 (68.2%) completed the 12-month visit. After 12 months, the IG showed net differences in weight (?0.26, 95% CI ?1.21 to 0.70 kg; P=.02), BMI (?0.06, 95% CI ?0.41 to 0.28 points; P=.01), waist-height ratio (?0.25, 95% CI ?0.94 to 0.44; P=.03), body adiposity index (?0.33, 95% CI ?0.77 to 0.11; P=.03), waist circumference (?0.48, 95% CI ?1.62 to 0.66 cm, P=.04) and hip circumference (?0.69, 95% CI ?1.62 to 0.25 cm; P=.03). Both groups lowered daily caloric intake and increased adherence to the Mediterranean diet, with no differences between the groups. The IG increased light physical activity time (32.6, 95% CI ?30.3 to 95.04 min/week; P=.02) compared with the CG. Analyses by subgroup showed changes in body composition variables in women, people aged >50 years, and married people. Conclusions: The low-intensity intervention of the Evident 3 study showed, in the IG, benefits in weight loss, some body composition variables, and time spent in light physical activity compared with the CG at 3 months, but once the devices were collected, the downward trend was not maintained at the 12-month follow-up. No differences in nutritional outcomes were observed between the groups. Trial Registration: ClinicalTrials.gov NCT03175614; https://clinicaltrials.gov/ct2/show/NCT03175614 International Registered Report Identifier (IRRID): RR2-10.1097/MD.0000000000009633 UR - https://www.jmir.org/2022/2/e30416 UR - http://dx.doi.org/10.2196/30416 UR - http://www.ncbi.nlm.nih.gov/pubmed/35103609 ID - info:doi/10.2196/30416 ER - TY - JOUR AU - Nizam, Zayan Mohammed AU - Powell, Leigh AU - Zary, Nabil PY - 2022/2/1 TI - Elements That Underpin the Design, Development, and Evaluation of Social Media Health Interventions: Protocol for a Scoping Review JO - JMIR Res Protoc SP - e31911 VL - 11 IS - 2 KW - social media KW - health intervention KW - behavior change models KW - health improvement KW - intervention design KW - models of design KW - evaluating interventions N2 - Background: Social media use has grown tremendously over the years. Given the volume and diversity of people on social media and the amount of information being exchanged, it is perhaps unsurprising that social media is being used as an avenue to disseminate and deliver health interventions. There exists an opportunity for social media health interventions to make a positive impact on health. However, there is a need to understand more about the ways in which these interventions are designed, developed, and evaluated. This scoping protocol will review the current state of this field by charting the elements that drive the design, development, and evaluation of these interventions. This includes charting models, frameworks, and rationales for the interventions, as well as the platforms being used, and the health behaviors being targeted. This intention of this scoping review is to help inform those who wish to develop effective social media health interventions. Objective: The objective of this review is to map the elements that drive the design, development, and evaluation of social media health interventions. We define ?social media health intervention? as interventions that make use of social media platforms to disseminate or deliver health-related information and educational initiatives to the public. We will seek to chart the elements that drive the design, development, and delivery of such interventions, including their platforms and targeted health behaviors. Methods: The methodological framework for this review is guided by Arksey and O?Malley and enhancements by later studies. We will search relevant literature from 9 databases: (1) PubMed, (2) PsycINFO, (3) EMBASE, (4) Web of Science, (5) Scopus, (6) CINAHL, (7) ERIC, (8) MEDLINE, and (9) Google Scholar. The literature will be screened by at least two reviewers in 2 stages: (1) title/abstract screening against the eligibility criteria; and (2) eligible articles will then undergo a full-text screening. Data will be charted using the data charting tool developed by the authors. Results: The results of this study will be presented in a final scoping review paper, divided into 2 sections. The first section will describe the search strategy and study selection process and will contain the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. The second section will provide key details pertaining to the review objective and question. Conclusions: This review will help guide scholars looking to build social media health interventions toward evidence-based practices in design and evaluation. International Registered Report Identifier (IRRID): PRR1-10.2196/31911 UR - https://www.researchprotocols.org/2022/2/e31911 UR - http://dx.doi.org/10.2196/31911 UR - http://www.ncbi.nlm.nih.gov/pubmed/34848388 ID - info:doi/10.2196/31911 ER - TY - JOUR AU - Mourad, Ghassan AU - Eriksson-Liebon, Magda AU - Karlström, Patric AU - Johansson, Peter PY - 2022/1/28 TI - The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial JO - J Med Internet Res SP - e31674 VL - 24 IS - 1 KW - cardiac anxiety KW - cognitive behavioral therapy KW - health-related quality of life KW - internet delivered KW - noncardiac chest pain KW - psychological distress N2 - Background: Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. Objective: This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Methods: Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ?24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. Results: No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (?11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. Conclusions: iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions. Trial Registration: ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112 UR - https://www.jmir.org/2022/1/e31674 UR - http://dx.doi.org/10.2196/31674 UR - http://www.ncbi.nlm.nih.gov/pubmed/35089153 ID - info:doi/10.2196/31674 ER - TY - JOUR AU - Stark, Lea Anna AU - Geukes, Cornelia AU - Dockweiler, Christoph PY - 2022/1/28 TI - Digital Health Promotion and Prevention in Settings: Scoping Review JO - J Med Internet Res SP - e21063 VL - 24 IS - 1 KW - setting approach KW - health promotion KW - health prevention KW - eHealth KW - internet KW - behavior change KW - web-based intervention KW - technology KW - mobile phone N2 - Background: Digital technologies are increasingly integrating into people?s daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings. Objective: This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps. Methods: The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting?based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace. Results: From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting?based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention. Conclusions: The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings. UR - https://www.jmir.org/2022/1/e21063 UR - http://dx.doi.org/10.2196/21063 UR - http://www.ncbi.nlm.nih.gov/pubmed/35089140 ID - info:doi/10.2196/21063 ER - TY - JOUR AU - Stansbury, L. Melissa AU - Harvey, Jean AU - Krukowski, A. Rebecca AU - Pellegrini, A. Christine AU - Wang, Xuewen AU - West, Smith Delia PY - 2022/1/28 TI - Describing Transitions in Adherence to Physical Activity Self-monitoring and Goal Attainment in an Online Behavioral Weight Loss Program: Secondary Analysis of a Randomized Controlled Trial JO - J Med Internet Res SP - e30673 VL - 24 IS - 1 KW - physical activity KW - adherence KW - self-monitoring KW - goal attainment KW - lifestyle intervention N2 - Background: Standard behavioral weight loss interventions often set uniform physical activity (PA) goals and promote PA self-monitoring; however, adherence remains a challenge, and recommendations may not accommodate all individuals. Identifying patterns of PA goal attainment and self-monitoring behavior will offer a deeper understanding of how individuals adhere to different types of commonly prescribed PA recommendations (ie, minutes of moderate-to-vigorous physical activity [MVPA] and daily steps) and guide future recommendations for improved intervention effectiveness. Objective: This study examined weekly patterns of adherence to step-based and minute-based PA goals and self-monitoring behavior during a 6-month online behavioral weight loss intervention. Methods: Participants were prescribed weekly PA goals for steps (7000-10,000 steps/day) and minutes of MVPA (50-200 minutes/week) as part of a lifestyle program. Goals gradually increased during the initial 2 months, followed by 4 months of fixed goals. PA was self-reported daily on the study website. For each week, participants were categorized as adherent if they self-monitored their PA and met the program PA goal, suboptimally adherent if they self-monitored but did not meet the program goal, or nonadherent if they did not self-monitor. The probability of transitioning into a less adherent status was examined using multinomial logistic regression. Results: Participants (N=212) were predominantly middle-aged females with obesity, and 67 (31.6%) self-identified as a racial/ethnic minority. Initially, 73 (34.4%) participants were categorized as adherent to step-based goals, with 110 [51.9%] suboptimally adherent and 29 [13.7%] nonadherent, and there was a high probability of either remaining suboptimally adherent from week to week or transitioning to a nonadherent status. However, 149 (70.3%) participants started out adherent to minute-based goals (34 [16%] suboptimally adherent and 29 [13.7%] nonadherent), with suboptimally adherent seen as the most variable status. During the graded goal phase, participants were more likely to transition to a less adherent status for minute-based goals (odds ratio [OR] 1.39, 95% CI 1.31-1.48) compared to step-based goals (OR 1.24, 95% CI 1.17-1.30); however, no differences were seen during the fixed goal phase (minute-based goals: OR 1.06, 95% CI 1.05-1.08; step-based goals: OR 1.07, 95% CI 1.05-1.08). Conclusions: States of vulnerability to poor PA adherence can emerge rapidly and early in obesity treatment. There is a window of opportunity within the initial 2 months to bring more people toward adherent behavior, especially those who fail to meet the prescribed goals but engage in self-monitoring. Although this study describes the probability of adhering to step- and minute-based targets, it will be prudent to determine how individual characteristics and contextual states relate to these behavioral patterns, which can inform how best to adapt interventions. Trial Registration: ClinicalTrials.gov NCT02688621; https://clinicaltrials.gov/ct2/show/NCT02688621 UR - https://www.jmir.org/2022/1/e30673 UR - http://dx.doi.org/10.2196/30673 UR - http://www.ncbi.nlm.nih.gov/pubmed/35089159 ID - info:doi/10.2196/30673 ER - TY - JOUR AU - Freyer-Adam, Jennis AU - Baumann, Sophie AU - Bischof, Gallus AU - Staudt, Andreas AU - Goeze, Christian AU - Gaertner, Beate AU - John, Ulrich PY - 2022/1/28 TI - Social Equity in the Efficacy of Computer-Based and In-Person Brief Alcohol Interventions Among General Hospital Patients With At-Risk Alcohol Use: A Randomized Controlled Trial JO - JMIR Ment Health SP - e31712 VL - 9 IS - 1 KW - brief alcohol intervention KW - electronic KW - eHealth KW - digital KW - motivational interviewing KW - socioeconomic status KW - equity KW - social inequality KW - transtheoretical model KW - moderator KW - mental health KW - public health KW - alcohol interventions KW - digital intervention KW - digital health intervention KW - alcohol use N2 - Background: Social equity in the efficacy of behavior change intervention is much needed. While the efficacy of brief alcohol interventions (BAIs), including digital interventions, is well established, particularly in health care, the social equity of interventions has been sparsely investigated. Objective: We aim to investigate whether the efficacy of computer-based versus in-person delivered BAIs is moderated by the participants? socioeconomic status (ie, to identify whether general hospital patients with low-level education and unemployed patients may benefit more or less from one or the other way of delivery compared to patients with higher levels of education and those that are employed). Methods: Patients with nondependent at-risk alcohol use were identified through systematic offline screening conducted on 13 general hospital wards. Patients were approached face-to-face and asked to respond to an app for self-assessment provided by a mobile device. In total, 961 (81% of eligible participants) were randomized and received their allocated intervention: computer-generated and individually tailored feedback letters (CO), in-person counseling by research staff trained in motivational interviewing (PE), or assessment only (AO). CO and PE were delivered on the ward and 1 and 3 months later, were based on the transtheoretical model of intentional behavior change and required the assessment of intervention data prior to each intervention. In CO, the generation of computer-based feedback was created automatically. The assessment of data and sending out feedback letters were assisted by the research staff. Of the CO and PE participants, 89% (345/387) and 83% (292/354) received at least two doses of intervention, and 72% (280/387) and 54% (191/354) received all three doses of intervention, respectively. The outcome was change in grams of pure alcohol per day after 6, 12, 18, and 24 months, with the latter being the primary time-point of interest. Follow-up interviewers were blinded. Study group interactions with education and employment status were tested as predictors of change in alcohol use using latent growth modeling. Results: The efficacy of CO and PE did not differ by level of education (P=.98). Employment status did not moderate CO efficacy (Ps?.66). Up to month 12 and compared to employed participants, unemployed participants reported significantly greater drinking reductions following PE versus AO (incidence rate ratio 0.44, 95% CI 0.21-0.94; P=.03) and following PE versus CO (incidence rate ratio 0.48, 95% CI 0.24?0.96; P=.04). After 24 months, these differences were statistically nonsignificant (Ps?.31). Conclusions: Computer-based and in-person BAI worked equally well independent of the patient?s level of education. Although findings indicate that in the short-term, unemployed persons may benefit more from BAI when delivered in-person rather than computer-based, the findings suggest that both BAIs have the potential to work well among participants with low socioeconomic status. Trial Registration: ClinicalTrials.gov NCT01291693; https://clinicaltrials.gov/ct2/show/NCT01291693 UR - https://mental.jmir.org/2022/1/e31712 UR - http://dx.doi.org/10.2196/31712 UR - http://www.ncbi.nlm.nih.gov/pubmed/35089156 ID - info:doi/10.2196/31712 ER - TY - JOUR AU - Duan, Yanping AU - Liang, Wei AU - Wang, Yanping AU - Lippke, Sonia AU - Lin, Zhihua AU - Shang, Borui AU - Baker, Steven Julien PY - 2022/1/26 TI - The Effectiveness of Sequentially Delivered Web-Based Interventions on Promoting Physical Activity and Fruit-Vegetable Consumption Among Chinese College Students: Mixed Methods Study JO - J Med Internet Res SP - e30566 VL - 24 IS - 1 KW - web-based intervention KW - physical activity KW - fruit-vegetable consumption KW - college students KW - health action process approach KW - mixed methods KW - quantitative research KW - qualitative research N2 - Background: Web-based interventions for multiple health behavior change (MHBC) appear to be a promising approach to change unhealthy habits. Limited research has tested this assumption in promoting physical activity (PA) and fruit-vegetable consumption (FVC) among Chinese college students. Moreover, the timing of MHBC intervention delivery and the order of components need to be addressed. Objective: This study aims to examine the effectiveness of 2 sequentially delivered 8-week web-based interventions on physical activity, FVC, and health-related outcomes (BMI, depression, and quality of life) and the differences in the intervention effects between the 2 sequential delivery patterns. The study also aims to explore participants? experiences of participating in the health program. Methods: We conducted a randomized controlled trial, in which 552 eligible college students (mean 19.99, SD 1.04 years, 322/552, 58.3% female) were randomly assigned to 1 of 3 groups: PA-first group (4 weeks of PA followed by 4 weeks of FVC intervention), FVC-first group (4 weeks of FVC followed by 4 weeks of PA intervention), and a control group (8 weeks of placebo treatment unrelated to PA and FVC). The treatment content of two intervention groups was designed based on the Health Action Process Approach (HAPA) framework. A total of four web-based assessments were conducted: at baseline (T1, n=565), after 4 weeks (T2, after the first behavior intervention, n=486), after 8 weeks (T3, after the second behavior intervention, n=420), and after 12 weeks (T4, 1-month postintervention follow-up, n=348). In addition, after the completion of the entire 8-week intervention, 18 participants (mean 19.56, SD 1.04 years, 10/18, 56% female) who completed the whole program were immediately invited to attend one-to-one and face-to-face semistructured interviews. The entire study was conducted during the fall semester of 2017. Results: The quantitative data supported superior effects on physical activity, FVC, and BMI in the 2 sequential intervention groups compared with the control group. There were no significant differences in physical activity, FVC, and health-related outcomes between the 2 intervention groups after 8 weeks. The FVC-first group contributed to more maintenance of FVC compared with the PA-first group after 12 weeks. Four major themes with several subthemes were identified in the qualitative thematic analysis: PA and FVC behavior, health-related outcomes, correlates of behavior change, and contamination detection. Conclusions: This study provides empirical evidence for the effectiveness of sequentially delivered, web-based MHBC interventions on PA and FVC among Chinese college students. The timing issue of MHBC intervention delivery was preliminarily addressed. Qualitative findings provide an in-depth understanding and supplement the quantitative findings. Overall, this study may contribute considerably to future web-based MHBC interventions. Trial Registration: ClinicalTrials.gov NCT03627949; https://clinicaltrials.gov/ct2/show/NCT03627949 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-019-7438-1 UR - https://www.jmir.org/2022/1/e30566 UR - http://dx.doi.org/10.2196/30566 UR - http://www.ncbi.nlm.nih.gov/pubmed/35080497 ID - info:doi/10.2196/30566 ER - TY - JOUR AU - Bonnell, N. Levi AU - Obi, Ngozi AU - Miller, Kimberly AU - Hu, Sophia AU - Dellavalle, Robert AU - Cockburn, Myles PY - 2022/1/25 TI - Intent to Change Sun-Protective Behaviors Among Hispanic People After a UV Photoaging Intervention: Cohort Study JO - JMIR Dermatol SP - e33339 VL - 5 IS - 1 KW - risk assessment KW - sun safety KW - intention to change KW - sun exposure behavior KW - melanoma KW - Hispanic KW - sun damage KW - skin cancer N2 - Background: Mortality rates from melanoma are higher among Hispanic populations than non-Hispanic White (NHW) populations. Interventions to improve sun safety are needed. The Reveal Imager is a camera that uses standard cross-polarized flash photography to record surface and subsurface skin conditions. Objective: This study aims to determine the intervention?s effectiveness in increasing awareness of sun damage and exposure reduction between Hispanic and NHW populations. Methods: A cohort of 322 participants, aged ?18 years, were recruited from community events in 2018. Baseline information was collected on demographics, sun exposure, and perception of risk factors. A facial image was then captured using the Reveal Imager. The results were explained and counseling on sun safety was given, followed by filling out an immediate postimage survey. Chi-square tests, analysis of variance, Wilcoxon signed-rank test, McNemar tests, and multivariable logistic regression were used. Results: At follow-up, 125 of 141 (89%) Hispanic participants reported that viewing the UV photoaged image influenced intent-to-change sun protection behaviors, compared to 88 of 121 (73%) NHW participants (odds ratio 2.9, 95% CI 1.5-5.6). Of 141 Hispanic participants, 96 (68%) reported that they intended to increase sunscreen use, compared to only 41 of 121 (34%) NHW participants (P<.001). Conclusions: We demonstrated an application of Reveal Imager for education and risk assessment. The Reveal Imager was especially helpful in motivating intention to change sun exposure among Hispanic populations. UR - https://derma.jmir.org/2022/1/e33339 UR - http://dx.doi.org/10.2196/33339 ID - info:doi/10.2196/33339 ER - TY - JOUR AU - Thesen, Terje AU - Himle, A. Joseph AU - Martinsen, W. Egil AU - Walseth, T. Liv AU - Thorup, Frode AU - Gallefoss, Frode AU - Jonsbu, Egil PY - 2022/1/24 TI - Effectiveness of Internet-Based Cognitive Behavioral Therapy With Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial JO - J Med Internet Res SP - e33631 VL - 24 IS - 1 KW - noncardiac chest pain KW - internet-based treatment KW - internet-assisted treatment KW - cognitive behavioral therapy KW - psychosomatic medicine KW - randomized controlled trial KW - pain KW - treatment KW - internet-based cognitive behavioral therapy KW - effectiveness KW - support KW - intervention N2 - Background: Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain. Objective: In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain. Methods: We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ?5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes. Results: In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (?3.4 points, 95% CI ?5.7 to ?1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (?2.7 points, 95% CI ?5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions. Conclusions: This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain. Trial Registration: ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925 UR - https://www.jmir.org/2022/1/e33631 UR - http://dx.doi.org/10.2196/33631 UR - http://www.ncbi.nlm.nih.gov/pubmed/35072641 ID - info:doi/10.2196/33631 ER - TY - JOUR AU - Agher, Dahbia AU - Sedki, Karima AU - Despres, Sylvie AU - Albinet, Jean-Pierre AU - Jaulent, Marie-Christine AU - Tsopra, Rosy PY - 2022/1/20 TI - Encouraging Behavior Changes and Preventing Cardiovascular Diseases Using the Prevent Connect Mobile Health App: Conception and Evaluation of App Quality JO - J Med Internet Res SP - e25384 VL - 24 IS - 1 KW - digital health KW - mHealth, mobile application KW - IT KW - technology KW - prevention KW - cardiovascular risk factor KW - behavior change KW - primary care N2 - Background: Cardiovascular diseases are a major cause of death worldwide. Mobile health apps could help in preventing cardiovascular diseases by improving modifiable risk factors such as eating habits, physical activity levels, and alcohol or tobacco consumption. Objective: The aim of this study was to design a mobile health app, Prevent Connect, and to assess its quality for (1) assessing patient behavior for 4 cardiovascular risk factors (unhealthy eating, sedentary lifestyle, alcohol, and tobacco consumption) and (2) suggesting personalized recommendations and mobile health interventions for risky behaviors. Methods: The knowledge base of the app is based on French national recommendations for healthy eating, physical activity, and limiting alcohol and tobacco consumption. It contains a list of patient behaviors and related personalized recommendations and digital health interventions. The interface was designed according to usability principles. Its quality was assessed by a panel of 52 users in a 5-step process: completion of the demographic form, visualization of a short presentation of the app, testing of the app, completion of the user version of the Mobile App Rating Scale (uMARS), and an open group discussion. Results: This app assesses patient behaviors through specific questionnaires about 4 risk factors (unhealthy eating, sedentary lifestyle, alcohol, and tobacco consumption) and suggests personalized recommendations and digital health interventions for improving behavior. The app was deemed to be of good quality, with a mean uMARS quality score of 4 on a 5-point Likert scale. The functionality and information content of the app were particularly appreciated, with a mean uMARS score above 4. Almost all the study participants appreciated the navigation system and found the app easy to use. More than three-quarters of the study participants found the app content relevant, concise, and comprehensive. The aesthetics and the engagement of the app were also appreciated (uMARS score, 3.7). Overall, 80% (42/52) of the study participants declared that the app helped them to become aware of the importance of addressing health behavior, and 65% (34/52) said that the app helped motivate them to change lifestyle habits. Conclusions: The app assessed the risky behaviors of the patients and delivered personalized recommendations and digital health interventions for multiple risk factors. The quality of the app was considered to be good, but the impact of the app on behavior changes is yet to be demonstrated and will be assessed in further studies. UR - https://www.jmir.org/2022/1/e25384 UR - http://dx.doi.org/10.2196/25384 UR - http://www.ncbi.nlm.nih.gov/pubmed/35049508 ID - info:doi/10.2196/25384 ER - TY - JOUR AU - Richardson, M. Kelli AU - Saleh, A. Ahlam AU - Jospe, R. Michelle AU - Liao, Yue AU - Schembre, M. Susan PY - 2022/1/18 TI - Using Biological Feedback to Promote Health Behavior Change in Adults: Protocol for a Scoping Review JO - JMIR Res Protoc SP - e32579 VL - 11 IS - 1 KW - monitoring KW - physiologic KW - biomarkers KW - feedback KW - psychological KW - health behavior KW - health promotion KW - biofeedback KW - health databases KW - health interventions N2 - Background: Many health conditions can be prevented, managed, or improved through behavioral interventions. As a component of health behavior change interventions, biological feedback is of particular interest given recent advances in wearable biosensing technology, digital health apps, and personalized health and wellness. Nevertheless, there is a paucity of literature to guide the design and implementation of interventions that incorporate biological feedback to motivate health behavior change. Objective: The goal of this scoping review is to deeply explore the use of biological feedback as a component of health behavior change interventions that target adults. The objectives of the review include (1) mapping the domains of research that incorporate biological feedback and (2) describing the operational characteristics of using biological feedback in the context of health behavior change. Methods: A comprehensive list of search terms was developed to capture studies from a wide range of domains. The studies to be included are randomized controlled trials published as primary research articles, theses, or dissertations targeting adults 18 years and older, who use biological feedback to change a health-related behavior. The following electronic databases were searched: Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, EBSCOhost, PsycINFO, and ProQuest Dissertations & Theses Global. The screening and data extraction process will be guided by the Joanna Briggs Institute Manual for Evidence Synthesis and conducted by trained reviewers. Results: Database searches were completed in June 2021. A total of 50,459 unique records were returned after the removal of 48,634 duplicate records. The scoping review is planned for completion in 2022. Conclusions: To our knowledge, this will be the first scoping review to map the literature that uses biological feedback as a component of health behavior change interventions targeting adults. The findings will be used to develop a framework to guide the design and implementation of future health behavior change interventions that incorporate biological feedback. Trial Registration: OSF Registries OSF.IO/YP5WA; https://osf.io/yp5wa International Registered Report Identifier (IRRID): DERR1-10.2196/32579 UR - https://www.researchprotocols.org/2022/1/e32579 UR - http://dx.doi.org/10.2196/32579 UR - http://www.ncbi.nlm.nih.gov/pubmed/35040792 ID - info:doi/10.2196/32579 ER - TY - JOUR AU - Poon, Kean PY - 2022/1/17 TI - Effects of Aerobic Exercise and High-Intensity Interval Training on the Mental Health of Adolescents Living in Poverty: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e34915 VL - 11 IS - 1 KW - adolescents KW - mental health KW - exercise KW - socioeconomic status KW - intervention N2 - Background: The increasing rate of mental health issues among adolescents has recently been a considerable concern in Hong Kong. In particular, adolescents with low socioeconomic status (SES) are likely to experience poor mental health, including low self-esteem and high levels of anxiety, anger, and depression. Previous research has found that physical activities have a positive impact on improving mental health outcomes among adolescents. However, approximately 96% of adolescents in Hong Kong do not engage in regular exercise, which potentially increases the risk of poor mental health. Objective: In this study, we aim to examine whether changes in the 3 indicators (reduced ill-being, enhanced well-being, and cognitive functions) of mental health among adolescents with low SES are evident before and after exercise. In addition, this study compares the effectiveness of aerobic exercise and high-intensity interval training on these indicators among adolescents with low SES. Methods: A total of 78 participants from low-income families aged between 12 and 15 years from 3 to 4 secondary schools will be recruited for this study. They will be randomly assigned to either an aerobic exercise group (26/78, 33%), a high-intensity interval training group (26/78, 33%), or a control group (26/78, 33%). Participants in the first 2 groups will take part in a 10-week training program period. Participants in the control group will participate in other physical activities during the same intervention period. The training sessions will be conducted 3 times per week on nonconsecutive days. A range of neuropsychological tests and psychometric scales will be used to measure the executive functions and indicators of psychological well-being and ill-being, including enjoyment, self-efficacy, mood, depression, anxiety, and stress at pretest, posttest, and follow-up assessments. Results: The project was funded in 2021 by the Research Matching Grant Scheme, through the University Grants Committee of the Hong Kong Special Administrative Region Government. Ethical approval has been obtained from the author?s institution. Participant recruitment will begin in January 2022 and continue through to April 2022. Data collection and follow-up are expected to be completed by the end of 2022. The results are expected to be submitted for publication in 2023. Conclusions: The findings will help inform policy makers and practitioners in promoting the importance of physical exercise to enhance mental health. Trial Registration: ClinicalTrials.gov NCT050293888; https://clinicaltrials.gov/ct2/show/record/NCT05029388 International Registered Report Identifier (IRRID): PRR1-10.2196/34915 UR - https://www.researchprotocols.org/2022/1/e34915 UR - http://dx.doi.org/10.2196/34915 UR - http://www.ncbi.nlm.nih.gov/pubmed/35037892 ID - info:doi/10.2196/34915 ER - TY - JOUR AU - Lee, Jaegyeong AU - Lim, Min Jung PY - 2022/1/14 TI - Factors Associated With the Experience of Cognitive Training Apps for the Prevention of Dementia: Cross-sectional Study Using an Extended Health Belief Model JO - J Med Internet Res SP - e31664 VL - 24 IS - 1 KW - cognitive training apps KW - dementia knowledge KW - health belief model KW - middle-aged KW - logistic regression analysis KW - dementia KW - Alzheimer disease KW - cognition KW - mobile apps KW - health apps N2 - Background: The prevalence and economic burden of dementia are increasing dramatically. Using information communication technology to improve cognitive functions is proven to be effective and holds the potential to serve as a new and efficient method for the prevention of dementia. Objective: The aim of this study was to identify factors associated with the experience of mobile apps for cognitive training in middle-aged adults. We evaluated the relationships between the experience of cognitive training apps and structural variables using an extended health belief model. Methods: An online survey was conducted on South Korean participants aged 40 to 64 years (N=320). General characteristics and dementia knowledge were measured along with the health belief model constructs. Statistical analysis and logistic regression analysis were performed. Results: Higher dementia knowledge (odds ratio [OR] 1.164, P=.02), higher perceived benefit (OR 1.373, P<.001), female gender (OR 0.499, P=.04), and family history of dementia (OR 1.933, P=.04) were significantly associated with the experience of cognitive training apps for the prevention of dementia. Conclusions: This study may serve as a theoretical basis for the development of intervention strategies to increase the use of cognitive training apps for the prevention of dementia. UR - https://www.jmir.org/2022/1/e31664 UR - http://dx.doi.org/10.2196/31664 UR - http://www.ncbi.nlm.nih.gov/pubmed/35029540 ID - info:doi/10.2196/31664 ER - TY - JOUR AU - Swindle, Taren AU - Poosala, B. Anwesh AU - Zeng, Nan AU - Børsheim, Elisabet AU - Andres, Aline AU - Bellows, L. Laura PY - 2022/1/11 TI - Digital Intervention Strategies for Increasing Physical Activity Among Preschoolers: Systematic Review JO - J Med Internet Res SP - e28230 VL - 24 IS - 1 KW - physical activity KW - preschool children KW - digital KW - technology KW - intervention N2 - Background: Digital interventions are increasingly used to improve health behaviors. Improved access and lower costs (relative to in-person interventions) make such interventions appealing. Specifically, digital platforms may be a promising approach for increasing physical activity (PA) in young children. Objective: The goal of this systematic review was three-pronged: (1) to determine the quality of studies using digital PA intervention strategies with preschool-aged children (ie, 3 to 5 years old); (2) to assess the efficacy of digital interventions and approaches designed to improve PA in preschool-aged children; and (3) to examine theoretical application and implementation outcomes with current approaches to digital PA interventions. Methods: This review identified and summarized studies on digitally supported interventions for promoting PA in preschool-aged children. We generated 3 lists of relevant search terms that included technology-related terms, PA-related terms, and weight-related terms. The search included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Study selection was led by a single author and verified by a second; the same 2 authors assessed study quality using a standardized tool, and 3 authors completed data extraction on PA outcomes, theory application, and implementation outcomes. Results: In total, 601 studies were identified; 8 met the inclusion criteria. For study quality, only 2 studies received an overall rating of strong quality and low risk of bias. All but 1 study had a small sample size (<100). Positive and significant changes in child PA outcomes were reported in only 2 studies with weak overall quality, both of which used child-directed approaches. In total, 5 studies applied a behavioral theory for designing the intervention; no patterns of effectiveness were identified based on the application of theory. Finally, no studies reported on the implementation outcomes of adoption, cost, penetration, or sustainability; 1 study did not assess any implementation outcomes, and no single study reported on more than 2 implementation outcomes. Studies measured the implementation outcome of acceptability most frequently (n=4), and researchers assessed fidelity in 3 studies. Conclusions: The interventions with a significant effect on PA used child-centered activities; parent-directed digital interventions alone were ineffective for improving PA. Future research with rigorous designs, monitoring of implementation outcomes, and testing of the contributions of digital components will advance understanding of the effectiveness of digital interventions for increasing PA in children. UR - https://www.jmir.org/2022/1/e28230 UR - http://dx.doi.org/10.2196/28230 UR - http://www.ncbi.nlm.nih.gov/pubmed/35014962 ID - info:doi/10.2196/28230 ER - TY - JOUR AU - Cincidda, Clizia AU - Pizzoli, Maria Silvia Francesca AU - Pravettoni, Gabriella PY - 2022/1/11 TI - Remote Psychological Interventions for Fear of Cancer Recurrence: Scoping Review JO - JMIR Cancer SP - e29745 VL - 8 IS - 1 KW - fear of cancer recurrence KW - cognitive behavioral therapy KW - acceptance and commitment therapy KW - mindfulness KW - eHealth KW - blended intervention N2 - Background: Patients with cancer and survivors may experience the fear of cancer recurrence (FCR), a preoccupation with the progression or recurrence of cancer. During the spread of COVID-19 in 2019, patients and survivors experienced increased levels of FCR. Hence, there is a greater need to identify effective evidence-based treatments to help people cope with FCR. Remotely delivered interventions might provide a valuable means to address FCR in patients with cancer. Objective: The aim of this study is to first discuss the available psychological interventions for FCR based on traditional cognitive behavioral therapies (CBTs) or contemporary CBTs, in particular, mindfulness and acceptance and commitment therapy, and then propose a possible approach based on the retrieved literature. Methods: We searched key electronic databases to identify studies that evaluated the effect of psychological interventions such as CBT on FCR among patients with cancer and survivors. Results: Current evidence suggests that face-to-face psychological interventions for FCR are feasible, acceptable, and efficacious for managing FCR. However, there are no specific data on the interventions that are most effective when delivered remotely. Conclusions: CBT interventions can be efficacious in managing FCR, especially at posttreatment, regardless of whether it is delivered face to face, on the web, or using a blended approach. To date, no study has simultaneously compared the effectiveness of face-to-face, web-based, and blended interventions. On the basis of the retrieved evidence, we propose the hypothetical program of an intervention for FCR based on both traditional CBT and contemporary CBT, named Change Of Recurrence, which aims to improve the management of FCR in patients with cancer and survivors. UR - https://cancer.jmir.org/2022/1/e29745 UR - http://dx.doi.org/10.2196/29745 UR - http://www.ncbi.nlm.nih.gov/pubmed/35014956 ID - info:doi/10.2196/29745 ER - TY - JOUR AU - Mattila, Elina AU - Hansen, Susanne AU - Bundgaard, Lise AU - Ramsey, Lauren AU - Dunning, Alice AU - Silva, N. Marlene AU - Harjumaa, Marja AU - Ermes, Miikka AU - Marques, M. Marta AU - Matos, Marcela AU - Larsen, C. Sofus AU - Encantado, Jorge AU - Santos, Inês AU - Horgan, Graham AU - O'Driscoll, Ruairi AU - Turicchi, Jake AU - Duarte, Cristiana AU - Palmeira, L. António AU - Stubbs, James R. AU - Heitmann, Lilienthal Berit AU - Lähteenmäki, Liisa PY - 2022/1/10 TI - Users? Experiences With the NoHoW Web-Based Toolkit With Weight and Activity Tracking in Weight Loss Maintenance: Long-term Randomized Controlled Trial JO - J Med Internet Res SP - e29302 VL - 24 IS - 1 KW - digital behavior change intervention KW - user experience KW - technology acceptance KW - weight-loss maintenance KW - focus groups KW - mixed methods KW - mobile phone N2 - Background: Digital behavior change interventions (DBCIs) offer a promising channel for providing health promotion services. However, user experience largely determines whether they are used, which is a precondition for effectiveness. Objective: The primary aim of this study is to evaluate user experiences with the NoHoW Toolkit (TK)?a DBCI that targets weight loss maintenance?over a 12-month period by using a mixed methods approach and to identify the main strengths and weaknesses of the TK and the external factors affecting its adoption. The secondary aim is to objectively describe the measured use of the TK and its association with user experience. Methods: An 18-month, 2×2 factorial randomized controlled trial was conducted. The trial included 3 intervention arms receiving an 18-week active intervention and a control arm. The user experience of the TK was assessed quantitatively through electronic questionnaires after 1, 3, 6, and 12 months of use. The questionnaires also included open-ended items that were thematically analyzed. Focus group interviews were conducted after 6 months of use and thematically analyzed to gain deeper insight into the user experience. Log files of the TK were used to evaluate the number of visits to the TK, the total duration of time spent in the TK, and information on intervention completion. Results: The usability level of the TK was rated as satisfactory. User acceptance was rated as modest; this declined during the trial in all the arms, as did the objectively measured use of the TK. The most appreciated features were weekly emails, graphs, goal setting, and interactive exercises. The following 4 themes were identified in the qualitative data: engagement with features, decline in use, external factors affecting user experience, and suggestions for improvements. Conclusions: The long-term user experience of the TK highlighted the need to optimize the technical functioning, appearance, and content of the DBCI before and during the trial, similar to how a commercial app would be optimized. In a trial setting, the users should be made aware of how to use the intervention and what its requirements are, especially when there is more intensive intervention content. Trial Registration: ISRCTN Registry ISRCTN88405328; https://www.isrctn.com/ISRCTN88405328 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2019-029425 UR - https://www.jmir.org/2022/1/e29302 UR - http://dx.doi.org/10.2196/29302 UR - http://www.ncbi.nlm.nih.gov/pubmed/35006081 ID - info:doi/10.2196/29302 ER - TY - JOUR AU - Kruzan, Payne Kaylee AU - Whitlock, Janis AU - Bazarova, N. Natalya AU - Bhandari, Aparajita AU - Chapman, Julia PY - 2022/1/10 TI - Use of a Mobile Peer Support App Among Young People With Nonsuicidal Self-injury: Small-scale Randomized Controlled Trial JO - JMIR Form Res SP - e26526 VL - 6 IS - 1 KW - nonsuicidal self-injury KW - randomized controlled trial KW - mobile app KW - peer support KW - urges KW - digital intervention N2 - Background: Nonsuicidal self-injury (NSSI) is a widespread behavior among adolescents and young adults. Although many individuals who self-injure do not seek treatment, there is evidence for web-based help-seeking through web-based communities and mobile peer support networks. However, few studies have rigorously tested the efficacy of such platforms on outcomes relevant for NSSI recovery. Objective: The aim of this small-scale preregistered randomized controlled trial is to provide preliminary insight into the shorter- and longer-term efficacy of the use of a peer support app, TalkLife, in reducing NSSI frequency and urges and increasing readiness to change. In addition, we explore contact with informal support, interest in therapy, and attitudes toward professional help?seeking. Methods: Individuals aged 16-25 years with current (within 3 months) and chronic (>6 episodes in the past year) NSSI history were eligible to participate in this study. After baseline assessments, the intervention group was instructed to use the app actively (eg, post or comment at least three times per week) and the control group received weekly psychoeducational materials through email, for 8 weeks. Follow-up was assessed at 1 month and 2 months. Linear mixed modeling was used to evaluate condition and time point effects for the primary outcomes of NSSI frequency and urges, readiness to change, contact with informal support, interest in therapy, and attitudes toward professional help?seeking. Results: A total of 131 participants were included in the analysis. We evidenced a significant effect of condition on NSSI frequency such that the participants using the peer support app self-injured less over the course of the study (mean 1.30, SE 0.18) than those in the control condition (mean 1.62, SE 0.18; P=.02; ?2=0.02). We also evidenced a significant condition effect of readiness to change such that the treatment participants reported greater confidence in their ability to change their NSSI behavior (mean 6.28, SE 0.41) than the control participants (mean 5.67, SE 0.41; P=.04; ?2=0.02). No significant differences were observed for contact with informal support, interest in therapy, or attitudes toward professional help?seeking. Conclusions: Use of the peer support app was related to reduced NSSI frequency and greater confidence in one?s ability to change NSSI behavior over the course of the study period, but no effects on NSSI urges, contact with informal support, interest in therapy, or attitudes toward professional help?seeking were observed. The findings provide preliminary support for considering the use of mobile peer support apps as a supplement to NSSI intervention and point to the need for larger-scale trials. Trial Registration: Open Science Foundation; https://osf.io/3uay9 UR - https://formative.jmir.org/2022/1/e26526 UR - http://dx.doi.org/10.2196/26526 UR - http://www.ncbi.nlm.nih.gov/pubmed/35006076 ID - info:doi/10.2196/26526 ER - TY - JOUR AU - Mazeas, Alexandre AU - Duclos, Martine AU - Pereira, Bruno AU - Chalabaev, Aïna PY - 2022/1/4 TI - Evaluating the Effectiveness of Gamification on Physical Activity: Systematic Review and Meta-analysis of Randomized Controlled Trials JO - J Med Internet Res SP - e26779 VL - 24 IS - 1 KW - behavior change KW - eHealth KW - gamification KW - health behavior KW - intervention KW - meta-analysis KW - mobile phone KW - physical activity KW - systematic review N2 - Background: Gamification refers to the use of game elements in nongame contexts. The use of gamification to change behaviors and promote physical activity (PA) is a promising avenue for tackling the global physical inactivity pandemic and the current prevalence of chronic diseases. However, there is no evidence of the effectiveness of gamified interventions with the existence of mixed results in the literature. Objective: The aim of this systematic review and meta-analysis is to evaluate the effectiveness of gamified interventions and their health care potential by testing the generalizability and sustainability of their influence on PA and sedentary behavior. Methods: A total of 5 electronic databases (PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials) were searched for randomized controlled trials published in English from 2010 to 2020. Eligibility criteria were based on the components of the participants, interventions, comparators, and outcomes framework. Studies were included when they used gamified interventions in daily life with an active or inactive control group and when they assessed a PA or sedentary behavior outcome. We conducted meta-analyses using a random-effects model approach. Sensitivity analyses, influence analyses, and publication bias analyses were performed to examine the robustness of our results. Results: The main meta-analysis performed on 16 studies and 2407 participants revealed a small to medium summary effect of gamified interventions on PA behavior (Hedges g=0.42, 95% CI 0.14-0.69). No statistical difference among different subgroups (adults vs adolescents and healthy participants vs adults with chronic diseases) and no interaction effects with moderators such as age, gender, or BMI were found, suggesting good generalizability of gamified interventions to different user populations. The effect was statistically significant when gamified interventions were compared with inactive control groups, such as waiting lists (Hedges g=0.58, 95% CI 0.08-1.07), and active control groups that included a nongamified PA intervention (Hedges g=0.23, 95% CI 0.05-0.41). This suggests that gamified interventions are not only efficient in changing behavior but also more effective compared with other behavioral interventions. The long-term effect (measured with follow-up averaging 14 weeks after the end of the intervention) was weaker, with a very small to small effect (Hedges g=0.15, 95% CI 0.07-0.23). Conclusions: This meta-analysis confirms that gamified interventions are promising for promoting PA in various populations. Additional analyses revealed that this effect persists after the follow-up period, suggesting that it is not just a novelty effect caused by the playful nature of gamification, and that gamified products appear effective compared with equivalent nongamified PA interventions. Future rigorous trials are required to confirm these findings. UR - https://www.jmir.org/2022/1/e26779 UR - http://dx.doi.org/10.2196/26779 UR - http://www.ncbi.nlm.nih.gov/pubmed/34982715 ID - info:doi/10.2196/26779 ER - TY - JOUR AU - Bai, Yang AU - Copeland, E. William AU - Burns, Ryan AU - Nardone, Hilary AU - Devadanam, Vinay AU - Rettew, Jeffrey AU - Hudziak, James PY - 2022/1/4 TI - Ecological Momentary Assessment of Physical Activity and Wellness Behaviors in College Students Throughout a School Year: Longitudinal Naturalistic Study JO - JMIR Public Health Surveill SP - e25375 VL - 8 IS - 1 KW - young adulthood KW - wellness KW - substance use KW - Apple Watch N2 - Background: The Wellness Environment app study is a longitudinal study focused on promoting health in college students. Objective: The two aims of this study were (1) to assess physical activity (PA) variation across the days of the week and throughout the academic year and (2) to explore the correlates that were associated with PA, concurrently and longitudinally. Methods: The participants were asked to report their wellness and risk behaviors on a 14-item daily survey through a smartphone app. Each student was provided an Apple Watch to track their real time PA. Data were collected from 805 college students from Sept 2017 to early May 2018. PA patterns across the days of the week and throughout the academic year were summarized. Concurrent associations of daily steps with wellness or risk behavior were tested in the general linear mixed-effects model. The longitudinal, reciprocal association between daily steps and health or risk behaviors were tested with cross-lagged analysis. Results: Female college students were significantly more active than male ones. The students were significantly more active during the weekday than weekend. Temporal patterns also revealed that the students were less active during Thanksgiving, winter, and spring breaks. Strong concurrent positive correlations were found between higher PA and self-reported happy mood, 8+ hours of sleep, ?1 fruit and vegetable consumption, ?4 bottles of water intake, and ?2 hours of screen time (P<.001). Similar longitudinal associations found that the previous day?s wellness behaviors independently predicted the following day?s higher PA except for mood. Conversely, the higher previous-day PA levels were associated with better mood, more fruit and vegetable consumption, and playing less music, but with higher liquor consumption the next day. Conclusions: This study provides a comprehensive surveillance of longitudinal PA patterns and their independent association with a variety of wellness and risk behaviors in college students. UR - https://publichealth.jmir.org/2022/1/e25375 UR - http://dx.doi.org/10.2196/25375 UR - http://www.ncbi.nlm.nih.gov/pubmed/34982721 ID - info:doi/10.2196/25375 ER - TY - JOUR AU - Lungu, Adrian Daniel AU - Røislien, Jo AU - Wiig, Siri AU - Shortt, Therese Marie AU - Ferrè, Francesca AU - Berg, Hilde Siv AU - Thune, Henriette AU - Brønnick, Kallesten Kolbjørn PY - 2021/12/30 TI - The Role of Recipient Characteristics in Health Video Communication Outcomes: Scoping Review JO - J Med Internet Res SP - e30962 VL - 23 IS - 12 KW - health communication KW - video communication KW - communication outcomes KW - recipient characteristics KW - recipient factors KW - health video communication N2 - Background: The importance of effective communication during public health emergencies has been highlighted by the World Health Organization, and it has published guidelines for effective communication in such situations. With video being a popular medium, video communication has been a growing area of study over the past decades and is increasingly used across different sectors and disciplines, including health. Health-related video communication gained momentum during the SARS-CoV-2 pandemic, and video was among the most frequently used modes of communication worldwide. However, although much research has been done regarding different characteristics of video content (the message) and its delivery (the messenger), there is a lack of knowledge about the role played by the characteristics of the recipients for the creation of effective communication. Objective: The aim of this review is to identify how health video communication outcomes are shaped by recipient characteristics, as such characteristics might affect the effectiveness of communication. The main research question of the study is as follows: do the characteristics of the recipients of health videos affect the outcomes of the communication? Methods: A scoping review describing the existing knowledge within the field was conducted. We searched for literature in 3 databases (PubMed, Scopus, and Embase) and defined eligibility criteria based on the relevance to the research question. Recipient characteristics and health video communication outcomes were identified and classified. Results: Of the 1040 documents initially identified, 128 (12.31%) met the criteria for full-text assessment, and 39 (3.75%) met the inclusion criteria. The included studies reported 56 recipient characteristics and 42 communication outcomes. The reported associations between characteristics and outcomes were identified, and the potential research opportunities were discussed. Contributions were made to theory development by amending the existing framework of the Integrated-Change model, which is an integrated model of motivational and behavioral change. Conclusions: Although several recipient characteristics and health video communication outcomes were identified, there is a lack of robust empirical evidence on the association between them. Further research is needed to understand how the preceding characteristics of the recipients might affect the various outcomes of health video communication. UR - https://www.jmir.org/2021/12/e30962 UR - http://dx.doi.org/10.2196/30962 UR - http://www.ncbi.nlm.nih.gov/pubmed/34967758 ID - info:doi/10.2196/30962 ER - TY - JOUR AU - Jones, R. Sarah AU - Vidrine, J. Damon AU - Wetter, W. David AU - Shih, Tina Ya-Chen AU - Sutton, K. Steven AU - Ramondetta, M. Lois AU - Elting, S. Linda AU - Walker, L. Joan AU - Smith, M. Katie AU - Frank-Pearce, G. Summer AU - Li, Yisheng AU - Simmons, N. Vani AU - Vidrine, I. Jennifer PY - 2021/12/30 TI - Evaluation of the Efficacy of a Smoking Cessation Intervention for Cervical Cancer Survivors and Women With High-Grade Cervical Dysplasia: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e34502 VL - 10 IS - 12 KW - smoking cessation KW - cervical cancer KW - cancer survivor KW - motivation KW - tobacco treatment KW - cancer KW - smoking KW - RCT KW - randomized controlled trial KW - cognitive behavior KW - intervention N2 - Background: The prevalence of smoking among cervical cancer survivors is strikingly high, yet no smoking cessation interventions to date have specifically targeted this population. This paper describes the study design, methods, and data analysis plans for a randomized clinical trial designed to evaluate the efficacy of a theoretically and empirically based Motivation And Problem Solving (MAPS) approach for promoting and facilitating smoking cessation among cervical cancer survivors. MAPS is a comprehensive, dynamic, and holistic intervention that incorporates empirically supported cognitive behavioral and social cognitive theory?based treatment strategies within an overarching motivational framework. MAPS is designed to be appropriate for all smokers regardless of their motivation to change and views motivation as dynamically fluctuating from moment to moment throughout the behavior change process. Objective: This 2-group randomized controlled trial compares the efficacy of standard treatment to MAPS in facilitating smoking cessation among women with a history of high-grade cervical dysplasia or cervical cancer. Methods: Participants (N=202) are current smokers with a history of high-grade cervical dysplasia or cervical cancer recruited nationally and randomly assigned to one of two treatment conditions: (1) standard treatment (ST) or (2) MAPS. ST consists of repeated letters referring participants to their state?s tobacco cessation quitline, standard self-help materials, and free nicotine replacement therapy when ready to quit. MAPS has all ST components along with 6 proactive telephone counseling sessions delivered over 12 months. The primary outcome is abstinence from tobacco at 18 months. Secondary outcomes include abstinence over time across all assessment points, abstinence at other individual assessment time points, quit attempts, cigarettes per day, and use of state quitlines. Hypothesized treatment mechanisms and cost-effectiveness will also be evaluated. Results: This study was approved by the institutional review boards at the University of Texas MD Anderson Cancer Center, the University of Oklahoma Health Sciences Center, and Moffitt Cancer Center. Participant enrollment concluded at Moffitt Cancer Center in January 2020, and follow-up data collection was completed in July 2021. Data analysis is ongoing. Conclusions: This study will yield crucial information regarding the efficacy and cost-effectiveness of a MAPS approach for smoking cessation tailored to the specific needs of women with a history of high-grade cervical dysplasia or cervical cancer. Findings indicating that MAPS has substantially greater efficacy than existing evidence-based tobacco cessation treatments would have tremendous public health significance. Trial Registration: ClinicalTrials.gov NCT02157610; https://clinicaltrials.gov/ct2/show/NCT02157610 International Registered Report Identifier (IRRID): DERR1-10.2196/34502 UR - https://www.researchprotocols.org/2021/12/e34502 UR - http://dx.doi.org/10.2196/34502 UR - http://www.ncbi.nlm.nih.gov/pubmed/34967755 ID - info:doi/10.2196/34502 ER - TY - JOUR AU - Goulding, H. Evan AU - Dopke, A. Cynthia AU - Michaels, Tania AU - Martin, R. Clair AU - Khiani, A. Monika AU - Garborg, Christopher AU - Karr, Chris AU - Begale, Mark PY - 2021/12/24 TI - A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Protocol Development for an Expert System to Provide Adaptive User Feedback JO - JMIR Form Res SP - e32932 VL - 5 IS - 12 KW - adaptive KW - personalized KW - self-management KW - smartphone KW - behavioral intervention technology KW - mHealth KW - bipolar disorder KW - depression KW - mania N2 - Background: Bipolar disorder is a severe mental illness that results in significant morbidity and mortality. While pharmacotherapy is the primary treatment, adjunctive psychotherapy can improve outcomes. However, access to therapy is limited. Smartphones and other technologies can increase access to therapeutic strategies that enhance self-management while simultaneously augmenting care by providing adaptive delivery of content to users as well as alerts to providers to facilitate clinical care communication. Unfortunately, while adaptive interventions are being developed and tested to improve care, information describing the components of adaptive interventions is often not published in sufficient detail to facilitate replication and improvement of these interventions. Objective: To contribute to and support the improvement and dissemination of technology-based mental health interventions, we provide a detailed description of the expert system for adaptively delivering content and facilitating clinical care communication for LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder. Methods: Information from empirically supported psychotherapies for bipolar disorder, health psychology behavior change theories, and chronic disease self-management models was combined with user-centered design data and psychiatrist feedback to guide the development of the expert system. Results: Decision points determining the timing of intervention option adaptation were selected to occur daily and weekly based on self-report data for medication adherence, sleep duration, routine, and wellness levels. These data were selected for use as the tailoring variables determining which intervention options to deliver when and to whom. Decision rules linking delivery of options and tailoring variable thresholds were developed based on existing literature regarding bipolar disorder clinical status and psychiatrist feedback. To address the need for treatment adaptation with varying clinical statuses, decision rules for a clinical status state machine were developed using self-reported wellness rating data. Clinical status from this state machine was incorporated into hierarchal decision tables that select content for delivery to users and alerts to providers. The majority of the adaptive content addresses sleep duration, medication adherence, managing signs and symptoms, building and utilizing support, and keeping a regular routine, as well as determinants underlying engagement in these target behaviors as follows: attitudes and perceptions, knowledge, support, evaluation, and planning. However, when problems with early warning signs, symptoms, and transitions to more acute clinical states are detected, the decision rules shift the adaptive content to focus on managing signs and symptoms, and engaging with psychiatric providers. Conclusions: Adaptive mental health technologies have the potential to enhance the self-management of mental health disorders. The need for individuals with bipolar disorder to engage in the management of multiple target behaviors and to address changes in clinical status highlights the importance of detailed reporting of adaptive intervention components to allow replication and improvement of adaptive mental health technologies for complex mental health problems. UR - https://formative.jmir.org/2021/12/e32932 UR - http://dx.doi.org/10.2196/32932 UR - http://www.ncbi.nlm.nih.gov/pubmed/34951598 ID - info:doi/10.2196/32932 ER - TY - JOUR AU - Krukowski, Rebecca AU - Johnson, Brandi AU - Kim, Hyeonju AU - Sen, Saunak AU - Homsi, Riad PY - 2021/12/24 TI - A Pragmatic Intervention Using Financial Incentives for Pregnancy Weight Management: Feasibility Randomized Controlled Trial JO - JMIR Form Res SP - e30578 VL - 5 IS - 12 KW - pregnancy KW - weight KW - physical activity KW - self-weighing N2 - Background: Excessive gestational weight gain (GWG) is common and can result in maternal and child health complications. Pragmatic behavioral interventions that can be incorporated into standard obstetric care are needed, and financial incentives are a promising approach. Objective: The aim of this study is to evaluate the feasibility of recruitment, randomization, and retention, as well as treatment engagement and intervention satisfaction, in a behavioral program. The program provided small incentives for meeting behavioral goals of self-weighing and physical activity as well as larger outcome incentives for meeting GWG goals. Methods: We recruited 40 adult women in their first trimester of pregnancy from February 2019 to September 2019 at an obstetric clinic. Participants were randomized to 3 intervention components using a 2×2×2 factorial design: daily incentives for self-weighing (lottery vs certain loss), incentives for adhering to the Institute of Medicine?s GWG guidelines based on BMI category (monthly vs overall), and incentives for reaching physical activity goals (yes vs no). Participants were asked to complete daily weigh-ins using the Withings Body wireless scale provided by the study, as well as wear a physical activity tracker (Fitbit Flex 2). Feasibility outcomes of recruitment, randomization, and retention, as well as treatment engagement and intervention satisfaction, were assessed. Weight assessments were conducted at baseline, 32-week gestation, and 36-week gestation. Results: Participants were enrolled at, on average, 9.6 (SD 1.8) weeks? gestation. Of the 39 participants who were oriented to their condition and received the intervention, 24 (62%) were Black or African American, 30 (77%) were not married, and 29 (74%) had an annual household income of less than US $50,000. Of the 39 participants, 35 (90%) completed the follow-up data collection visit. Participants were generally quite positive about the intervention components, with a particular emphasis on the helpfulness of, and the enjoyment of using, the e-scale in both the quantitative and qualitative feedback. Participants who received the loss incentive, on average, had 2.86 times as many days of self-weighing as those who received the lottery incentive. Participants had a relatively low level of activity, with no difference between those who received a physical activity incentive and those who did not. Conclusions: A financial incentive?based pragmatic intervention was feasible and acceptable for pregnant women for promoting self-weighing, physical activity, and healthy GWG. Participants were successfully recruited early in their first trimester of pregnancy and retained for follow-up data collection in the third trimester. Participants demonstrated promising engagement in self-weighing, particularly with loss-based incentives, and reported finding the self-weighing especially helpful. This study supports further investigation of pragmatic, clinic-based financial incentive?based interventions for healthy GWG behaviors. Trial Registration: ClinicalTrials.gov NCT03834194; https://clinicaltrials.gov/ct2/show/NCT03834194 UR - https://formative.jmir.org/2021/12/e30578 UR - http://dx.doi.org/10.2196/30578 UR - http://www.ncbi.nlm.nih.gov/pubmed/34951594 ID - info:doi/10.2196/30578 ER - TY - JOUR AU - Rogerson, C. Michelle AU - Jackson, C. Alun AU - Navaratnam, S. Hema AU - Le Grande, R. Michael AU - Higgins, O. Rosemary AU - Clarke, Joanne AU - Murphy, M. Barbara PY - 2021/12/23 TI - Getting ?Back on Track? After a Cardiac Event: Protocol for a Randomized Controlled Trial of a Web-Based Self-management Program JO - JMIR Res Protoc SP - e34534 VL - 10 IS - 12 KW - coronary heart disease KW - heart disease KW - coronary KW - cardiovascular KW - prevention KW - RCT KW - randomized control trial KW - secondary prevention KW - self-management KW - online KW - randomised controlled trial KW - health behaviours KW - health behaviour KW - health behavior KW - depression KW - cognitive behaviour therapy KW - motivational interviewing N2 - Background: After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management. Objective: The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone. Methods: People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either ?self-directed? completion of the Back on Track program (without assistance) or ?supported? completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. Results: Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study. Conclusions: The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/34534 UR - https://www.researchprotocols.org/2021/12/e34534 UR - http://dx.doi.org/10.2196/34534 UR - http://www.ncbi.nlm.nih.gov/pubmed/34941550 ID - info:doi/10.2196/34534 ER - TY - JOUR AU - Stecher, Chad AU - Sullivan, Mariah AU - Huberty, Jennifer PY - 2021/12/22 TI - Using Personalized Anchors to Establish Routine Meditation Practice With a Mobile App: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e32794 VL - 9 IS - 12 KW - mindfulness KW - meditation KW - mobile meditation app KW - behavioral persistence KW - habit formation KW - randomized controlled trial KW - mental health KW - physical health KW - app engagement KW - routine N2 - Background: Physical and mental health benefits can be attained from persistent, long-term performance of mindfulness meditation with a mobile meditation app, but in general, few mobile health app users persistently engage at a level necessary to attain the corresponding health benefits. Anchoring or pairing meditation with a mobile app to an existing daily routine can establish an unconsciously initiated meditation routine that may improve meditation persistence. Objective: The purpose of this study was to test the use of either personalized anchors or fixed anchors for establishing a persistent meditation app routine with the mobile app, Calm. Methods: We conducted a randomized controlled trial and randomly assigned participants to one of 3 study groups: (1) a personalized anchor (PA) group, (2) fixed anchor (FA) group, or (3) control group that did not use the anchoring strategy. All participants received app-delivered reminder messages to meditate for at least 10 minutes a day using the Calm app for an 8-week intervention period, and app usage data continued to be collected for an additional 8-week follow-up period to measure meditation persistence. Baseline, week 8, and week 16 surveys were administered to assess demographics, socioeconomic status, and changes in self-reported habit strength. Results: A total of 101 participants across the 3 study groups were included in the final analysis: (1) PA (n=56), (2) FA (n=49), and (3) control group (n=62). Participants were predominantly White (83/101, 82.2%), female (77/101, 76.2%), and college educated (ie, bachelor?s or graduate degree; 82/101, 81.2%). The FA group had a significantly higher average odds of daily meditation during the intervention (1.14 odds ratio [OR]; 95% CI 1.02-1.33; P=.04), and all participants experienced a linear decline in their odds of daily meditation during the 8-week intervention (0.96 OR; 95% CI 0.95-0.96; P<.001). Importantly, the FA group showed a significantly smaller decline in the linear trend of their odds of daily meditation during the 8-week follow-up (their daily trend increased by 1.04 OR from their trend during the intervention; 95% CI 1.01-1.06; P=.03). Additionally, those who more frequently adhered to their anchoring strategy during the intervention typically used anchors that occurred in the morning and showed a significantly smaller decline in their odds of daily meditation during the 8-week follow-up period (1.13 OR; 95% CI 1.02-1.35; P=.007). Conclusions: The FA group had more persistent meditation with the app, but participants in the FA or PA groups who more frequently adhered to their anchoring strategy during the intervention had the most persistent meditation routines, and almost all of these high anchorers used morning anchors. These findings suggest that the anchoring strategy can create persistent meditation routines with a mobile app. However, future studies should combine anchoring with additional intervention tools (eg, incentives) to help more participants successfully establish an anchored meditation routine. Trial Registration: ClinicalTrials.gov NCT04378530; https://clinicaltrials.gov/ct2/show/NCT04378530 UR - https://mhealth.jmir.org/2021/12/e32794 UR - http://dx.doi.org/10.2196/32794 UR - http://www.ncbi.nlm.nih.gov/pubmed/34941558 ID - info:doi/10.2196/32794 ER - TY - JOUR AU - Tzelepis, Flora AU - Mitchell, Aimee AU - Wilson, Louise AU - Byrnes, Emma AU - Haschek, Alexandra AU - Leigh, Lucy AU - Oldmeadow, Christopher PY - 2021/12/21 TI - The Long-Term Effectiveness of Internet-Based Interventions on Multiple Health Risk Behaviors: Systematic Review and Robust Variance Estimation Meta-analysis JO - J Med Internet Res SP - e23513 VL - 23 IS - 12 KW - internet KW - multiple health behaviors KW - tobacco KW - nutrition KW - alcohol KW - physical activity N2 - Background: Smoking tobacco, poor nutrition, risky alcohol use, and physical inactivity (SNAP) behaviors tend to cluster together. Health benefits may be maximized if interventions targeted multiple health risk behaviors together rather than addressing single behaviors. The internet has wide reach and is a sustainable mode for delivery of interventions for multiple health behaviors. However, no systematic reviews have examined the long-term effectiveness of internet-based interventions on any combination of or all SNAP behaviors in adults aged 18 years or older. Objective: This systematic review examined, among adults (aged ?18 years), the effectiveness of internet-based interventions on SNAP behaviors collectively in the long term compared with a control condition. Methods: The electronic databases Medline, PsycINFO, Embase, CINAHL, and Scopus were searched to retrieve studies describing the effectiveness of internet-based interventions on ?2 SNAP behaviors published by November 18, 2019. The reference lists of retrieved articles were also checked to identify eligible publications. The inclusion criteria were randomized controlled trials or cluster randomized controlled trials with adults examining an internet-based intervention measuring the effect on ?2 SNAP behaviors at least 6 months postrecruitment and published in English in a peer-reviewed journal. Two reviewers independently extracted data from included studies and assessed methodological quality using the Quality Assessment Tool for Quantitative Studies. A robust variance estimation meta-analysis was performed to examine the long-term effectiveness of internet-based interventions on all 4 SNAP risk behavior outcomes. All SNAP outcomes were coded so they were in the same direction, with higher scores equating to worse health risk behaviors. Results: The inclusion criteria were met by 11 studies: 7 studies measured the effect of an internet-based intervention on nutrition and physical activity; 1 study measured the effect on smoking, nutrition, and physical activity; and 3 studies measured the effect on all SNAP behaviors. Compared with the control group, internet-based interventions achieved an overall significant improvement across all SNAP behaviors in the long term (standardized mean difference ?0.12 [improvement as higher scores = worse health risk outcomes], 95% CI ?0.19 to ?0.05; I2=1.5%, P=.01). The global methodological quality rating was ?moderate? for 1 study, while the remaining 10 studies were rated as ?weak.? Conclusions: Internet-based interventions were found to produce an overall significant improvement across all SNAP behaviors collectively in the long term. Internet-based interventions targeting multiple SNAP behaviors have the potential to maximize long-term improvements to preventive health outcomes. UR - https://www.jmir.org/2021/12/e23513 UR - http://dx.doi.org/10.2196/23513 UR - http://www.ncbi.nlm.nih.gov/pubmed/34931990 ID - info:doi/10.2196/23513 ER - TY - JOUR AU - Wu, S. Monica AU - Wickham, E. Robert AU - Chen, Shih-Yin AU - Chen, Connie AU - Lungu, Anita PY - 2021/12/17 TI - Examining the Impact of Digital Components Across Different Phases of Treatment in a Blended Care Cognitive Behavioral Therapy Intervention for Depression and Anxiety: Pragmatic Retrospective Study JO - JMIR Form Res SP - e33452 VL - 5 IS - 12 KW - blended care KW - cognitive-behavioral therapy KW - depression KW - anxiety KW - digital KW - phase KW - mental health KW - digital health KW - digital therapy N2 - Background: Depression and anxiety incur significant personal and societal costs. Effective psychotherapies exist, such as cognitive behavioral therapy (CBT); however, timely access to quality care is limited by myriad barriers. Blended care therapy models incorporate traditional face-to-face therapy with scalable, digital components of care, expanding the reach of evidence-based care. Objective: The aim of this study is to determine the effectiveness of a blended care CBT program (BC-CBT) in real-world settings and examine the unique impacts of the (1) digital components of care (video lessons and digital exercises) and (2) phase of treatment (early versus late) in decreasing symptoms of anxiety and depression. Methods: This retrospective cohort analysis included 3401 US-based individuals enrolled in a BC-CBT program, who presented with clinical levels of depression and/or anxiety. The treatment program consisted of regular therapy sessions augmented by clinician-assigned digital video lessons and exercises. A growth curve model incorporating time-varying covariates examined the relationship between engagement with BCT components (ie, therapy sessions, digital video lessons, and digital exercises) during the early (weeks 0-7) and late (weeks 8-15) phases of treatment, and weekly symptom reports on depression and anxiety measures. Results: On average, a significant decline in depression and anxiety symptoms was observed during the initial weeks of treatment (P<.001), with a continued, though slower, decline over subsequent weeks (P<.001). Each session completed was associated with significant decreases in anxiety (b=?0.72) and depression (b=?0.83) in the early phase, as well as in the late phase (anxiety, b=?0.47; depression, b=?0.27). Significant decreases in anxiety (b=?0.15) and depression (b=?0.12) were observed for time spent on video lessons (measured in 10-minute intervals) in the early phase of treatment. Engaging with exercises was associated with statistically significant increases in anxiety symptoms (b=0.03) during the early phase of treatment. However, sensitivity analyses examining the effects of exercises in isolation revealed significant decreases in anxiety (b=?0.05) in the early phase, suggesting a potential suppression effect in the larger model. Conclusions: Using a retrospective cohort design, therapy sessions and digital video lessons were uniquely predictive of improvements in depression and anxiety symptoms, and their effects were modulated based on the phase of treatment (early vs late). Future research should investigate whether other treatment variables, such as therapeutic alliance or familiarity with technology, are related to differential effects on various components of care. UR - https://formative.jmir.org/2021/12/e33452 UR - http://dx.doi.org/10.2196/33452 UR - http://www.ncbi.nlm.nih.gov/pubmed/34927591 ID - info:doi/10.2196/33452 ER - TY - JOUR AU - Black, Melissa AU - Brunet, Jennifer PY - 2021/12/16 TI - A Wearable Activity Tracker Intervention With and Without Weekly Behavioral Support Emails to Promote Physical Activity Among Women Who Are Overweight or Obese: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e28128 VL - 9 IS - 12 KW - behavior change KW - motivation KW - obesity KW - physical activity KW - women KW - mobile phone N2 - Background: Physical activity (PA) plays a fundamental role in combating the current obesity epidemic; however, most women who are overweight or obese are generally physically inactive. Wearable activity tracker interventions can help increase the PA levels in this population. Supplementing such interventions with behavioral support emails may further improve their effectiveness, but this remains to be confirmed. Objective: This study aims to determine if adding behavioral support emails to a wearable activity tracker intervention can further increase PA levels among women who are overweight or obese in comparison to a wearable activity tracker?only intervention and a control condition. Methods: Women with a BMI ?25 kg/m2 who were not meeting the Canadian PA guidelines for aerobic and strength training were randomized into 1 of 3 groups. Group 1 received 6 weekly behavioral support emails, a wearable activity tracker, and a copy of the Canadian PA guidelines. Group 2 received a wearable activity tracker and a copy of the Canadian PA guidelines, and group 3 (control condition) received a copy of the Canadian PA guidelines. Self-reported data for walking and moderate to vigorous intensity PA were collected preintervention (week 0; prerandomization), postintervention (7 weeks postrandomization), and at follow-up (21 weeks postrandomization) and analyzed as metabolic equivalent of task minutes per week. In addition, potential mechanisms of behavior change (ie, basic psychological needs satisfaction and motivational regulations) were assessed for within- and between-group differences at all 3 time points. Data were analyzed using nonparametric statistical tests. Results: A total of 49 women were recruited; data from 47 women (mean age 37.57 years, SD 11.78 years; mean BMI 31.69 kg/m2, SD 5.97 kg/m2) were available for analysis. Group 1 reported a significant increase in walking from preintervention to postintervention (?22=7.5; P=.02) but not in moderate to vigorous intensity PA (P=.24). Group 1 also reported significant increases in perceptions of competence from preintervention to follow-up (?22=7.6; P=.02) and relatedness from preintervention to follow-up (?22=8.7; P=.005). Increases in perceived autonomy were observed for group 2 (?22=7.0) and group 3 (?22=10.6). There were no significant changes in the motivational regulations within the groups. The difference between the groups was not significant for any outcome variable. Conclusions: The results suggest that adding behavioral support emails to a wearable activity tracker intervention may help to increase time spent walking and perceptions of competence and relatedness for PA among women who are overweight or obese. Trial Registration: ClinicalTrials.gov NCT03601663; http://clinicaltrials.gov/ct2/show/NCT03601663 UR - https://mhealth.jmir.org/2021/12/e28128 UR - http://dx.doi.org/10.2196/28128 UR - http://www.ncbi.nlm.nih.gov/pubmed/34927590 ID - info:doi/10.2196/28128 ER - TY - JOUR AU - Szinay, Dorothy AU - Perski, Olga AU - Jones, Andy AU - Chadborn, Tim AU - Brown, Jamie AU - Naughton, Felix PY - 2021/12/16 TI - Perceptions of Factors Influencing Engagement With Health and Well-being Apps in the United Kingdom: Qualitative Interview Study JO - JMIR Mhealth Uhealth SP - e29098 VL - 9 IS - 12 KW - behavior change KW - health apps KW - mHealth KW - smartphone app KW - framework analysis KW - COM-B KW - TDF KW - user engagement KW - motivation KW - usability KW - engagement KW - mobile phone N2 - Background: Digital health devices, such as health and well-being smartphone apps, could offer an accessible and cost-effective way to deliver health and well-being interventions. A key component of the effectiveness of health and well-being apps is user engagement. However, engagement with health and well-being apps is typically poor. Previous studies have identified a list of factors that could influence engagement; however, most of these studies were conducted on a particular population or for an app targeting a particular behavior. An understanding of the factors that influence engagement with a wide range of health and well-being apps can inform the design and the development of more engaging apps in general. Objective: The aim of this study is to explore user experiences of and reasons for engaging and not engaging with a wide range of health and well-being apps. Methods: A sample of adults in the United Kingdom (N=17) interested in using a health or well-being app participated in a semistructured interview to explore experiences of engaging and not engaging with these apps. Participants were recruited via social media platforms. Data were analyzed with the framework approach, informed by the Capability, Opportunity, Motivation?Behaviour (COM-B) model and the Theoretical Domains Framework, which are 2 widely used frameworks that incorporate a comprehensive set of behavioral influences. Results: Factors that influence the capability of participants included available user guidance, statistical and health information, reduced cognitive load, well-designed reminders, self-monitoring features, features that help establish a routine, features that offer a safety net, and stepping-stone app characteristics. Tailoring, peer support, and embedded professional support were identified as important factors that enhance user opportunities for engagement with health and well-being apps. Feedback, rewards, encouragement, goal setting, action planning, self-confidence, and commitment were judged to be the motivation factors that affect engagement with health and well-being apps. Conclusions: Multiple factors were identified across all components of the COM-B model that may be valuable for the development of more engaging health and well-being apps. Engagement appears to be influenced primarily by features that provide user guidance, promote minimal cognitive load, support self-monitoring (capability), provide embedded social support (opportunity), and provide goal setting with action planning (motivation). This research provides recommendations for policy makers, industry, health care providers, and app developers for increasing effective engagement. UR - https://mhealth.jmir.org/2021/12/e29098 UR - http://dx.doi.org/10.2196/29098 UR - http://www.ncbi.nlm.nih.gov/pubmed/34927597 ID - info:doi/10.2196/29098 ER - TY - JOUR AU - Bezabih, Mequanint Alemitu AU - Gerling, Kathrin AU - Abebe, Workeabeba AU - Abeele, Vanden Vero PY - 2021/12/10 TI - Behavioral Theories and Motivational Features Underlying eHealth Interventions for Adolescent Antiretroviral Adherence: Systematic Review JO - JMIR Mhealth Uhealth SP - e25129 VL - 9 IS - 12 KW - HIV KW - adolescents KW - ART adherence KW - eHealth KW - health theories KW - behavior change techniques KW - motivational design principles N2 - Background: eHealth systems provide new opportunities for the delivery of antiretroviral therapy (ART) adherence interventions for adolescents. They may be more effective if grounded in health behavior theories and behavior change techniques (BCTs). Prior reviews have examined the effectiveness, feasibility, and acceptability of these eHealth systems. However, studies have not systematically explored the use of health behavior theories and BCTs in the design of these applications. Objective: The purpose of this review was to explore whether health behavior theories and BCTs were considered to ground designs of eHealth systems supporting adolescents? (10-24 years) ART adherence. More specifically, we examined which specific theories and BCTs were applied, and how these BCTs were implemented as design features. Additionally, we investigated the quality and effect of eHealth systems. Methods: A systematic search was performed on IEEE Xplore, ACM, ScienceDirect, PubMed, Scopus, and Web of Science databases from 2000 to 2020. Theory use and BCTs were coded using the Theory Coding Scheme and the Behavior Change Technique Taxonomy version 1 (BCTTv1), respectively. Design features were identified using the lenses of motivational design for mobile health (mHealth). The number of BCTs and design features for each eHealth system and their prevalence across all systems were assessed. Results: This review identified 16 eHealth systems aiming to support ART adherence among adolescents. System types include SMS text message reminders (n=6), phone call reminders (n=3), combined SMS text message and phone call reminders (n=1), electronic adherence monitoring devices (n=3), smartphone apps (n=1), smartphone serious games (n=1), gamified smartphone apps (n=1), leveraging existing social media (n=2), web-based applications (n=1), videoconferencing (n=1), and desktop applications (n=1). Nine were grounded in theory, of which 3 used theories extensively. The impact of adolescent developmental changes on ART adherence was not made explicit. A total of 42 different BCTs and 24 motivational design features were used across systems. Ten systems reported positive effects on 1 or more outcomes; however, of these ten systems, only 3 reported exclusively positive effects on all the outcomes they measured. As much as 6 out of 16 reported purely no effect in all the outcomes measured. Conclusions: Basic applications (SMS text messaging and phone calls) were most frequent, although more advanced systems such as mobile apps and games are also emerging. This review indicated gaps in the use of theory and BCTs, and particularly the impact of developmental changes on ART adherence was not adequately considered. Together with adopting a developmental orientation, future eHealth systems should effectively leverage health theories and consider developing more advanced systems that open the door to using BCTs more comprehensively. Overall, the impact of eHealth systems on adolescent ART adherence and its mediators is promising, but conclusive evidence on effect still needs to be provided. UR - https://mhealth.jmir.org/2021/12/e25129 UR - http://dx.doi.org/10.2196/25129 UR - http://www.ncbi.nlm.nih.gov/pubmed/34890353 ID - info:doi/10.2196/25129 ER - TY - JOUR AU - Reilly, Dawna Erin AU - Robinson, A. Stephanie AU - Petrakis, Ann Beth AU - Gardner, M. Melissa AU - Wiener, Soylemez Renda AU - Castaneda-Sceppa, Carmen AU - Quigley, S. Karen PY - 2021/12/9 TI - Mobile Intervention to Improve Sleep and Functional Health of Veterans With Insomnia: Randomized Controlled Trial JO - JMIR Form Res SP - e29573 VL - 5 IS - 12 KW - cognitive behavioral therapy KW - mobile app KW - physical activity KW - insomnia N2 - Background: Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI. Objective: This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone. Methods: A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment. Results: Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02). Conclusions: These findings suggest that the use of a mobile app?delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea. Trial Registration: ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354 UR - https://formative.jmir.org/2021/12/e29573 UR - http://dx.doi.org/10.2196/29573 UR - http://www.ncbi.nlm.nih.gov/pubmed/34889746 ID - info:doi/10.2196/29573 ER - TY - JOUR AU - Merolli, Mark AU - Francis, J. Jill AU - Vallance, Patrick AU - Bennell, L. Kim AU - Malliaras, Peter AU - Hinman, S. Rana PY - 2021/12/9 TI - Patient-Facing Mobile Apps to Support Physiotherapy Care: Protocol for a Systematic Review of Apps Within App Stores JO - JMIR Res Protoc SP - e29047 VL - 10 IS - 12 KW - physiotherapy KW - physical therapy KW - digital health intervention KW - mobile app KW - eHealth KW - behavior change technique KW - behavior change KW - exercise KW - digital health KW - mHealth N2 - Background: Care delivered by physiotherapists aims to facilitate engagement in positive health behaviors by patients (eg, adherence to exercise). However, research suggests that behavioral interventions are frequently omitted from care. Hence, better understanding of strategies that can be used by physiotherapists to support patients to engage in positive behaviors is important and likely to optimize outcomes. Digital health interventions delivered via mobile apps are garnering attention for their ability to support behavior change. They have potential to incorporate numerous behavior change techniques (BCTs) to support goals of physiotherapy care, including but not limited to self-monitoring, goal setting, and prompts/alerts. Despite their potential to support physiotherapy care, much is still unknown about what apps are available to consumers, the BCTs they use, their quality, and their potential to change behaviors. Objective: The primary aim of this study is to systematically review the mobile apps available in app stores that are intended for use by patients to support physiotherapy care, including the BCTs within these apps. The secondary aims are to evaluate the quality and behavior change potential of these apps. Methods: A systematic review of mobile apps in app stores will be undertaken. This will be guided by recommendations for systematic reviews in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement but adapted to suit our app store search, consistent with similar systematic reviews of apps published in the Journal of Medical Internet Research. Apple Store and Google Play will be searched with a two-step search strategy, using terms relevant to physiotherapy, physiotherapists, and common physiotherapy care. Key eligibility criteria will include apps that are intended for use by patients and are self-contained or stand-alone without the need of additional wearable devices or other add-ons. Included apps will be coded for BCTs and rated for quality using the Mobile Application Rating Scale (MARS) and for potential to change behavior using the App Behavior Change Scale (ABACUS). Results: App store search and screening are expected to be completed in 2021. Data extraction and quality appraisal are expected to commence by November 2021. The study results are expected to be published in a subsequent paper in 2022. Conclusions: Knowledge gained from this review will support clinical practice and inform research by providing a greater understanding of the quality of currently available mobile apps and their potential to support patient behavior change goals of physiotherapy care. International Registered Report Identifier (IRRID): PRR1-10.2196/29047 UR - https://www.researchprotocols.org/2021/12/e29047 UR - http://dx.doi.org/10.2196/29047 UR - http://www.ncbi.nlm.nih.gov/pubmed/34889767 ID - info:doi/10.2196/29047 ER - TY - JOUR AU - Eklund, Caroline AU - Söderlund, Anne AU - Elfström, L. Magnus PY - 2021/12/9 TI - Evaluation of a Web-Based Stress Management Program for Persons Experiencing Work-Related Stress in Sweden (My Stress Control): Randomized Controlled Trial JO - JMIR Ment Health SP - e17314 VL - 8 IS - 12 KW - behavior change KW - behavior medicine KW - internet KW - stress prevention N2 - Background: Stress is one of the most common reasons for sick leave. Web-based interventions have the potential to reach an unlimited number of users at a low cost and have been shown to be effective in addressing several health-related problems. Handling stress on an individual level is related to behavior change. To support behavioral changes in stress management, My Stress Control (MSC) was developed. The development of MSC was based on several health psychology theories and models; however, central in the development were Social Cognitive Theory, Theory of Reasoned Action, Theory of Planned Behavior, Transactional Theory of Stress and Coping, and the Transtheoretical Model and Stages of Change. MSC is a fully automated program. The program is tailored to the user?s specific needs for stress management and behavior change. Objective: In this study, we aim to conduct a randomized controlled trial to evaluate the extent to which MSC affects perceived stress in persons experiencing work-related stress. Methods: This was a randomized controlled trial with 2 arms. Study participants were recruited by visiting the worksites and workplace meetings. Participants were assigned to the intervention or wait-list group. Web-based questionnaires were used before and after the intervention to collect data. Perceived stress measured using the Perceived Stress Scale-14 was the primary outcome measurement. Analyses were conducted for both between-group and within-group changes. Results: A total of 92 participants were included in this study: 48 (52%) in the intervention group and 44 (48%) in the wait-list group. Overall, 25% (12/48) of participants in the intervention group and 43% (19/44) of participants in the wait-list group completed the postintervention assessment. There were no significant effects on perceived stress between the intervention and wait-list groups or within the groups. A small effect size (Cohen d=0.25) was found when comparing mean change over time on the primary outcome measure between the intervention and wait-list groups. In addition, a small effect size was found between pre- and postintervention assessments within the intervention group (Cohen d=0.38) as well as within the wait-list group (Cohen d=0.25). Conclusions: The effect of MSC on perceived stress remains uncertain. As adherence was low in the intervention group, elements or features that facilitate adherence and engagement must be further developed before firmer conclusions regarding the effect of MSC can be made. Trial Registration: ClinicalTrials.gov NCT03077568; https://clinicaltrials.gov/ct2/show/NCT03077568 UR - https://mental.jmir.org/2021/12/e17314 UR - http://dx.doi.org/10.2196/17314 UR - http://www.ncbi.nlm.nih.gov/pubmed/34889772 ID - info:doi/10.2196/17314 ER - TY - JOUR AU - Xu, Yuepei AU - Yue, Ling-Zi AU - Wang, Wei AU - Wu, Xiao-Ju AU - Liang, Zhu-Yuan PY - 2021/12/7 TI - Gender-Specific Impact of Self-Monitoring and Social Norm Information on Walking Behavior Among Chinese College Students Assessed Using WeChat: Longitudinal Tracking Study JO - J Med Internet Res SP - e29167 VL - 23 IS - 12 KW - self-monitoring KW - social norm KW - group identity KW - gender differences KW - mHealth KW - mobile health N2 - Background: Walking is a simple but beneficial form of physical activity (PA). Self-monitoring and providing information about social norms are the 2 most widely used ?mobile health (mHealth)? strategies to promote walking behavior. However, previous studies have failed to discriminate the effect of self-monitoring from the combination of the 2 strategies, and provide practical evidence within Chinese culture. Some essential moderators, such as gender and group identity, were also overlooked. Objective: We aimed to investigate the effectiveness of social norm and self-monitoring interventions for walking behavior and assess the moderating effects of gender and group identity, which could guide optimal mHealth intervention projects in China. Methods: In 2 longitudinal tracking studies (study 1, 22 days; study 2, 31 days), Chinese college students wore trackers for at least 8 hours per day (MASAI 3D Pedometer and Xiaomi Wristband 2) to record their daily step counts in baseline, intervention, and follow-up stages. In each study, participants (study 1: n=117, 54% female, mean age 25.60 years; study 2: n=180, 51% female, mean age 22.60 years) were randomly allocated to 1 of the following 3 groups: a self-monitoring group and 2 social norm intervention groups. In the 2 intervention groups and during the intervention stage, participants received different social norm information regarding group member step rankings corresponding to their grouping type of social norm information. In study 1, participants were grouped by within-group member PA levels (PA consistent vs PA inconsistent), and in study 2, participants were grouped by their received gender-specific social norm information (gender consistent vs gender inconsistent). Piece-wise linear mixed models were used to compare the difference in walking steps between groups. Results: In study 1, for males in the self-monitoring group, walking steps significantly decreased from the baseline stage to the intervention stage (change in slope=?1422.16; P=.02). However, additional social norm information regardless of group consistency kept their walking unchanged. For females, social norm information did not provide any extra benefit beyond self-monitoring. Females exposed to PA-inconsistent social norm information even walked less (slope during the intervention=?122.18; P=.03). In study 2, for males, a similar pattern was observed, with a decrease in walking steps in the self-monitoring group (change in slope=?151.33; P=.08), but there was no decrease in the 2 social norm intervention groups. However, for females, gender-consistent social norm information decreased walking steps (slope during the intervention=?143.68; P=.03). Conclusions: Both gender and group identity moderated the effect of social norm information on walking. Among females, social norm information showed no benefit for walking behavior and may have exerted a backfire effect. Among males, while walking behavior decreased with self-monitoring only, the inclusion of social norm information held the level of walking behavior steady. UR - https://www.jmir.org/2021/12/e29167 UR - http://dx.doi.org/10.2196/29167 UR - http://www.ncbi.nlm.nih.gov/pubmed/34878992 ID - info:doi/10.2196/29167 ER - TY - JOUR AU - van Genugten, Rosalie Claire AU - Schuurmans, Josien AU - Hoogendoorn, W. Adriaan AU - Araya, Ricardo AU - Andersson, Gerhard AU - Baños, Rosa AU - Botella, Cristina AU - Cerga Pashoja, Arlinda AU - Cieslak, Roman AU - Ebert, Daniel David AU - García-Palacios, Azucena AU - Hazo, Jean-Baptiste AU - Herrero, Rocío AU - Holtzmann, Jérôme AU - Kemmeren, Lise AU - Kleiboer, Annet AU - Krieger, Tobias AU - Smoktunowicz, Ewelina AU - Titzler, Ingrid AU - Topooco, Naira AU - Urech, Antoine AU - Smit, H. Johannes AU - Riper, Heleen PY - 2021/12/6 TI - Examining the Theoretical Framework of Behavioral Activation for Major Depressive Disorder: Smartphone-Based Ecological Momentary Assessment Study JO - JMIR Ment Health SP - e32007 VL - 8 IS - 12 KW - depression KW - behavioral activation KW - theoretical framework KW - ecological momentary assessment KW - random-intercept cross-lagged panel model KW - behavior KW - framework KW - EMA KW - smartphone KW - mental health KW - treatment KW - engagement KW - mood N2 - Background: Behavioral activation (BA), either as a stand-alone treatment or as part of cognitive behavioral therapy, has been shown to be effective for treating depression. The theoretical underpinnings of BA derive from Lewinsohn et al?s theory of depression. The central premise of BA is that having patients engage in more pleasant activities leads to them experiencing more pleasure and elevates their mood, which, in turn, leads to further (behavioral) activation. However, there is a dearth of empirical evidence about the theoretical framework of BA. Objective: This study aims to examine the assumed (temporal) associations of the 3 constructs in the theoretical framework of BA. Methods: Data were collected as part of the ?European Comparative Effectiveness Research on Internet-based Depression Treatment versus treatment-as-usual? trial among patients who were randomly assigned to receive blended cognitive behavioral therapy (bCBT). As part of bCBT, patients completed weekly assessments of their level of engagement in pleasant activities, the pleasure they experienced as a result of these activities, and their mood over the course of the treatment using a smartphone-based ecological momentary assessment (EMA) application. Longitudinal cross-lagged and cross-sectional associations of 240 patients were examined using random intercept cross-lagged panel models. Results: The analyses did not reveal any statistically significant cross-lagged coefficients (all P>.05). Statistically significant cross-sectional positive associations between activities, pleasure, and mood levels were identified. Moreover, the levels of engagement in activities, pleasure, and mood slightly increased over the duration of the treatment. In addition, mood seemed to carry over, over time, while both levels of engagement in activities and pleasurable experiences did not. Conclusions: The results were partially in accordance with the theoretical framework of BA, insofar as the analyses revealed cross-sectional relationships between levels of engagement in activities, pleasurable experiences deriving from these activities, and enhanced mood. However, given that no statistically significant temporal relationships were revealed, no conclusions could be drawn about potential causality. A shorter measurement interval (eg, daily rather than weekly EMA reports) might be more attuned to detecting potential underlying temporal pathways. Future research should use an EMA methodology to further investigate temporal associations, based on theory and how treatments are presented to patients. Trial Registration: ClinicalTrials.gov, NCT02542891, https://clinicaltrials.gov/ct2/show/NCT02542891; German Clinical Trials Register, DRKS00006866, https://tinyurl.com/ybja3xz7; Netherlands Trials Register, NTR4962, https://www.trialregister.nl/trial/4838; ClinicalTrials.Gov, NCT02389660, https://clinicaltrials.gov/ct2/show/NCT02389660; ClinicalTrials.gov, NCT02361684, https://clinicaltrials.gov/ct2/show/NCT02361684; ClinicalTrials.gov, NCT02449447, https://clinicaltrials.gov/ct2/show/NCT02449447; ClinicalTrials.gov, NCT02410616, https://clinicaltrials.gov/ct2/show/NCT02410616; ISRCTN registry, ISRCTN12388725, https://www.isrctn.com/ISRCTN12388725 UR - https://mental.jmir.org/2021/12/e32007 UR - http://dx.doi.org/10.2196/32007 UR - http://www.ncbi.nlm.nih.gov/pubmed/34874888 ID - info:doi/10.2196/32007 ER - TY - JOUR AU - Goldstein, P. Stephanie AU - Zhang, Fengqing AU - Klasnja, Predrag AU - Hoover, Adam AU - Wing, R. Rena AU - Thomas, Graham John PY - 2021/12/6 TI - Optimizing a Just-in-Time Adaptive Intervention to Improve Dietary Adherence in Behavioral Obesity Treatment: Protocol for a Microrandomized Trial JO - JMIR Res Protoc SP - e33568 VL - 10 IS - 12 KW - obesity KW - weight loss KW - dietary adherence KW - just-in-time adaptive intervention KW - microrandomized trial KW - mobile phone N2 - Background: Behavioral obesity treatment (BOT) is a gold standard approach to weight loss and reduces the risk of cardiovascular disease. However, frequent lapses from the recommended diet stymie weight loss and prevent individuals from actualizing the health benefits of BOT. There is a need for innovative treatment solutions to improve adherence to the prescribed diet in BOT. Objective: The aim of this study is to optimize a smartphone-based just-in-time adaptive intervention (JITAI) that uses daily surveys to assess triggers for dietary lapses and deliver interventions when the risk of lapse is high. A microrandomized trial design will evaluate the efficacy of any interventions (ie, theory-driven or a generic alert to risk) on the proximal outcome of lapses during BOT, compare the effects of theory-driven interventions with generic risk alerts on the proximal outcome of lapse, and examine contextual moderators of interventions. Methods: Adults with overweight or obesity and cardiovascular disease risk (n=159) will participate in a 6-month web-based BOT while using the JITAI to prevent dietary lapses. Each time the JITAI detects elevated lapse risk, the participant will be randomized to no intervention, a generic risk alert, or 1 of 4 theory-driven interventions (ie, enhanced education, building self-efficacy, fostering motivation, and improving self-regulation). The primary outcome will be the occurrence of lapse in the 2.5 hours following randomization. Contextual moderators of intervention efficacy will also be explored (eg, location and time of day). The data will inform an optimized JITAI that selects the theory-driven approach most likely to prevent lapses in a given moment. Results: The recruitment for the microrandomized trial began on April 19, 2021, and is ongoing. Conclusions: This study will optimize a JITAI for dietary lapses so that it empirically tailors the provision of evidence-based intervention to the individual and context. The finalized JITAI will be evaluated for efficacy in a future randomized controlled trial of distal health outcomes (eg, weight loss). Trial Registration: ClinicalTrials.gov NCT04784585; http://clinicaltrials.gov/ct2/show/NCT04784585 International Registered Report Identifier (IRRID): DERR1-10.2196/33568 UR - https://www.researchprotocols.org/2021/12/e33568 UR - http://dx.doi.org/10.2196/33568 UR - http://www.ncbi.nlm.nih.gov/pubmed/34874892 ID - info:doi/10.2196/33568 ER - TY - JOUR AU - Marques, M. Marta AU - Matos, Marcela AU - Mattila, Elina AU - Encantado, Jorge AU - Duarte, Cristiana AU - Teixeira, J. Pedro AU - Stubbs, James R. AU - Sniehotta, F. Falko AU - Ermes, Miikka AU - Harjumaa, Marja AU - Leppänen, Juha AU - Välkkynen, Pasi AU - Silva, N. Marlene AU - Ferreira, Cláudia AU - Carvalho, Sérgio AU - Palmeira, Lara AU - Horgan, Graham AU - Heitmann, Lilienthal Berit AU - Evans, H. Elizabeth AU - Palmeira, L. António PY - 2021/12/3 TI - A Theory- and Evidence-Based Digital Intervention Tool for Weight Loss Maintenance (NoHoW Toolkit): Systematic Development and Refinement Study JO - J Med Internet Res SP - e25305 VL - 23 IS - 12 KW - mHealth KW - behavior change techniques KW - weight management KW - motivation KW - self-regulation KW - emotion regulation KW - self-monitoring KW - user testing KW - logic models N2 - Background: Many weight loss programs show short-term effectiveness, but subsequent weight loss maintenance is difficult to achieve. Digital technologies offer a promising means of delivering behavior change approaches at low costs and on a wide scale. The Navigating to a Healthy Weight (NoHoW) project, which was funded by the European Union?s Horizon 2020 research and innovation program, aimed to develop, test, and evaluate a digital toolkit designed to promote successful long-term weight management. The toolkit was tested in an 18-month, large-scale, international, 2×2 factorial (motivation and self-regulation vs emotion regulation) randomized controlled trial that was conducted on adults with overweight or obesity who lost ?5% of their body weight in the preceding 12 months before enrollment into the intervention. Objective: This paper aims to describe the development of the NoHoW Toolkit, focusing on the logic models, content, and specifications, as well as the results from user testing. Methods: The toolkit was developed by using a systematic approach, which included the development of the theory-based logic models, the selection of behavior change techniques, the translation of these techniques into a web-based app (NoHoW Toolkit components), technical development, and the user evaluation and refinement of the toolkit. Results: The toolkit included a set of web-based tools and inputs from digital tracking devices (smart scales and activity trackers) and modules that targeted weight, physical activity, and dietary behaviors. The final toolkit comprised 34 sessions that were distributed through 15 modules and provided active content over a 4-month period. The motivation and self-regulation arm consisted of 8 modules (17 sessions), the emotion regulation arm was presented with 7 modules (17 sessions), and the combined arm received the full toolkit (15 modules; 34 sessions). The sessions included a range of implementations, such as videos, testimonies, and questionnaires. Furthermore, the toolkit contained 5 specific data tiles for monitoring weight, steps, healthy eating, mood, and sleep. Conclusions: A systematic approach to the development of digital solutions based on theory, evidence, and user testing may significantly contribute to the advancement of the science of behavior change and improve current solutions for sustained weight management. Testing the toolkit by using a 2×2 design provided a unique opportunity to examine the effect of motivation and self-regulation and emotion regulation separately, as well as the effect of their interaction in weight loss maintenance. UR - https://www.jmir.org/2021/12/e25305 UR - http://dx.doi.org/10.2196/25305 UR - http://www.ncbi.nlm.nih.gov/pubmed/34870602 ID - info:doi/10.2196/25305 ER - TY - JOUR AU - Robertson, C. Michael AU - Baranowski, Tom AU - Thompson, Debbe AU - Basen-Engquist, M. Karen AU - Swartz, Chang Maria AU - Lyons, J. Elizabeth PY - 2021/12/3 TI - Using the Behaviour Change Wheel Program Planning Model to Design Games for Health: Development Study JO - JMIR Serious Games SP - e29964 VL - 9 IS - 4 KW - physical activity KW - video games KW - eHealth KW - intervention KW - behavior and behavior mechanisms KW - psychological theory KW - serious games KW - gamification KW - older women KW - older adults KW - behavior change KW - behavioral interventions KW - mobile phone N2 - Background: Games for health are a promising approach to health promotion. Their success depends on achieving both experiential (game) and instrumental (health) objectives. There is little to guide game for health (G4H) designers in integrating the science of behavior change with the art of game design. Objective: The aim of this study is to extend the Behaviour Change Wheel program planning model to develop Challenges for Healthy Aging: Leveraging Limits for Engaging Networked Game-Based Exercise (CHALLENGE), a G4H centered on increasing physical activity in insufficiently active older women. Methods: We present and apply the G4H Mechanics, Experiences, and Change (MECHA) process, which supplements the Behaviour Change Wheel program planning model. The additional steps are centered on identifying target G4H player experiences and corresponding game mechanics to help game designers integrate design elements and G4H objectives into behavioral interventions. Results: We identified a target behavior of increasing moderate-intensity walking among insufficiently active older women and key psychosocial determinants of this behavior from self-determination theory (eg, autonomy). We used MECHA to map these constructs to intervention functions (eg, persuasion) and G4H target player experiences (eg, captivation). Next, we identified behavior change techniques (eg, framing or reframing) and specific game mechanics (eg, transforming) to help realize intervention functions and elicit targeted player experiences. Conclusions: MECHA can help researchers map specific linkages between distal intervention objectives and more proximal game design mechanics in games for health. This can facilitate G4H program planning, evaluation, and clearer scientific communication. UR - https://games.jmir.org/2021/4/e29964 UR - http://dx.doi.org/10.2196/29964 UR - http://www.ncbi.nlm.nih.gov/pubmed/34870604 ID - info:doi/10.2196/29964 ER - TY - JOUR AU - Dhinagaran, Ardhithy Dhakshenya AU - Sathish, Thirunavukkarasu AU - Soong, AiJia AU - Theng, Yin-Leng AU - Best, James AU - Tudor Car, Lorainne PY - 2021/12/3 TI - Conversational Agent for Healthy Lifestyle Behavior Change: Web-Based Feasibility Study JO - JMIR Form Res SP - e27956 VL - 5 IS - 12 KW - chatbot KW - conversational agents KW - behavior change KW - healthy lifestyle behavior change KW - pilot study KW - feasibility trial KW - usability KW - acceptability KW - preliminary efficacy KW - mobile phone N2 - Background: The rising incidence of chronic diseases is a growing concern, especially in Singapore, which is one of the high-income countries with the highest prevalence of diabetes. Interventions that promote healthy lifestyle behavior changes have been proven to be effective in reducing the progression of prediabetes to diabetes, but their in-person delivery may not be feasible on a large scale. Novel technologies such as conversational agents are a potential alternative for delivering behavioral interventions that promote healthy lifestyle behavior changes to the public. Objective: The aim of this study is to assess the feasibility and acceptability of using a conversational agent promoting healthy lifestyle behavior changes in the general population in Singapore. Methods: We performed a web-based, single-arm feasibility study. The participants were recruited through Facebook over 4 weeks. The Facebook Messenger conversational agent was used to deliver the intervention. The conversations focused on diet, exercise, sleep, and stress and aimed to promote healthy lifestyle behavior changes and improve the participants? knowledge of diabetes. Messages were sent to the participants four times a week (once for each of the 4 topics of focus) for 4 weeks. We assessed the feasibility of recruitment, defined as at least 75% (150/200) of our target sample of 200 participants in 4 weeks, as well as retention, defined as 33% (66/200) of the recruited sample completing the study. We also assessed the participants? satisfaction with, and usability of, the conversational agent. In addition, we performed baseline and follow-up assessments of quality of life, diabetes knowledge and risk perception, diet, exercise, sleep, and stress. Results: We recruited 37.5% (75/200) of the target sample size in 1 month. Of the 75 eligible participants, 60 (80%) provided digital informed consent and completed baseline assessments. Of these 60 participants, 56 (93%) followed the study through till completion. Retention was high at 93% (56/60), along with engagement, denoted by 50% (30/60) of the participants communicating with the conversational agent at each interaction. Acceptability, usability, and satisfaction were generally high. Preliminary efficacy of the intervention showed no definitive improvements in health-related behavior. Conclusions: The delivery of a conversational agent for healthy lifestyle behavior change through Facebook Messenger was feasible and acceptable. We were unable to recruit our planned sample solely using the free options in Facebook. However, participant retention and conversational agent engagement rates were high. Our findings provide important insights to inform the design of a future randomized controlled trial. UR - https://formative.jmir.org/2021/12/e27956 UR - http://dx.doi.org/10.2196/27956 UR - http://www.ncbi.nlm.nih.gov/pubmed/34870611 ID - info:doi/10.2196/27956 ER - TY - JOUR AU - Laforest, Marie-Eve AU - Ward, Stephanie AU - Landry, Liette-Andrée AU - Mobetty, Fabrice PY - 2021/12/2 TI - The Relationship Between Paternal Preconception Obesity and Health Behaviors and Childhood Obesity: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e31254 VL - 10 IS - 12 KW - childhood obesity KW - preconception KW - paternal obesity KW - health behaviours KW - obesity KW - public health KW - children KW - adolescents KW - body weight KW - parenting KW - health behaviors N2 - Background: Childhood obesity is a global public health concern and is a priority for researchers and policy makers. To overcome the epidemic of obesity, influencing factors throughout the life span need to be addressed, including those in the preconception period. A better understanding of the association between paternal preconception factors and childhood obesity is important for public health interventions. Objective: This systematic review will examine the relationship between paternal preconception obesity and health behaviors and their offspring?s overweight or obesity. Methods: Peer-reviewed quantitative studies and grey literature that report associations between paternal preconception obesity and health behaviors?such as smoking, exercise, and eating habits?and childhood overweight and obesity will be identified through a computerized literature search in 7 databases. The quality of each study will be assessed using the Quality Assessment Tool for Quantitative Studies. Characteristics of the included studies will be reported, and relevant findings from each paternal preconception exposure will be narratively synthesized. This review will follow the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) 2020 guidelines. Results: This systematic review is anticipated to begin in December 2021 and be completed by the end of August 2022. Conclusions: This systematic review will contribute to a better understanding of the relationship between preconception paternal exposures and their offspring?s overweight or obesity. Findings will help support health professionals working with prospective parents to educate fathers on the benefits of improving their weight and health behaviors during the preconception period. International Registered Report Identifier (IRRID): PRR1-10.2196/31254 UR - https://www.researchprotocols.org/2021/12/e31254 UR - http://dx.doi.org/10.2196/31254 UR - http://www.ncbi.nlm.nih.gov/pubmed/34860672 ID - info:doi/10.2196/31254 ER - TY - JOUR AU - Wyse, Rebecca AU - Delaney, Tessa AU - Stacey, Fiona AU - Lecathelinais, Christophe AU - Ball, Kylie AU - Zoetemeyer, Rachel AU - Lamont, Hannah AU - Sutherland, Rachel AU - Nathan, Nicole AU - Wiggers, H. John AU - Wolfenden, Luke PY - 2021/11/29 TI - Long-term Effectiveness of a Multistrategy Behavioral Intervention to Increase the Nutritional Quality of Primary School Students? Online Lunch Orders: 18-Month Follow-up of the Click & Crunch Cluster Randomized Controlled Trial JO - J Med Internet Res SP - e31734 VL - 23 IS - 11 KW - child diet KW - consumer behavior KW - intervention KW - RCT KW - public health nutrition KW - obesity KW - school KW - school canteen KW - long-term follow-up KW - choice architecture KW - public health KW - nutrition KW - children KW - diet KW - eHealth KW - school lunch N2 - Background: School food services, including cafeterias and canteens, are an ideal setting in which to improve child nutrition. Online canteen ordering systems are increasingly common and provide unique opportunities to deliver choice architecture strategies to nudge users to select healthier items. Despite evidence of short-term effectiveness, there is little evidence regarding the long-term effectiveness of choice architecture interventions, particularly those delivered online. Objective: This study determined the long-term effectiveness of a multistrategy behavioral intervention (Click & Crunch) embedded within an existing online school lunch-ordering system on the energy, saturated fat, sugar, and sodium content of primary school students? lunch orders 18 months after baseline. Methods: This cluster randomized controlled trial (RCT) involved a cohort of 2207 students (aged 5-12 years) from 17 schools in New South Wales, Australia. Schools were randomized to receive either a multistrategy behavioral intervention or the control (usual online ordering only). The intervention strategies ran continuously for 14-16.5 months until the end of follow-up data collection. Trial primary outcomes (ie, mean total energy, saturated fat, sugar and sodium content of student online lunch orders) and secondary outcomes (ie, the proportion of online lunch order items that were categorized as everyday, occasional, and caution) were assessed over an 8-week period at baseline and 18-month follow-up. Results: In all, 16 schools (94%) participated in the 18-month follow-up. Over time, from baseline to follow-up, relative to control orders, intervention orders had significantly lower energy (?74.1 kJ; 95% CI [?124.7, ?23.4]; P=.006) and saturated fat (?0.4 g; 95% CI [?0.7, ?0.1]; P=.003) but no significant differences in sugar or sodium content. Relative to control schools, the odds of purchasing everyday items increased significantly (odds ratio [OR] 1.2; 95% CI [1.1, 1.4]; P=.009, corresponding to a +3.8% change) and the odds of purchasing caution items significantly decreased among intervention schools (OR 0.7, 95% CI [0.6, 0.9]; P=.002, corresponding to a ?2.6% change). There was no between-group difference over time in canteen revenue. Conclusions: This is the first study to investigate the sustained effect of a choice architecture intervention delivered via an online canteen ordering systems in schools. The findings suggest that there are intervention effects up to 18-months postbaseline in terms of decreased energy and saturated fat content and changes in the relative proportions of healthy and unhealthy food purchased for student lunches. As such, this intervention approach may hold promise as a population health behavior change strategy within schools and may have implications for the use of online food-ordering systems more generally; however, more research is required. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000855224; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375075 UR - https://www.jmir.org/2021/11/e31734 UR - http://dx.doi.org/10.2196/31734 UR - http://www.ncbi.nlm.nih.gov/pubmed/34847063 ID - info:doi/10.2196/31734 ER - TY - JOUR AU - Domhardt, Matthias AU - Engler, Sophie AU - Nowak, Hannah AU - Lutsch, Arne AU - Baumel, Amit AU - Baumeister, Harald PY - 2021/11/26 TI - Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review JO - J Med Internet Res SP - e29742 VL - 23 IS - 11 KW - children and adolescents KW - mental disorders KW - mediator KW - mechanisms of change KW - digital health intervention KW - psychotherapy KW - mobile phone N2 - Background: Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking. Objective: This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents. Methods: A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research). Results: A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded. Conclusions: The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future. UR - https://www.jmir.org/2021/11/e29742 UR - http://dx.doi.org/10.2196/29742 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842543 ID - info:doi/10.2196/29742 ER - TY - JOUR AU - Luquiens, Amandine AU - von Hammerstein, Cora AU - Benyamina, Amine AU - Perney, Pascal PY - 2021/11/26 TI - Burden and Help-Seeking Behaviors Linked to Problem Gambling and Gaming: Observational Quantitative and Qualitative Analysis JO - JMIR Ment Health SP - e26521 VL - 8 IS - 11 KW - gambling KW - gaming KW - helpline KW - burden, relatives KW - qualitative research N2 - Background: Models based on the uniqueness of addiction processes between behavioral addictions are highly contentious, and the inclusion of gaming disorder in the addiction nosography remains controversial. An exploratory approach could clarify a hypothesized common and subjectively identifiable process in addictive behaviors and the necessarily different expressions of the disorder due to behavior specificities, in particular the sociocultural characteristics and profiles of users. Objective: The aim of this study was to describe the nature of contacts to a help service by exploring commonality and specificities of burden and help-seeking for problem gambling or gaming. Methods: This was an observational quantitative-qualitative study. We included all contacts (ie, online questions and contacts by phone or chat when the helper completed a summary) to a helpline for gamers, gamblers, and relatives over a 7-year period. We constituted a text corpus with online questions and summaries of contacts by phone or chat. We collected basic sociodemographic data, including the device used to contact the service (phone or internet), contacting the service for oneself (?user?) or being a relative of a user and type of relative, gambling (yes/no), gaming (yes/no), and age and sex of the gambler/gamer. We describe the corpus descriptively and report the computerized qualitative analysis of online questions, chat, and summary of phone calls. We performed a descendant hierarchical analysis on the data. Results: A total of 14,564 contacts were made to the helpline, including 10,017 users and 4547 relatives. The corpus was composed of six classes: (1) gaming specificities, (2) shared psychological distress and negative emotions, (3) the procedure for being banned from gambling, (4) the provided help, (5) gambling specificities, and (6) financial problems. Conclusions: Negative emotions and shared distress linked to gambling and gaming support current scientific consensus that these behaviors can produce psychological distress in se; however, meaningful differences were observed in core symptoms of addiction between gamers and gamblers, beyond specificities related to the behavior itself: loss of control was elicited in the class corresponding to gambling specificities and not by gamers and their relatives. UR - https://mental.jmir.org/2021/11/e26521 UR - http://dx.doi.org/10.2196/26521 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842562 ID - info:doi/10.2196/26521 ER - TY - JOUR AU - McCarthy, Marie AU - Zhang, Lili AU - Monacelli, Greta AU - Ward, Tomas PY - 2021/11/26 TI - Using Methods From Computational Decision-making to Predict Nonadherence to Fitness Goals: Protocol for an Observational Study JO - JMIR Res Protoc SP - e29758 VL - 10 IS - 11 KW - decision-making games KW - computational psychology KW - fitness goals KW - advanced analytics KW - mobile app KW - computational modeling KW - fitness tracker KW - mobile phone N2 - Background: Can methods from computational models of decision-making be used to build a predictive model to identify individuals most likely to be nonadherent to personal fitness goals? Such a model may have significant value in the global battle against obesity. Despite growing awareness of the impact of physical inactivity on human health, sedentary behavior is increasingly linked to premature death in the developed world. The annual impact of sedentary behavior is significant, causing an estimated 2 million deaths. From a global perspective, sedentary behavior is one of the 10 leading causes of mortality and morbidity. Annually, considerable funding and countless public health initiatives are applied to promote physical fitness, with little impact on sustained behavioral change. Predictive models developed from multimodal methodologies combining data from decision-making tasks with contextual insights and objective physical activity data could be used to identify those most likely to abandon their fitness goals. This has the potential to enable development of more targeted support to ensure that those who embark on fitness programs are successful. Objective: The aim of this study is to determine whether it is possible to use decision-making tasks such as the Iowa Gambling Task to help determine those most likely to abandon their fitness goals. Predictive models built using methods from computational models of decision-making, combining objective data from a fitness tracker with personality traits and modeling from decision-making games delivered via a mobile app, will be used to ascertain whether a predictive algorithm can identify digital personae most likely to be nonadherent to self-determined exercise goals. If it is possible to phenotype these individuals, it may be possible to tailor initiatives to support these individuals to continue exercising. Methods: This is a siteless study design based on a bring your own device model. A total of 200 healthy adults who are novice exercisers and own a Fitbit (Fitbit Inc) physical activity tracker will be recruited via social media for this study. Participants will provide consent via the study app, which they will download from the Google Play store (Alphabet Inc) or Apple App Store (Apple Inc). They will also provide consent to share their Fitbit data. Necessary demographic information concerning age and sex will be collected as part of the recruitment process. Over 12 months, the scheduled study assessments will be pushed to the subjects to complete. The Iowa Gambling Task will be administered via a web app shared via a URL. Results: Ethics approval was received from Dublin City University in December 2020. At manuscript submission, study recruitment was pending. The expected results will be published in 2022. Conclusions: It is hoped that the study results will support the development of a predictive model and the study design will inform future research approaches. Trial Registration: ClinicalTrials.gov NCT04783298; https://clinicaltrials.gov/ct2/show/NCT04783298 UR - https://www.researchprotocols.org/2021/11/e29758 UR - http://dx.doi.org/10.2196/29758 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842557 ID - info:doi/10.2196/29758 ER - TY - JOUR AU - Prowse, Rachel AU - Carsley, Sarah PY - 2021/11/25 TI - Digital Interventions to Promote Healthy Eating in Children: Umbrella Review JO - JMIR Pediatr Parent SP - e30160 VL - 4 IS - 4 KW - children KW - healthy eating KW - eHealth KW - nutrition intervention KW - nutrition education KW - food literacy KW - digital health KW - virtual delivery KW - digital interventions KW - nutrition interventions KW - best practices KW - education KW - mobile phone N2 - Background: eHealth and web-based service delivery have become increasingly common during the COVID-19 pandemic. Digital interventions may be highly appealing to young people; however, their effectiveness compared with that of the usual face-to-face interventions is unknown. As nutrition interventions merge with the digital world, there is a need to determine the best practices for digital interventions for children. Objective: The aim of this study is to examine the effectiveness of digital nutrition interventions for children on dietary outcomes compared with status quo interventions (eg, conventional face-to-face programming or nondigital support). Methods: We conducted an umbrella review of systematic reviews of studies assessing primary research on digital interventions aimed at improving food and nutrition outcomes for children aged <18 years compared with conventional nutrition education were eligible for inclusion. Results: In total, 11 systematic reviews published since 2015 were included (7/11, 64%, were of moderate quality). Digital interventions ranged from internet, computer, or mobile interventions to websites, programs, apps, email, videos, CD-ROMs, games, telehealth, SMS text messages, and social media, or a combination thereof. The dose and duration of the interventions varied widely (single to multiple exposures; 1-60 minutes). Many studies have been informed by theory or used behavior change techniques (eg, feedback, goal-setting, and tailoring). The effect of digital nutrition interventions for children on dietary outcomes is small and inconsistent. Digital interventions seemed to be the most promising for improving fruit and vegetable intake compared with other nutrition outcomes; however, reviews have found mixed results. Conclusions: Owing to the heterogeneity and duration of digital interventions, follow-up evaluations, comparison groups, and outcomes measured, the effectiveness of these interventions remains unclear. High-quality evidence with common definitions for digital intervention types evaluated with validated measures is needed to improve the state of evidence, to inform policy and program decisions for health promotion in children. Now is the time for critical, robust evaluation of the adopted digital interventions during and after the COVID-19 pandemic to establish best practices for nutrition interventions for children. UR - https://pediatrics.jmir.org/2021/4/e30160 UR - http://dx.doi.org/10.2196/30160 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842561 ID - info:doi/10.2196/30160 ER - TY - JOUR AU - Carlin, Thomas AU - Soulard, Julie AU - Aubourg, Timothée AU - Knitza, Johannes AU - Vuillerme, Nicolas PY - 2021/11/25 TI - Objective Measurements of Physical Activity and Sedentary Behavior Using Wearable Devices in Patients With Axial Spondyloarthritis: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e23359 VL - 10 IS - 11 KW - axial spondyloarthritis KW - rheumatology KW - physical activity KW - sedentary behavior KW - objective measures KW - wearable KW - systematic review N2 - Background: Axial spondyloarthritis (axSpA) is a subgroup of inflammatory rheumatic diseases. Practicing regular exercise is critical to manage pain and stiffness, reduce disease activity, and improve physical functioning, spinal mobility, and cardiorespiratory function. Accordingly, monitoring physical activity and sedentary behavior in patients with axSpA is relevant for clinical outcomes and disease management. Objective: This review aims to determine which wearable devices, assessment methods, and associated metrics are commonly used to quantify physical activity or sedentary behavior in patients with axSpA. Methods: The PubMed, Physiotherapy Evidence Database (PEDro), and Cochrane electronic databases will be searched, with no limit on publication date, to identify all the studies matching the inclusion criteria. Only original English-language articles published in a peer-reviewed journal will be included. The search strategy will include a combination of keywords related to the study population, wearable devices, physical activity, and sedentary behavior. We will use the Boolean operators ?AND? and ?OR? to combine keywords as well as Medical Subject Headings terms. Results: Search strategy was completed in June 2020 with 23 records obtained. Data extraction and synthesis are currently ongoing. Dissemination of study results in peer-reviewed journals is expected at the end of 2021. Conclusions: This review will provide a comprehensive and detailed synthesis of published studies that examine the use of wearable devices for objective assessment of physical activity and sedentary behavior in patients with axSpA. Trial Registration: PROSPERO CRD42020182398; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=182398 International Registered Report Identifier (IRRID): PRR1-10.2196/23359 UR - https://www.researchprotocols.org/2021/11/e23359 UR - http://dx.doi.org/10.2196/23359 UR - http://www.ncbi.nlm.nih.gov/pubmed/34842559 ID - info:doi/10.2196/23359 ER - TY - JOUR AU - Johansson, Magnus AU - Berman, H. Anne AU - Sinadinovic, Kristina AU - Lindner, Philip AU - Hermansson, Ulric AU - Andréasson, Sven PY - 2021/11/24 TI - Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial JO - J Med Internet Res SP - e29666 VL - 23 IS - 11 KW - alcohol dependence KW - alcohol use disorders KW - internet-based interventions KW - internet-based cognitive behavioral therapy KW - ICBT KW - cognitive behavioral therapy KW - CBT KW - eHealth KW - alcohol use KW - substance abuse KW - outcomes KW - help-seeking behavior KW - mobile phone N2 - Background: Alcohol use is a major contributor to health loss. Many persons with harmful use or alcohol dependence do not obtain treatment because of limited availability or stigma. They may use internet-based interventions as an alternative way of obtaining support. Internet-based interventions have previously been shown to be effective in reducing alcohol consumption in studies that included hazardous use; however, few studies have been conducted with a specific focus on harmful use or alcohol dependence. The importance of therapist guidance in internet-based cognitive behavioral therapy (ICBT) programs is still unclear. Objective: This trial aims to investigate the effects of a web-based alcohol program with or without therapist guidance among anonymous adult help-seekers. Methods: A three-armed randomized controlled trial was conducted to compare therapist-guided ICBT and self-help ICBT with an information-only control condition. Swedish-speaking adult internet users with alcohol dependence (3 or more International Classification of Diseases, Tenth Revision criteria) or harmful alcohol use (alcohol use disorder identification test>15) were included in the study. Participants in the therapist-guided ICBT and self-help ICBT groups had 12-week access to a program consisting of 5 main modules, as well as a drinking calendar with automatic feedback. Guidance was given by experienced therapists trained in motivational interviewing. The primary outcome measure was weekly alcohol consumption in standard drinks (12 g of ethanol). Secondary outcomes were alcohol-related problems measured using the total alcohol use disorder identification test-score, diagnostic criteria for alcohol dependence and alcohol use disorder, depression, anxiety, health, readiness to change, and access to other treatments or support. Follow-up was conducted 3 (posttreatment) and 6 months after recruitment. Results: During the recruitment period, from March 2015 to March 2017, 1169 participants were included. Participants had a mean age of 45 (SD 13) years, and 56.72% (663/1169) were women. At the 3-month follow-up, the therapist-guided ICBT and control groups differed significantly in weekly alcohol consumption (?3.84, 95% Cl ?6.53 to ?1.16; t417=2.81; P=.005; Cohen d=0.27). No significant differences were found in weekly alcohol consumption between the self-help ICBT group and the therapist-guided ICBT at 3 months, between the self-help ICBT and the control group at 3 months, or between any of the groups at the 6-month follow-up. A limitation of the study was the large number of participants who were completely lost to follow-up (477/1169, 40.8%). Conclusions: In this study, a therapist-guided ICBT program was not found to be more effective than the same program in a self-help ICBT version for reducing alcohol consumption or other alcohol-related outcomes. In the short run, therapist-guided ICBT was more effective than information. Only some internet help-seekers may need a multisession program and therapist guidance to change their drinking when they use internet-based interventions. Trial Registration: ClinicalTrials.gov NCT02377726; https://clinicaltrials.gov/ct2/show/NCT02377726 UR - https://www.jmir.org/2021/11/e29666 UR - http://dx.doi.org/10.2196/29666 UR - http://www.ncbi.nlm.nih.gov/pubmed/34821563 ID - info:doi/10.2196/29666 ER - TY - JOUR AU - Taguchi, Kayoko AU - Numata, Noriko AU - Takanashi, Rieko AU - Takemura, Ryo AU - Yoshida, Tokiko AU - Kutsuzawa, Kana AU - Yoshimura, Kensuke AU - Nozaki-Taguchi, Natsuko AU - Ohtori, Seiji AU - Shimizu, Eiji PY - 2021/11/22 TI - Clinical Effectiveness and Cost-effectiveness of Videoconference-Based Integrated Cognitive Behavioral Therapy for Chronic Pain: Randomized Controlled Trial JO - J Med Internet Res SP - e30690 VL - 23 IS - 11 KW - cognitive behavioral therapy KW - chronic pain KW - medical economic evaluation KW - EQ-5D-5L KW - telemedicine N2 - Background: Cognitive behavioral therapy is known to improve the management of chronic pain. However, the components of this therapy are still being investigated and debated. Objective: This study aimed to examine the effectiveness of an integrated cognitive behavioral therapy program with new components (attention-shift, memory work, video feedback, and image training) delivered via videoconferencing. Methods: This study was unblinded and participants were recruited and assessed face-to-face in the outpatient department. We conducted a randomized controlled trial for chronic pain to compare 16 weekly videoconference-based cognitive behavioral therapy (vCBT) sessions provided by a therapist with treatment as usual (TAU). Thirty patients (age range, 22-75 years) with chronic pain were randomly assigned to either vCBT (n=15) or TAU (n=15). Patients were evaluated at week 1 (baseline), week 8 (midintervention), and week 16 (postintervention). The primary outcome was the change in pain intensity, which was recorded using the numerical rating scale at 16 weeks from the baseline. Secondary outcomes were pain severity and pain interference, which were assessed using the Brief Pain Inventory. Additionally, we evaluated disability, pain catastrophizing cognition, depression, anxiety, quality of life, and cost utility. Results: In the eligibility assessment, 30 patients were eventually randomized and enrolled; finally, 15 patients in the vCBT and 14 patients in the TAU group were analyzed. Although no significant difference was found between the 2 groups in terms of changes in pain intensity by the numerical rating scale scores at week 16 from baseline (P=.36), there was a significant improvement in the comprehensive evaluation of pain by total score of Brief Pain Inventory (?1.43, 95% CI ?2.49 to ?0.37, df=24; P=.01). Further, significant improvement was seen in pain interference by using the Brief Pain Inventory (?9.42, 95% CI ?14.47 to ?4.36, df=25; P=.001) and in disability by using the Pain Disability Assessment Scale (?1.95, 95% CI ?3.33 to ?0.56, df=24; P=.008) compared with TAU. As for the Medical Economic Evaluation, the incremental cost-effectiveness ratio for 1 year was estimated at 2.9 million yen (about US $25,000) per quality-adjusted life year gained. Conclusions: The findings of our study suggest that integrated cognitive behavioral therapy delivered by videoconferencing in regular medical care may reduce pain interference but not pain intensity. Further, this treatment method may be cost-effective, although this needs to be further verified using a larger sample size. Trial Registration: University Hospital Medical Information Network UMIN000031124; https://tinyurl.com/2pr3xszb UR - https://www.jmir.org/2021/11/e30690 UR - http://dx.doi.org/10.2196/30690 UR - http://www.ncbi.nlm.nih.gov/pubmed/34813489 ID - info:doi/10.2196/30690 ER - TY - JOUR AU - Hachaturyan, Violetta AU - Adam, Maya AU - Favaretti, Caterina AU - Greuel, Merlin AU - Gates, Jennifer AU - Bärnighausen, Till AU - Vandormael, Alain PY - 2021/11/22 TI - Reactance to Social Authority in a Sugar Reduction Informational Video: Web-Based Randomized Controlled Trial of 4013 Participants JO - J Med Internet Res SP - e29664 VL - 23 IS - 11 KW - sugar reduction KW - reactance KW - animated video KW - digital intervention KW - health communication N2 - Background: Short and animated story-based (SAS) videos can be an effective strategy for promoting health messages. However, health promotion strategies often motivate the rejection of health messages, a phenomenon known as reactance. In this study, we examine whether the child narrator of a SAS video (perceived as nonthreatening, with low social authority) minimizes reactance to a health message about the consumption of added sugars. Objective: This study aims to determine whether our SAS intervention video attenuates reactance to the sugar message when compared with a content placebo video (a health message about sunscreen) and a placebo video (a nonhealth message about earthquakes) and determine if the child narrator is more effective at reducing reactance to the sugar message when compared with the mother narrator (equivalent social authority to target audience) or family physician narrator (high social authority) of the same SAS video. Methods: This is a web-based randomized controlled trial comparing an intervention video about sugar reduction narrated by a child, the child?s mother, or the family physician with a content placebo video about sunscreen use and a placebo video about earthquakes. The primary end points are differences in the antecedents to reactance (proneness to reactance, threat level of the message), its components (anger and negative cognition), and outcomes (source appraisal and attitude). We performed analysis of variance on data collected (N=4013) from participants aged 18 to 59 years who speak English and reside in the United Kingdom. Results: Between December 9 and December 11, 2020, we recruited 38.62% (1550/4013) men, 60.85% (2442/4013) women, and 0.52% (21/4013) others for our study. We found a strong causal relationship between the persuasiveness of the content promoted by the videos and the components of reactance. Compared with the placebo (mean 1.56, SD 0.63) and content placebo (mean 1.76, SD 0.69) videos, the intervention videos (mean 1.99, SD 0.83) aroused higher levels of reactance to the message content (P<.001). We found no evidence that the child narrator (mean 1.99, SD 0.87) attenuated reactance to the sugar reduction message when compared with the physician (mean 1.95, SD 0.79; P=.77) and mother (mean 2.03, SD 0.83; P=.93). In addition, the physician was perceived as more qualified, reliable, and having more expertise than the child (P<.001) and mother (P<.001) narrators. Conclusions: Although children may be perceived as nonthreatening messengers, we found no evidence that a child narrator attenuated reactance to a SAS video about sugar consumption when compared with a physician. Furthermore, our intervention videos, with well-intended goals toward audience health awareness, aroused higher levels of reactance when compared with the placebo videos. Our results highlight the challenges in developing effective interventions to promote persuasive health messages. Trial Registration: German Clinical Trials Registry DRKS00022340; https://tinyurl.com/mr8dfena International Registered Report Identifier (IRRID): RR2-10.2196/25343 UR - https://www.jmir.org/2021/11/e29664 UR - http://dx.doi.org/10.2196/29664 UR - http://www.ncbi.nlm.nih.gov/pubmed/34813490 ID - info:doi/10.2196/29664 ER - TY - JOUR AU - Jonathan, K. Geneva AU - Dopke, A. Cynthia AU - Michaels, Tania AU - Martin, R. Clair AU - Ryan, Chloe AU - McBride, Alyssa AU - Babington, Pamela AU - Goulding, H. Evan PY - 2021/11/22 TI - A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process JO - JMIR Ment Health SP - e32306 VL - 8 IS - 11 KW - behavioral intervention technology KW - mHealth KW - bipolar disorder KW - depression KW - illness management KW - smartphone KW - behavior change KW - early warning signs KW - self-management KW - qualitative KW - behavior KW - intervention KW - management KW - user experience KW - perception KW - utilization N2 - Background: Bipolar disorder is a severe mental illness characterized by recurrent episodes of depressed, elevated, and mixed mood states. The addition of psychotherapy to pharmacological management can decrease symptoms, lower relapse rates, and improve quality of life; however, access to psychotherapy is limited. Mental health technologies such as smartphone apps are being studied as a means to increase access to and enhance the effectiveness of adjunctive psychotherapies for bipolar disorder. Individuals with bipolar disorder find this intervention format acceptable, but our understanding of how people utilize and integrate these tools into their behavior change and maintenance processes remains limited. Objective: The objective of this study was to explore how individuals with bipolar disorder perceive and utilize a smartphone intervention for health behavior change and maintenance. Methods: Individuals with bipolar disorder were recruited via flyers placed at university-affiliated and private outpatient mental health practices to participate in a pilot study of LiveWell, a smartphone-based self-management intervention. At the end of the study, all participants completed in-depth qualitative exit interviews. The behavior change framework developed to organize the intervention design was used to deductively code behavioral targets and determinants involved in target engagement. Inductive coding was used to identify themes not captured by this framework. Results: In terms of behavioral targets, participants emphasized the importance of managing mood episode?related signs and symptoms. They also discussed the importance of maintaining regular routines, sleep duration, and medication adherence. Participants emphasized that receiving support from a coach as well as seeking and receiving assistance from family, friends, and providers were important for managing behavioral targets and staying well. In terms of determinants, participants stressed the important role of monitoring for their behavior change and maintenance efforts. Monitoring facilitated self-awareness and reflection, which was considered valuable for staying well. Some participants also felt that the intervention facilitated learning information necessary for managing bipolar disorder but others felt that the information provided was too basic. Conclusions: In addition to addressing acceptability, satisfaction, and engagement, a person-based design of mental health technologies can be used to understand how people experience the impact of these technologies on their behavior change and maintenance efforts. This understanding may then be used to guide ongoing intervention development. The participants? perceptions aligned with the intervention?s primary behavioral targets and use of a monitoring tool as a core intervention feature. Participant feedback further indicates that developing additional content and tools to address building and engaging social support may be an important avenue for improving LiveWell. A comprehensive behavior change framework to understand participant perceptions of their behavior change and maintenance efforts may help facilitate ongoing intervention development. UR - https://mental.jmir.org/2021/11/e32306 UR - http://dx.doi.org/10.2196/32306 UR - http://www.ncbi.nlm.nih.gov/pubmed/34813488 ID - info:doi/10.2196/32306 ER - TY - JOUR AU - Shin, Bokyoung AU - Oh, Jooyoung AU - Kim, Byung-Hoon AU - Kim, Erin Hesun AU - Kim, Hyunji AU - Kim, Suji AU - Kim, Jae-Jin PY - 2021/11/22 TI - Effectiveness of Self-Guided Virtual Reality?Based Cognitive Behavioral Therapy for Panic Disorder: Randomized Controlled Trial JO - JMIR Ment Health SP - e30590 VL - 8 IS - 11 KW - virtual reality KW - panic disorder KW - cognitive behavioral therapy KW - exposure therapy KW - intervention N2 - Background: Virtual reality (VR) is as effective a technique as traditional cognitive behavioral therapy (CBT) and a promising tool for treating panic disorder symptoms because VR exposure can be safer and has better acceptability than in vivo exposure and is more immersive than exposure through imagination. CBT techniques can be delivered more effectively using VR as well. So far, VR has required high-quality devices, but the development of mobile VR technology has improved user availability. At the same time, a well-structured form of VR can be reproduced and used anywhere. This means that VR can be used to provide a self-guided form of treatment and address the high treatment costs of evidence-based therapy and the lack of professional therapists. This study aimed to investigate the potential of self-guided VR as an alternative to high-cost treatment. Objective: The main goal of this study was to offer data about the efficacy of a mobile app-based self-led VR CBT in the treatment of panic disorder. Methods: A total of 54 subjects with panic disorder were enrolled in this study and randomly assigned to either the VR treatment group or waitlist group. The VR treatment was designed to be total 12 sessions for 4 weeks. The VR treatment consists of 4 steps in which patients are gradually exposed to phobic stimuli while learning to cope with panic symptoms in each stage. The effectiveness of treatment was assessed through the Panic Disorder Severity Scale, Hamilton Rating Scale for Depression, Body Sensations Questionnaire, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Index, State-Trait Anxiety Inventory, Hospital Anxiety and Depression Scale, Korean Inventory of Social Avoidance and Distress Scale, Korean Inventory of Depressive Symptomatology, and Perceived Stress Scale. In addition, physiological changes using heart rate variability were evaluated. Results: In within-group analyses, the VR treatment group exhibited improvements in panic disorder symptoms, anxiety, and depression after 4 weeks, while the waitlist group did not show any significant improvement. Compared to the waitlist group, the VR treatment group showed significantly greater improvements in the Panic Disorder Severity Scale in both completer analysis and intention-to-treat analysis. Heart rate variability in the VR treatment group showed improvement in normalized high frequency from baseline to postassessment with no significant differences in any outcome measure between groups. Conclusions: The self-guided, mobile app-based VR intervention was effective in the treatment of panic symptoms and restoring the autonomic nervous system demonstrating the validity of the use of VR for self-guided treatment. VR treatment can be a cost-effective therapeutic approach. Trial Registration: ClinicalTrials.gov NCT04985019; https://clinicaltrials.gov/ct2/show/NCT04985019 UR - https://mental.jmir.org/2021/11/e30590 UR - http://dx.doi.org/10.2196/30590 UR - http://www.ncbi.nlm.nih.gov/pubmed/34813486 ID - info:doi/10.2196/30590 ER - TY - JOUR AU - Dao, Phuong Kim AU - De Cocker, Katrien AU - Tong, Ly Huong AU - Kocaballi, Baki A. AU - Chow, Clara AU - Laranjo, Liliana PY - 2021/11/19 TI - Smartphone-Delivered Ecological Momentary Interventions Based on Ecological Momentary Assessments to Promote Health Behaviors: Systematic Review and Adapted Checklist for Reporting Ecological Momentary Assessment and Intervention Studies JO - JMIR Mhealth Uhealth SP - e22890 VL - 9 IS - 11 KW - ecological momentary assessment KW - ecological momentary intervention KW - behavior change KW - health behavior KW - mHealth KW - mobile health KW - smartphone apps KW - mobile phone N2 - Background: Healthy behaviors are crucial for maintaining a person?s health and well-being. The effects of health behavior interventions are mediated by individual and contextual factors that vary over time. Recently emerging smartphone-based ecological momentary interventions (EMIs) can use real-time user reports (ecological momentary assessments [EMAs]) to trigger appropriate support when needed in daily life. Objective: This systematic review aims to assess the characteristics of smartphone-delivered EMIs using self-reported EMAs in relation to their effects on health behaviors, user engagement, and user perspectives. Methods: We searched MEDLINE, Embase, PsycINFO, and CINAHL in June 2019 and updated the search in March 2020. We included experimental studies that incorporated EMIs based on EMAs delivered through smartphone apps to promote health behaviors in any health domain. Studies were independently screened. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. We performed a narrative synthesis of intervention effects, user perspectives and engagement, and intervention design and characteristics. Quality appraisal was conducted for all included studies. Results: We included 19 papers describing 17 unique studies and comprising 652 participants. Most studies were quasi-experimental (13/17, 76%), had small sample sizes, and great heterogeneity in intervention designs and measurements. EMIs were most popular in the mental health domain (8/17, 47%), followed by substance abuse (3/17, 18%), diet, weight loss, physical activity (4/17, 24%), and smoking (2/17, 12%). Of the 17 studies, the 4 (24%) included randomized controlled trials reported nonstatistically significant effects on health behaviors, and 4 (24%) quasi-experimental studies reported statistically significant pre-post improvements in self-reported primary outcomes, namely depressive (P<.001) and psychotic symptoms (P=.03), drinking frequency (P<.001), and eating patterns (P=.01). EMA was commonly used to capture subjective experiences as well as behaviors, whereas sensors were rarely used. Generally, users perceived EMIs to be helpful. Common suggestions for improvement included enhancing personalization, multimedia and interactive capabilities (eg, voice recording), and lowering the EMA reporting burden. EMI and EMA components were rarely reported and were not described in a standardized manner across studies, hampering progress in this field. A reporting checklist was developed to facilitate the interpretation and comparison of findings and enhance the transparency and replicability of future studies using EMAs and EMIs. Conclusions: The use of smartphone-delivered EMIs using self-reported EMAs to promote behavior change is an emerging area of research, with few studies evaluating efficacy. Such interventions could present an opportunity to enhance health but need further assessment in larger participant cohorts and well-designed evaluations following reporting checklists. Future research should explore combining self-reported EMAs of subjective experiences with objective data passively collected via sensors to promote personalization while minimizing user burden, as well as explore different EMA data collection methods (eg, chatbots). Trial Registration: PROSPERO CRD42019138739; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=138739 UR - https://mhealth.jmir.org/2021/11/e22890 UR - http://dx.doi.org/10.2196/22890 UR - http://www.ncbi.nlm.nih.gov/pubmed/34806995 ID - info:doi/10.2196/22890 ER - TY - JOUR AU - Becker, RB Elisabeth AU - Shegog, Ross AU - Savas, S. Lara AU - Frost, L. Erica AU - Healy, Mary C. AU - Spinner, W. Stanley AU - Vernon, W. Sally PY - 2021/11/19 TI - Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study JO - JMIR Form Res SP - e28846 VL - 5 IS - 11 KW - human papillomavirus KW - vaccination KW - qualitative KW - focus groups KW - sexually transmitted infection N2 - Background: Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. Objective: This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. Methods: We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. Results: The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. Conclusions: Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child?s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents. UR - https://formative.jmir.org/2021/11/e28846 UR - http://dx.doi.org/10.2196/28846 UR - http://www.ncbi.nlm.nih.gov/pubmed/34806991 ID - info:doi/10.2196/28846 ER - TY - JOUR AU - Singh, Tavleen AU - Olivares, Sofia AU - Cohen, Trevor AU - Cobb, Nathan AU - Wang, Jing AU - Franklin, Amy AU - Myneni, Sahiti PY - 2021/11/17 TI - Pragmatics to Reveal Intent in Social Media Peer Interactions: Mixed Methods Study JO - J Med Internet Res SP - e32167 VL - 23 IS - 11 KW - online health communities KW - diabetes self-management KW - tobacco cessation KW - speech acts KW - behavior change KW - communication themes N2 - Background: Online health communities (OHCs) have emerged as the leading venues for behavior change and health-related information seeking. The soul and success of these digital platforms lie in their ability to foster social togetherness and a sense of community by providing personalized support. However, we have a minimal understanding of how conversational posts in these settings lead to collaborative societies and ultimately result in positive health changes through social influence. Objective: Our objective is to develop a content-specific and intent-sensitive methodological framework for analyzing peer interactions in OHCs. Methods: We developed and applied a mixed-methods approach to understand the manifestation of expressions in peer interactions in OHCs. We applied our approach to describe online social dialogue in the context of two online communities, QuitNet (QN) and the American Diabetes Association (ADA) support community. A total of 3011 randomly selected peer interactions (n=2005 from QN, n=1006 from ADA) were analyzed. Specifically, we conducted thematic analysis to characterize communication content and linguistic expressions (speech acts) embedded within the two data sets. We also developed an empirical user persona based on their engagement levels and behavior profiles. Further, we examined the association between speech acts and communication themes across observed tiers of user engagement and self-reported behavior profiles using the chi-square test or the Fisher test. Results: Although social support, the most prevalent communication theme in both communities, was expressed in several subtle manners, the prevalence of emotions was higher in the tobacco cessation community and assertions were higher in the diabetes self-management (DSM) community. Specific communication theme-speech act relationships were revealed, such as the social support theme was significantly associated (P<.05) with 9 speech acts from a total of 10 speech acts (ie, assertion, commissive, declarative, desire, directive, expressive, question, stance, and statement) within the QN community. Only four speech acts (ie, commissive, emotion, expressive, and stance) were significantly associated (P<.05) with the social support theme in the ADA community. The speech acts were also significantly associated with the users? abstinence status within the QN community and with the users? lifestyle status within the ADA community (P<.05). Conclusions: Such an overlay of communication intent implicit in online peer interactions alongside content-specific theory-linked characterizations of social media discourse can inform the development of effective digital health technologies in the field of health promotion and behavior change. Our analysis revealed a rich gradient of expressions across a standardized thematic vocabulary, with a distinct variation in emotional and informational needs, depending on the behavioral and disease management profiles within and across the communities. This signifies the need and opportunities for coupling pragmatic messaging in digital therapeutics and care management pathways for personalized support. UR - https://www.jmir.org/2021/11/e32167 UR - http://dx.doi.org/10.2196/32167 UR - http://www.ncbi.nlm.nih.gov/pubmed/34787578 ID - info:doi/10.2196/32167 ER - TY - JOUR AU - Chatterjee, Ayan AU - Prinz, Andreas AU - Gerdes, Martin AU - Martinez, Santiago PY - 2021/11/17 TI - Digital Interventions on Healthy Lifestyle Management: Systematic Review JO - J Med Internet Res SP - e26931 VL - 23 IS - 11 KW - eHealth KW - digital intervention KW - lifestyle KW - obesity KW - challenges KW - mobile phone N2 - Background: Digital interventions have tremendous potential to improve well-being and health care conveyance by improving adequacy, proficiency, availability, and personalization. They have gained acknowledgment in interventions for the management of a healthy lifestyle. Therefore, we are reviewing existing conceptual frameworks, digital intervention approaches, and associated methods to identify the impact of digital intervention on adopting a healthier lifestyle. Objective: This study aims to evaluate the impact of digital interventions on weight management in maintaining a healthy lifestyle (eg, regular physical activity, healthy habits, and proper dietary patterns). Methods: We conducted a systematic literature review to search the scientific databases (Nature, SpringerLink, Elsevier, IEEE Xplore, and PubMed) that included digital interventions on healthy lifestyle, focusing on preventing obesity and being overweight as a prime objective. Peer-reviewed articles published between 2015 and 2020 were included. We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and a framework for an evidence-based systematic review. Furthermore, we improved the review process by adopting the Rayyan tool and the Scale for the Assessment of Narrative Review Articles. Results: Our initial searches identified 780 potential studies through electronic and manual searches; however, 107 articles in the final stage were cited following the specified inclusion and exclusion criteria. The identified methods for a successful digital intervention to promote a healthy lifestyle are self-monitoring, self-motivation, goal setting, personalized feedback, participant engagement, psychological empowerment, persuasion, digital literacy, efficacy, and credibility. In this study, we identified existing conceptual frameworks for digital interventions, different approaches to provide digital interventions, associated methods, and execution challenges and their impact on the promotion of healthy lifestyle management. Conclusions: This systematic literature review selected intervention principles (rules), theories, design features, ways to determine efficient interventions, and weaknesses in healthy lifestyle management from established digital intervention approaches. The results help us understand how digital interventions influence lifestyle management and overcome the existing shortcomings. It serves as a basis for further research with a focus on designing, developing, testing, and evaluating the generation of personalized lifestyle recommendations as a part of digital health interventions. UR - https://www.jmir.org/2021/11/e26931 UR - http://dx.doi.org/10.2196/26931 UR - http://www.ncbi.nlm.nih.gov/pubmed/34787575 ID - info:doi/10.2196/26931 ER - TY - JOUR AU - Muñoz-Mancisidor, Aranzazu AU - Martin-Payo, Ruben AU - Gonzalez-Mendez, Xana AU - Fernández-Álvarez, Mar María Del PY - 2021/11/17 TI - Content, Behavior Change Techniques, and Quality of Pregnancy Apps in Spain: Systematic Search on App Stores JO - JMIR Mhealth Uhealth SP - e27995 VL - 9 IS - 11 KW - pregnancy KW - mobile apps KW - behavior KW - technology assessment, biomedical KW - telemedicine N2 - Background: Women consult information in mobile apps (apps) during pregnancy, and even obstetrics specialists highlight that pregnancy is the ideal moment for the use of apps as consultation sources. However, the high number of apps designed for pregnancy requires a careful assessment to determine their suitability before recommendation. Objective: The aim of this study is to identify the apps available in Spanish that can be recommended based on their content, behavior change techniques (BCTs), and quality as a complementary tool during pregnancy. Methods: A systematic search on app stores to identify apps was performed in the Apple App Store and Google Play with the subject term ?pregnancy.? The apps meeting the following criteria were chosen: pregnancy-related content, free, and available in Spanish. An app was excluded if it was classified as a game or entertainment and thus lacking an educational or health aim and if it did not target the population under study. The selected apps were downloaded, and their quality was assessed using the Mobile Application Rating Scale (MARS), with the BCTs included evaluated using the BCT taxonomy version 1 and its content. Results: A total of 457 apps were identified, 25 of which were downloaded for assessment (5.6%). The median for objective and subjective quality was 2.94 (IQR 2.71-3.46) and 1.75 (IQR 1.25-2.25), respectively. Regarding content, the median of topics included in the apps was 23 (IQR 16-23), with weight gain, nutrition, fetal development, and physical activity being the most common. The median number of BCTs was 12 (IQR 0.5-3.5). The most frequently identified BCTs in the apps were ?Self-Monitoring of Outcomes,? followed by ?Goal Behavior? and ?Instructions.? Statistically significant correlations were observed between objective quality and content (?=0.624; P=.001), subjective quality and content (?=0.638; P=.001), objective quality and BCTs (?=0.672; P<.001), subjective quality and BCTs (?=0.623; P<.001), and BCTs and content (?=0.580; P=.002). Conclusions: The results of this study suggest that only a small percentage of free pregnancy apps available in Spanish should be recommended. The apps with the best MARS scores were those that addressed a higher number of topics and included a higher number of BCTs. Those with the best content and quality, and a higher number of BCTs included could be recommended by health professionals. UR - https://mhealth.jmir.org/2021/11/e27995 UR - http://dx.doi.org/10.2196/27995 UR - http://www.ncbi.nlm.nih.gov/pubmed/34787587 ID - info:doi/10.2196/27995 ER - TY - JOUR AU - Ang, Min Siew AU - Chen, Juliana AU - Liew, Huan Jia AU - Johal, Jolyn AU - Dan, Young Yock AU - Allman-Farinelli, Margaret AU - Lim, Lin Su PY - 2021/11/16 TI - Efficacy of Interventions That Incorporate Mobile Apps in Facilitating Weight Loss and Health Behavior Change in the Asian Population: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e28185 VL - 23 IS - 11 KW - systematic review KW - meta-analysis KW - mobile app KW - obesity KW - weight loss KW - Asian KW - diet KW - physical activity KW - adults KW - mobile phone N2 - Background: Smartphone apps have shown potential in enhancing weight management in Western populations in the short to medium term. With a rapidly growing obesity burden in Asian populations, researchers are turning to apps as a service delivery platform to reach a larger target audience to efficiently address the problem. Objective: This systematic review and meta-analysis aims to determine the efficacy of interventions that incorporate apps in facilitating weight loss and health behavior change in the Asian population. Methods: A total of 6 databases were searched in June 2020. The eligible studies included controlled trials in which an app was used in the intervention. The participants were aged 18 years or older and were of Asian ethnicity. A meta-analysis to test intervention efficacy, subgroup analyses, and post hoc analyses was conducted to determine the effects of adding an app to usual care and study duration. The primary outcome was absolute or percentage weight change, whereas the secondary outcomes were changes to lifestyle behaviors. Results: A total of 21 studies were included in this review, and 17 (81%) were selected for the meta-analysis. The pooled effect size across 82% (14/17) of the randomized controlled trials for weight change was small to moderate (Hedges g=?0.26; 95% CI ?0.41 to ?0.11), indicating slightly greater weight loss achieved in the intervention group; however, this may not be representative of long-term studies (lasting for more than a year). Supplementing multicomponent usual care with an app led to greater weight loss (Hedges g=?0.28; 95% CI ?0.47 to ?0.09). Asian apps were largely culturally adapted and multifunctional, with the most common app features being communication with health professionals and self-monitoring of behaviors and outcomes. Conclusions: More evidence is required to determine the efficacy of apps in the long term and address the low uptake of apps to maximize the potential of the intervention. Future research should determine the efficacy of each component of the multicomponent intervention to facilitate the designing of studies that are most effective and cost-efficient for weight management. Trial Registration: PROSPERO CRD42020165240; https://tinyurl.com/2db4tvn6 UR - https://www.jmir.org/2021/11/e28185 UR - http://dx.doi.org/10.2196/28185 UR - http://www.ncbi.nlm.nih.gov/pubmed/34783674 ID - info:doi/10.2196/28185 ER - TY - JOUR AU - Ben-Zeev, Dror AU - Chander, Ayesha AU - Tauscher, Justin AU - Buck, Benjamin AU - Nepal, Subigya AU - Campbell, Andrew AU - Doron, Guy PY - 2021/11/12 TI - A Smartphone Intervention for People With Serious Mental Illness: Fully Remote Randomized Controlled Trial of CORE JO - J Med Internet Res SP - e29201 VL - 23 IS - 11 KW - mobile health KW - schizophrenia KW - bipolar disorder KW - depression KW - mobile phone N2 - Background: People with serious mental illness (SMI) have significant unmet mental health needs. Development and testing of digital interventions that can alleviate the suffering of people with SMI is a public health priority. Objective: The aim of this study is to conduct a fully remote randomized waitlist-controlled trial of CORE, a smartphone intervention that comprises daily exercises designed to promote reassessment of dysfunctional beliefs in multiple domains. Methods: Individuals were recruited via the web using Google and Facebook advertisements. Enrolled participants were randomized into either active intervention or waitlist control groups. Participants completed the Beck Depression Inventory-Second Edition (BDI-II), Generalized Anxiety Disorder-7 (GAD-7), Hamilton Program for Schizophrenia Voices, Green Paranoid Thought Scale, Recovery Assessment Scale (RAS), Rosenberg Self-Esteem Scale (RSES), Friendship Scale, and Sheehan Disability Scale (SDS) at baseline (T1), 30-day (T2), and 60-day (T3) assessment points. Participants in the active group used CORE from T1 to T2, and participants in the waitlist group used CORE from T2 to T3. Both groups completed usability and accessibility measures after they concluded their intervention periods. Results: Overall, 315 individuals from 45 states participated in this study. The sample comprised individuals with self-reported bipolar disorder (111/315, 35.2%), major depressive disorder (136/315, 43.2%), and schizophrenia or schizoaffective disorder (68/315, 21.6%) who displayed moderate to severe symptoms and disability levels at baseline. Participants rated CORE as highly usable and acceptable. Intent-to-treat analyses showed significant treatment×time interactions for the BDI-II (F1,313=13.38; P<.001), GAD-7 (F1,313=5.87; P=.01), RAS (F1,313=23.42; P<.001), RSES (F1,313=19.28; P<.001), and SDS (F1,313=10.73; P=.001). Large effects were observed for the BDI-II (d=0.58), RAS (d=0.61), and RSES (d=0.64); a moderate effect size was observed for the SDS (d=0.44), and a small effect size was observed for the GAD-7 (d=0.20). Similar changes in outcome measures were later observed in the waitlist control group participants following crossover after they received CORE (T2 to T3). Approximately 41.5% (64/154) of participants in the active group and 60.2% (97/161) of participants in the waitlist group were retained at T2, and 33.1% (51/154) of participants in the active group and 40.3% (65/161) of participants in the waitlist group were retained at T3. Conclusions: We successfully recruited, screened, randomized, treated, and assessed a geographically dispersed sample of participants with SMI entirely via the web, demonstrating that fully remote clinical trials are feasible in this population; however, study retention remains challenging. CORE showed promise as a usable, acceptable, and effective tool for reducing the severity of psychiatric symptoms and disability while improving recovery and self-esteem. Rapid adoption and real-world dissemination of evidence-based mobile health interventions such as CORE are needed if we are to shorten the science-to-service gap and address the significant unmet mental health needs of people with SMI during the COVID-19 pandemic and beyond. Trial Registration: ClinicalTrials.gov NCT04068467; https://clinicaltrials.gov/ct2/show/NCT04068467 UR - https://www.jmir.org/2021/11/e29201 UR - http://dx.doi.org/10.2196/29201 UR - http://www.ncbi.nlm.nih.gov/pubmed/34766913 ID - info:doi/10.2196/29201 ER - TY - JOUR AU - Cyriac, Jissy AU - Jenkins, Sarah AU - Patten, A. Christi AU - Hayes, N. Sharonne AU - Jones, Clarence AU - Cooper, A. Lisa AU - Brewer, C. LaPrincess PY - 2021/11/12 TI - Improvements in Diet and Physical Activity?Related Psychosocial Factors Among African Americans Using a Mobile Health Lifestyle Intervention to Promote Cardiovascular Health: The FAITH! (Fostering African American Improvement in Total Health) App Pilot Study JO - JMIR Mhealth Uhealth SP - e28024 VL - 9 IS - 11 KW - African Americans KW - cardiovascular health disparities KW - mHealth lifestyle intervention KW - diet KW - physical activity KW - mobile phone N2 - Background: African Americans continue to have suboptimal cardiovascular health (CVH) related to diet and physical activity (PA) behaviors compared with White people. Mobile health (mHealth) interventions are innovative platforms to improve diet and PA and have the potential to mitigate these disparities. However, these are understudied among African Americans. Objective: This study aims to examine whether an mHealth lifestyle intervention is associated with improved diet and PA-related psychosocial factors in African Americans and whether these changes correlate with diet and PA behavioral change. Methods: This study is a retrospective analysis evaluating changes in diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors (daily fruit and vegetable intake and moderate-intensity PA [MPA] per week) in 45 African American adults (mean age 48.7 years, SD 12.9 years; 33/45, 73% women) enrolled in the FAITH! (Fostering African American Improvement in Total Health) app pilot study. The intervention is a 10-week, behavioral theory?informed, community-based mHealth lifestyle intervention delivered through a mobile app platform. Participants engaged with 3 core FAITH! app features: multimedia education modules focused on CVH with self-assessments of CVH knowledge, self-monitoring of daily fruit and vegetable intake and PA, and a sharing board for social networking. Changes in self-reported diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors were assessed by electronic surveys collected at baseline and 28 weeks postintervention. Changes in diet and PA-related psychosocial factors from pre- to postintervention were assessed using paired 2-tailed t tests. The association of changes in diet and PA-related psychosocial variables with daily fruit and vegetable intake and MPA per week was assessed using Spearman correlation. Associations between baseline and 28-week postintervention changes in diet and PA-related psychosocial measures and CVH behaviors with covariates were assessed by multivariable linear regression. Results: Participants reported improvements in 2 subscales of diet self-regulation (decrease fat and calorie intake, P=.01 and nutrition tracking, P<.001), one subscale of social support for healthy diet (friend discouragement, P=.001), perceived barriers to healthy diet (P<.001), and daily fruit and vegetable intake (P<.001). Improvements in diet self-regulation (increase fruit, vegetable, and grain intake, and nutrition tracking) and social support for healthy diet (friend encouragement) had moderate positive correlations with daily fruit and vegetable intake (r=0.46, r=0.34, and r=0.43, respectively). A moderate negative correlation was observed between perceived barriers to healthy diet and daily fruit and vegetable intake (r=?0.25). Participants reported increases in PA self-regulation (P<.001). Increase in social support subscales for PA (family and friend participation) had a moderate positive correlation with MPA per week (r=0.51 and r=0.61, respectively). Conclusions: Our findings highlight key diet and PA-related psychosocial factors to target in future mHealth lifestyle interventions aimed at promoting CVH in African Americans. UR - https://mhealth.jmir.org/2021/11/e28024 UR - http://dx.doi.org/10.2196/28024 UR - http://www.ncbi.nlm.nih.gov/pubmed/34766917 ID - info:doi/10.2196/28024 ER - TY - JOUR AU - Leese, Jenny AU - MacDonald, Graham AU - Backman, L. Catherine AU - Townsend, Anne AU - Nimmon, Laura AU - Li, C. Linda PY - 2021/11/12 TI - Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens JO - JMIR Mhealth Uhealth SP - e30332 VL - 9 IS - 11 KW - relational ethics KW - physical activity KW - wearable KW - arthritis KW - qualitative N2 - Background: Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways. Objective: Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study. Methods: This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants? relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens. Results: Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor?s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate. Conclusions: Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation. UR - https://mhealth.jmir.org/2021/11/e30332 UR - http://dx.doi.org/10.2196/30332 UR - http://www.ncbi.nlm.nih.gov/pubmed/34766912 ID - info:doi/10.2196/30332 ER - TY - JOUR AU - Laursen, Lund Sidsel AU - Helweg-Jørgensen, Stig AU - Langergaard, Astrid AU - Søndergaard, Jesper AU - Sørensen, Storgaard Sabrina AU - Mathiasen, Kim AU - Lichtenstein, Beck Mia AU - Ehlers, Holger Lars PY - 2021/11/11 TI - Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation JO - J Med Internet Res SP - e28874 VL - 23 IS - 11 KW - borderline personality disorder KW - dialectical behavior therapy KW - mobile app KW - psychotherapy KW - cost-consequence KW - mHealth KW - mobile phone N2 - Background: The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown. Objective: This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility. Methods: This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app. Results: A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference ?0.054; SE 0.03) and reduction in depression severity (adjusted difference ?1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice ?1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations. Conclusions: This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness. Trial Registration: ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID): RR2-10.2196/17737 UR - https://www.jmir.org/2021/11/e28874 UR - http://dx.doi.org/10.2196/28874 UR - http://www.ncbi.nlm.nih.gov/pubmed/34762057 ID - info:doi/10.2196/28874 ER - TY - JOUR AU - Dhinagaran, Ardhithy Dhakshenya AU - Sathish, Thirunavukkarasu AU - Kowatsch, Tobias AU - Griva, Konstadina AU - Best, Donovan James AU - Tudor Car, Lorainne PY - 2021/11/11 TI - Public Perceptions of Diabetes, Healthy Living, and Conversational Agents in Singapore: Needs Assessment JO - JMIR Form Res SP - e30435 VL - 5 IS - 11 KW - conversational agents KW - chatbots KW - diabetes KW - prediabetes KW - healthy lifestyle change KW - mobile phone N2 - Background: The incidence of chronic diseases such as type 2 diabetes is increasing in countries worldwide, including Singapore. Health professional?delivered healthy lifestyle interventions have been shown to prevent type 2 diabetes. However, ongoing personalized guidance from health professionals is not feasible or affordable at the population level. Novel digital interventions delivered using mobile technology, such as conversational agents, are a potential alternative for the delivery of healthy lifestyle change behavioral interventions to the public. Objective: We explored perceptions and experiences of Singaporeans on healthy living, diabetes, and mobile health (mHealth) interventions (apps and conversational agents). This study was conducted to help inform the design and development of a conversational agent focusing on healthy lifestyle changes. Methods: This qualitative study was conducted in August and September 2019. A total of 20 participants were recruited from relevant healthy living Facebook pages and groups. Semistructured interviews were conducted in person or over the telephone using an interview guide. Interviews were transcribed and analyzed in parallel by 2 researchers using Burnard?s method, a structured approach for thematic content analysis. Results: The collected data were organized into 4 main themes: use of conversational agents, ubiquity of smartphone apps, understanding of diabetes, and barriers and facilitators to a healthy living in Singapore. Most participants used health-related mobile apps as well as conversational agents unrelated to health care. They provided diverse suggestions for future conversational agent-delivered interventions. Participants also highlighted several knowledge gaps in relation to diabetes and healthy living. Regarding barriers to healthy living, participants mentioned frequent dining out, high stress levels, lack of work-life balance, and lack of free time to engage in physical activity. In contrast, discipline, preplanning, and sticking to a routine were important for enabling a healthy lifestyle. Conclusions: Participants in this study commonly used mHealth interventions and provided important insights into their knowledge gaps and needs in relation to changes in healthy lifestyle behaviors. Future digital interventions such as conversational agents focusing on healthy lifestyle and diabetes prevention should aim to address the barriers highlighted in our study and motivate individuals to adopt healthy lifestyle behavior. UR - https://formative.jmir.org/2021/11/e30435 UR - http://dx.doi.org/10.2196/30435 UR - http://www.ncbi.nlm.nih.gov/pubmed/34762053 ID - info:doi/10.2196/30435 ER - TY - JOUR AU - Elavsky, Steriani AU - Klocek, Adam AU - Knapova, Lenka AU - Smahelova, Martina AU - Smahel, David AU - Cimler, Richard AU - Kuhnova, Jitka PY - 2021/11/10 TI - Feasibility of Real-time Behavior Monitoring Via Mobile Technology in Czech Adults Aged 50 Years and Above: 12-Week Study With Ecological Momentary Assessment JO - JMIR Aging SP - e15220 VL - 4 IS - 4 KW - mHealth KW - mobile phone KW - older adults KW - health behavior KW - physical activity KW - Fitbit N2 - Background: Czech older adults have lower rates of physical activity than the average population and lag behind in the use of digital technologies, compared with their peers from other European countries. Objective: This study aims to assess the feasibility of intensive behavior monitoring through technology in Czech adults aged ?50 years. Methods: Participants (N=30; mean age 61.2 years, SD 6.8 years, range 50-74 years; 16/30, 53% male; 7/30, 23% retired) were monitored for 12 weeks while wearing a Fitbit Charge 2 monitor and completed three 8-day bursts of intensive data collection through surveys presented on a custom-made mobile app. Web-based surveys were also completed before and at the end of the 12-week period (along with poststudy focus groups) to evaluate participants? perceptions of their experience in the study. Results: All 30 participants completed the study. Across the three 8-day bursts, participants completed 1454 out of 1744 (83% compliance rate) surveys administered 3 times per day on a pseudorandom schedule, 451 out of 559 (81% compliance rate) end-of-day surveys, and 736 episodes of self-reported planned physical activity (with 29/736, 3.9% of the reports initiated but returned without data). The overall rating of using the mobile app and Fitbit was above average (74.5 out of 100 on the System Usability Scale). The majority reported that the Fitbit (27/30, 90%) and mobile app (25/30, 83%) were easy to use and rated their experience positively (25/30, 83%). Focus groups revealed that some surveys were missed owing to notifications not being noticed or that participants needed a longer time window for survey completion. Some found wearing the monitor in hot weather or at night uncomfortable, but overall, participants were highly motivated to complete the surveys and be compliant with the study procedures. Conclusions: The use of a mobile survey app coupled with a wearable device appears feasible for use among Czech older adults. Participants in this study tolerated the intensive assessment schedule well, but lower compliance may be expected in studies of more diverse groups of older adults. Some difficulties were noted with the pairing and synchronization of devices on some types of smartphones, posing challenges for large-scale studies. UR - https://aging.jmir.org/2021/4/e15220 UR - http://dx.doi.org/10.2196/15220 UR - http://www.ncbi.nlm.nih.gov/pubmed/34757317 ID - info:doi/10.2196/15220 ER - TY - JOUR AU - Bricker, B. Jonathan AU - Levin, Michael AU - Lappalainen, Raimo AU - Mull, Kristin AU - Sullivan, Brianna AU - Santiago-Torres, Margarita PY - 2021/11/9 TI - Mechanisms of Smartphone Apps for Cigarette Smoking Cessation: Results of a Serial Mediation Model From the iCanQuit Randomized Trial JO - JMIR Mhealth Uhealth SP - e32847 VL - 9 IS - 11 KW - mediation KW - engagement KW - digital KW - mHealth: smartphone KW - acceptance KW - smoking KW - cessation KW - app KW - randomized controlled trial KW - model KW - intervention N2 - Background: Engagement with digital interventions is a well-known predictor of treatment outcomes, but this knowledge has had limited actionable value. Instead, learning why engagement with digital interventions impact treatment outcomes can lead to targeted improvements in their efficacy. Objective: This study aimed to test a serial mediation model of an Acceptance and Commitment Therapy (ACT) smartphone intervention for smoking cessation. Methods: In this randomized controlled trial, participants (N=2415) from 50 US states were assigned to the ACT-based smartphone intervention (iCanQuit) or comparison smartphone intervention (QuitGuide). Their engagement with the apps (primary measure: number of logins) was measured during the first 3 months, ACT processes were measured at baseline and 3 months (acceptance of internal cues to smoke, valued living), and smoking cessation was measured at 12 months with 87% follow-up retention. Results: There was a significant serial mediation effect of iCanQuit on smoking cessation through multiple indicators of intervention engagement (ie, total number of logins, total number of minutes used, and total number of unique days of use) and in turn through increases in mean acceptance of internal cues to smoke from baseline to 3 months. Analyses of the acceptance subscales showed that the mediation was through acceptance of physical sensations and emotions, but not acceptance of thoughts. There was no evidence that the effect of the iCanQuit intervention was mediated through changes in valued living. Conclusions: In this first study of serial mediators underlying the efficacy of smartphone apps for smoking cessation, our results suggest the effect of the iCanQuit ACT-based smartphone app on smoking cessation was mediated through multiple indicators of engagement and in turn through increases in the acceptance of physical sensations and emotions that cue smoking. Trial Registration: Clinical Trials.gov NCT02724462; https://clinicaltrials.gov/ct2/show/NCT02724462 UR - https://mhealth.jmir.org/2021/11/e32847 UR - http://dx.doi.org/10.2196/32847 UR - http://www.ncbi.nlm.nih.gov/pubmed/34751662 ID - info:doi/10.2196/32847 ER - TY - JOUR AU - Carey, Alissa AU - Yang, Qiuchen AU - DeLuca, Laura AU - Toro-Ramos, Tatiana AU - Kim, Youngin AU - Michaelides, Andreas PY - 2021/11/8 TI - The Relationship Between Weight Loss Outcomes and Engagement in a Mobile Behavioral Change Intervention: Retrospective Analysis JO - JMIR Mhealth Uhealth SP - e30622 VL - 9 IS - 11 KW - engagement KW - mHealth KW - obesity KW - weight management KW - Noom KW - application KW - app KW - behavioral change KW - digital behavior change interventions N2 - Background: There is large variance in weight loss outcomes of digital behavior change interventions (DBCIs). It has been suggested that different patterns of engagement in the program could be responsible for this variance in outcomes. Previous studies have found that the amount of engagement on DBCIs, such as the number of meals logged or articles read, is positively associated with weight loss. Objective: This retrospective study extends previous research by observing how important weight loss outcomes (high weight loss: 10% or greater body weight loss; moderate weight loss: between 5% to 10%; stable weight: 0 plus or minus 1%) are associated with engagement on a publicly available mobile DBCI (Noom) from 9 to 52 weeks. Methods: Engagement and weight data for eligible participants (N=11,252) were extracted from the Noom database. Engagement measures included the number of articles read, meals logged, steps recorded, messages to coach, exercise logged, weigh-ins, and days with 1 meal logged per week. Weight was self-reported on the program. Multiple linear regressions examined how weight loss outcome (moderate and high vs stable) was associated with each engagement measure across 3 study time periods: 9-16 weeks, 17-32 weeks, and 33-52 weeks. Results: At 9-16 weeks, among the 11,252 participants, 2594 (23.05%) had stable weight, 6440 (57.23%) had moderate weight loss, and 2218 (19.71%) had high weight loss. By 33-52 weeks, 525 (18.21%) had stable weight, 1214 (42.11%) had moderate weight loss, and 1144 (39.68%) had high weight loss. Regression results showed that moderate weight loss and high weight loss outcomes were associated with all engagement measures to a significantly greater degree than was stable weight (all P values <.001). These differences held across all time periods with the exception of exercise for the moderate weight loss category at 1 time period of 33-52 weeks. Exercise logging increased from 9 to 52 weeks regardless of the weight loss group. Conclusions: Our results suggest that these clinically important weight loss outcomes are related to the number of articles read, meals logged, steps recorded, messages to coach, exercise logged, weigh-ins, and days with 1 meal logged per week both in the short-term and long-term (ie, 1 year) on Noom. This provides valuable data on engagement patterns over time on a self-directed mobile DBCI, can help inform how interventions tailor recommendations for engagement depending on how much weight individuals have lost, and raises important questions for future research on engagement in DBCIs. UR - https://mhealth.jmir.org/2021/11/e30622 UR - http://dx.doi.org/10.2196/30622 UR - http://www.ncbi.nlm.nih.gov/pubmed/34747706 ID - info:doi/10.2196/30622 ER - TY - JOUR AU - Bonner, Carissa AU - Batcup, Carys AU - Cornell, Samuel AU - Fajardo, Anthony Michael AU - Hawkes, L. Anna AU - Trevena, Lyndal AU - Doust, Jenny PY - 2021/11/5 TI - Interventions Using Heart Age for Cardiovascular Disease Risk Communication: Systematic Review of Psychological, Behavioral, and Clinical Effects JO - JMIR Cardio SP - e31056 VL - 5 IS - 2 KW - heart age KW - cardiovascular disease KW - risk assessment KW - risk communication KW - prevention N2 - Background: Cardiovascular disease (CVD) risk communication is a challenge for clinical practice, where physicians find it difficult to explain the absolute risk of a CVD event to patients with varying health literacy. Converting the probability to heart age is increasingly used to promote lifestyle change, but a rapid review of biological age interventions found no clear evidence that they motivate behavior change. Objective: In this review, we aim to identify the content and effects of heart age interventions. Methods: We conducted a systematic review of studies presenting heart age interventions to adults for CVD risk communication in April 2020 (later updated in March 2021). The Johanna Briggs risk of bias assessment tool was applied to randomized studies. Behavior change techniques described in the intervention methods were coded. Results: From a total of 7926 results, 16 eligible studies were identified; these included 5 randomized web-based experiments, 5 randomized clinical trials, 2 mixed methods studies with quantitative outcomes, and 4 studies with qualitative analysis. Direct comparisons between heart age and absolute risk in the 5 web-based experiments, comprising 5514 consumers, found that heart age increased positive or negative emotional responses (4/5 studies), increased risk perception (4/5 studies; but not necessarily more accurate) and recall (4/4 studies), reduced credibility (2/3 studies), and generally had no effect on lifestyle intentions (4/5 studies). One study compared heart age and absolute risk to fitness age and found reduced lifestyle intentions for fitness age. Heart age combined with additional strategies (eg, in-person or phone counseling) in applied settings for 9582 patients improved risk control (eg, reduced cholesterol levels and absolute risk) compared with usual care in most trials (4/5 studies) up to 1 year. However, clinical outcomes were no different when directly compared with absolute risk (1/1 study). Mixed methods studies identified consultation time and content as important outcomes in actual consultations using heart age tools. There were differences between people receiving an older heart age result and those receiving a younger or equal to current heart age result. The heart age interventions included a wide range of behavior change techniques, and conclusions were sometimes biased in favor of heart age with insufficient supporting evidence. The risk of bias assessment indicated issues with all randomized clinical trials. Conclusions: The findings of this review provide little evidence that heart age motivates lifestyle behavior change more than absolute risk, but either format can improve clinical outcomes when combined with other behavior change strategies. The label for the heart age concept can affect outcomes and should be pretested with the intended audience. Future research should consider consultation time and differentiate between results of older and younger heart age. International Registered Report Identifier (IRRID): NPRR2-10.1101/2020.05.03.20089938 UR - https://cardio.jmir.org/2021/2/e31056 UR - http://dx.doi.org/10.2196/31056 UR - http://www.ncbi.nlm.nih.gov/pubmed/34738908 ID - info:doi/10.2196/31056 ER - TY - JOUR AU - Rabbani, Golam Md AU - Akter, Orin AU - Hasan, Zahid Md AU - Samad, Nandeeta AU - Mahmood, Shaila Shehrin AU - Joarder, Taufique PY - 2021/11/5 TI - COVID-19 Knowledge, Attitudes, and Practices Among People in Bangladesh: Telephone-Based Cross-sectional Survey JO - JMIR Form Res SP - e28344 VL - 5 IS - 11 KW - COVID-19 KW - knowledge KW - attitude KW - practice KW - risk communication and community engagement KW - social and behavior change communication KW - Bangladesh KW - risk KW - pandemic KW - risk communication N2 - Background: The world has been grappling with the COVID-19 pandemic, a dire public health crisis, since December 2019. Preventive and control measures have been adopted to reduce the spread of COVID-19. To date, the public?s knowledge, attitudes, and practices regarding COVID-19 across Bangladesh have been poorly understood. Therefore, it is important to assess people?s knowledge, attitudes, and practices (KAP) toward the disease and suggest appropriate strategies to combat COVID-19 effectively. Objective: This study aimed to assess the KAP of Bangladeshi people toward COVID-19 and to identify their determinants. Methods: We conducted a country-wide cross-sectional telephonic survey from May 7 to 29, 2020. A purposive sampling method was applied, and adult Bangladeshi citizens who have mobile phones were approached to participate in the survey. Interviews were conducted based on verbal consent. Multiple logistic regression analyses and several tests were performed to identify the factors associated with KAP related to COVID-19. Results: A total of 492 of 576 Bangladeshi adults aged 18 years and above completed the interview, with a response rate of 85.4% (492/576). Of the 492 participants, 321 (65.2%) were male, and 304 (61.8%) lived in a rural area. Mean scores for knowledge, attitudes, and practices were 10.56 (SD 2.86), 1.24 (SD 0.83), and 3.17 (SD 1.5), respectively. Among the 492 respondents, 273 (55.5%) had poor knowledge, and 251 (49%) expressed a negative attitude; 192 out of 359 respondents (53.5%) had poor practices toward COVID-19. Mean scores of knowledge, attitudes, and practices differed significantly across various demographic and socioeconomic groups. Rural residents had lower mean scores of knowledge (mean 9.8, SD 3.1, P<.001) and adherence to appropriate practice measures (mean 4, SD 1.4, P<.001) compared to their urban counterparts. Positive and statistically strong correlations between knowledge and attitudes (r=0.21, P<.001), knowledge and practices (r=0.45, P<.001), and attitudes and practices (r=0.27, P<.001) were observed. Television (53.7%) was identified as the major source of knowledge regarding COVID-19. Almost three-quarters of the respondents (359/492, 73%) went outside the home during the lockdown period. Furthermore, the study found that good knowledge (odds ratio [OR] 3.13, 95% CI 2.03-4.83, and adjusted OR 2.33, 95% CI 1.16-4.68) and a positive attitude (OR 2.43, 95% CI 1.59-3.72, and adjusted OR 3.87, 95% CI 1.95-7.68) are significantly associated with better practice of COVID-19 health measures. Conclusions: Evidence-informed and context-specific risk communication and community engagement, and a social and behavior change communication strategy against COVID-19 should be developed in Bangladesh based on the findings of this study, targeting different socioeconomic groups. UR - https://formative.jmir.org/2021/11/e28344 UR - http://dx.doi.org/10.2196/28344 UR - http://www.ncbi.nlm.nih.gov/pubmed/34519660 ID - info:doi/10.2196/28344 ER - TY - JOUR AU - Lilja, Lotten Josefine AU - Rupcic Ljustina, Mirna AU - Nissling, Linnea AU - Larsson, Caroline Anna AU - Weineland, Sandra PY - 2021/11/1 TI - Youths? and Parents? Experiences and Perceived Effects of Internet-Based Cognitive Behavioral Therapy for Anxiety Disorders in Primary Care: Mixed Methods Study JO - JMIR Pediatr Parent SP - e26842 VL - 4 IS - 4 KW - internet KW - CBT KW - cognitive behavioral therapy KW - adolescents KW - parents KW - anxiety KW - primary care KW - mixed methods KW - experiences KW - youths KW - digital health N2 - Background: Anxiety is common among youths in primary care. Face-to-face treatment has been the first choice for clinicians, but during the COVID-19 pandemic, digital psychological interventions have substantially increased. Few studies have examined young people?s interest in internet treatment or the attitudes they and their parents have toward it. Objective: This study aims to investigate adolescents? and parents? attitudes toward and experiences of internet-based cognitive behavioral anxiety treatment in primary care and its presumptive effects. Methods: The study used mixed methods, analyzing qualitative data thematically and quantitative data with nonparametric analysis. Participants were 14 adolescents and 14 parents recruited in adolescent primary health care clinics. The adolescents and their parents filled out mental health questionnaires before and after treatment, and were interviewed during ongoing treatment. Results: The quantitative data indicated that the internet-delivered cognitive behavioral therapy program used in this study was successful in reducing symptoms (?22=8.333; P=.02) and that adolescents? motivation is essential to the treatment outcome (r=0.58; P=.03). The qualitative results show that youths highly value their independence and freedom to organize treatment work on their own terms. The parents expressed uncertainty about their role and how to support their child in treatment. It was important for parents to respect the youths? need for autonomy while also engaging with them in the treatment work. Conclusions: Internet treatment in primary care is accepted by both youths and their parents, who need clarification about the difference between their role and the therapist?s role. Patient motivation should be considered before treatment, and therapists need to continue to develop the virtual alliance. Finally, primary care should be clearer in informing adolescents and their parents about the possibility of internet treatment. UR - https://pediatrics.jmir.org/2021/4/e26842 UR - http://dx.doi.org/10.2196/26842 UR - http://www.ncbi.nlm.nih.gov/pubmed/34723830 ID - info:doi/10.2196/26842 ER - TY - JOUR AU - Doukani, Asmae AU - Cerga Pashoja, Arlinda AU - Fanaj, Naim AU - Qirjako, Gentiana AU - Meksi, Andia AU - Mustafa, Sevim AU - Vis, Christiaan AU - Hug, Juliane PY - 2021/11/1 TI - Organizational Readiness for Implementing an Internet-Based Cognitive Behavioral Therapy Intervention for Depression Across Community Mental Health Services in Albania and Kosovo: Directed Qualitative Content Analysis JO - JMIR Form Res SP - e29280 VL - 5 IS - 11 KW - e-mental health KW - digital mental health KW - internet-based cognitive behavioral therapy KW - implementation science KW - organizational readiness for implementing change KW - community mental health center KW - qualitative interviews KW - content analysis KW - Albania and Kosovo N2 - Background: The use of digital mental health programs such as internet-based cognitive behavioral therapy (iCBT) holds promise in increasing the quality and access of mental health services. However very little research has been conducted in understanding the feasibility of implementing iCBT in Eastern Europe. Objective: The aim of this study was to qualitatively assess organizational readiness for implementing iCBT for depression within community mental health centers (CMHCs) across Albania and Kosovo. Methods: We used qualitative semistructured focus group discussions that were guided by Bryan Weiner?s model of organizational readiness for implementing change. The questions broadly explored shared determination to implement change (change commitment) and shared belief in their collective capability to do so (change efficacy). Data were collected between November and December 2017. A range of health care professionals working in and in association with CMHCs were recruited from 3 CMHCs in Albania and 4 CMHCs in Kosovo, which were participating in a large multinational trial on the implementation of iCBT across 9 countries (Horizon 2020 ImpleMentAll project). Data were analyzed using a directed approach to qualitative content analysis, which used a combination of both inductive and deductive approaches. Results: Six focus group discussions involving 69 mental health care professionals were conducted. Participants from Kosovo (36/69, 52%) and Albania (33/69, 48%) were mostly females (48/69, 70%) and nurses (26/69, 38%), with an average age of 41.3 years. A directed qualitative content analysis revealed several barriers and facilitators potentially affecting the implementation of digital CBT interventions for depression in community mental health settings. While commitment for change was high, change efficacy was limited owing to a range of situational factors. Barriers impacting ?change efficacy? included lack of clinical fit for iCBT, high stigma affecting help-seeking behaviors, lack of human resources, poor technological infrastructure, and high caseload. Facilitators included having a high interest and capability in receiving training for iCBT. For ?change commitment,? participants largely expressed welcoming innovation and that iCBT could increase access to treatments for geographically isolated people and reduce the stigma associated with mental health care. Conclusions: In summary, participants perceived iCBT positively in relation to promoting innovation in mental health care, increasing access to services, and reducing stigma. However, a range of barriers was also highlighted in relation to accessing the target treatment population, a culture of mental health stigma, underdeveloped information and communications technology infrastructure, and limited appropriately trained health care workforce, which reduce organizational readiness for implementing iCBT for depression. Such barriers may be addressed through (1) a public-facing campaign that addresses mental health stigma, (2) service-level adjustments that permit staff with the time, resources, and clinical supervision to deliver iCBT, and (3) establishment of a suitable clinical training curriculum for health care professionals. Trial Registration: ClinicalTrials.gov NCT03652883; https://clinicaltrials.gov/ct2/show/NCT03652883 UR - https://formative.jmir.org/2021/11/e29280 UR - http://dx.doi.org/10.2196/29280 UR - http://www.ncbi.nlm.nih.gov/pubmed/34723822 ID - info:doi/10.2196/29280 ER - TY - JOUR AU - Agrawal, Lavlin AU - Ndabu, Theophile AU - Mulgund, Pavankumar AU - Sharman, Raj PY - 2021/10/28 TI - Factors Affecting the Extent of Patients? Electronic Medical Record Use: An Empirical Study Focusing on System and Patient Characteristics JO - J Med Internet Res SP - e30637 VL - 23 IS - 10 KW - electronic medical record KW - patient safety KW - caregiver KW - chronic conditions KW - HINTS dataset KW - patient technology acceptance model N2 - Background: Patients? access to and use of electronic medical records (EMRs) places greater information in their hands, which helps them better comanage their health, leading to better clinical outcomes. Despite numerous benefits that promote health and well-being, patients? acceptance and use of EMRs remains low. We study the impact of predictors that affect the use of EMR by patients to understand better the underlying causal factors for the lower use of EMR. Objective: This study aims to examine the critical system (eg, performance expectancy and effort expectancy) and patient characteristics (eg, health condition, issue involvement, preventive health behaviors, and caregiving status) that influence the extent of patients? EMR use. Methods: We used secondary data collected by Health Information National Trends Survey 5 cycle 3 and performed survey data analysis using structural equation modeling technique to test our hypotheses. Structural equation modeling is a technique commonly used to measure and analyze the relationships of observed and latent variables. We also addressed common method bias to understand if there was any systematic effect on the observed correlation between the measures for the predictor and predicted variables. Results: The statistically significant drivers of the extent of EMR use were performance expectancy (?=.253; P<.001), perceived behavior control (?=.236; P<.001), health knowledge (?=?.071; P=.007), caregiving status (?=.059; P=.013), issue involvement (?=.356; P<.001), chronic conditions (?=.071; P=.016), and preventive health behavior (?=.076; P=.005). The model accounted for 32.9% of the variance in the extent of EMR use. Conclusions: The study found that health characteristics, such as chronic conditions and patient disposition (eg, preventive health behavior and issue involvement), directly affect the extent of EMR use. The study also revealed that issue involvement mediates the impact of preventive health behaviors and the presence of chronic conditions on the extent of patients? EMR use. UR - https://www.jmir.org/2021/10/e30637 UR - http://dx.doi.org/10.2196/30637 UR - http://www.ncbi.nlm.nih.gov/pubmed/34709181 ID - info:doi/10.2196/30637 ER - TY - JOUR AU - Yadav, Lalit AU - Gill, K. Tiffany AU - Taylor, Anita AU - De Young, Jennifer AU - Chehade, J. Mellick PY - 2021/10/28 TI - Identifying Opportunities, and Motivation to Enhance Capabilities, Influencing the Development of a Personalized Digital Health Hub Model of Care for Hip Fractures: Mixed Methods Exploratory Study JO - J Med Internet Res SP - e26886 VL - 23 IS - 10 KW - digital health KW - mixed-methods KW - hip fractures KW - behavior change KW - patient education KW - model of care KW - mobile phone KW - patient networked units N2 - Background: Most older people after a hip fracture injury never return to their prefracture status, and some are admitted to residential aged care facilities. Advancement of digital technology has helped in optimizing health care including self-management and telerehabilitation. Objective: This study aims to understand the perspectives of older patients with hip fracture and their family members and residential aged caregivers on the feasibility of developing a model of care using a personalized digital health hub. Methods: We conducted a mixed methods study in South Australia involving patients aged 50 years and older, their family members, and residential aged caregivers. Quantitative data analysis included basic demographic characteristics, and access to digital devices was analyzed using descriptive statistics. Spearman rank-order correlation was used to examine correlations between the perceived role of a personalized digital health hub in improving health and the likelihood of subsequent use. Findings from qualitative analysis were interpreted using constructs of capability, opportunity, and motivation to help understand the factors influencing the likelihood of potential personalized digital health hub use. Results: This study recruited 100 participants?55 patients, 13 family members, and 32 residential aged caregivers. The mean age of the patients was 76.4 (SD 8.4, range 54-88) years, and 60% (33/55) of the patients were female. Approximately 50% (34/68) of the patients and their family members had access to digital devices, despite less than one-third using computers as part of their occupation. Approximately 72% (72/100) of the respondents thought that personalized digital health hub could improve health outcomes in patients. However, a moderate negative correlation existed with increasing age and likelihood of personalized digital health hub use (Spearman ?=?0.50; P<.001), and the perceived role of the personalized digital health hub in improving health had a strong positive correlation with the likelihood of personalized digital health hub use by self (Spearman ?=0.71; P<.001) and by society, including friends and family members (Spearman ?=0.75; P<.001). Most patients (54/55, 98%) believed they had a family member, friend, or caregiver who would be able to help them use a personalized digital health hub. Qualitative analysis explored capability by understanding aspects of existing knowledge, including willingness to advance digital navigation skills. Access could be improved through supporting opportunities, and factors influencing intrinsic motivation were considered crucial for designing a personalized digital health hub?enabled model of care. Conclusions: This study emphasized the complex relationship between capabilities, motivation, and opportunities for patients, their family members, and formal caregivers as a patient networked unit. The next stage of research will continue to involve a cocreation approach followed by iterative processes and understand the factors influencing the development and successful integration of complex digital health care interventions in real-world scenarios. UR - https://www.jmir.org/2021/10/e26886 UR - http://dx.doi.org/10.2196/26886 UR - http://www.ncbi.nlm.nih.gov/pubmed/34709183 ID - info:doi/10.2196/26886 ER - TY - JOUR AU - Yu, Yanqiu AU - Mo, Kit-Han Phoenix AU - Zhang, Jianxin AU - Li, Jibin AU - Lau, Tak-Fai Joseph PY - 2021/10/27 TI - Impulsivity, Self-control, Interpersonal Influences, and Maladaptive Cognitions as Factors of Internet Gaming Disorder Among Adolescents in China: Cross-sectional Mediation Study JO - J Med Internet Res SP - e26810 VL - 23 IS - 10 KW - cognition KW - adolescent health KW - health risk behaviors KW - internet KW - self-control KW - China N2 - Background: Gaming disorder, including internet gaming disorder (IGD), was recently defined by the World Health Organization as a mental disease in the 11th Revision of the International Classification of Diseases (ICD-11). Thus, reducing IGD is warranted. Maladaptive cognitions related to internet gaming (MCIG) have been associated with IGD, while impulsivity, self-control, parental influences, and peer influences are key risk factors of IGD. Previous literature suggests that MCIG is associated with the aforementioned 4 risk factors and IGD, and may thus mediate between these risk factors and IGD. These potential mediations, if significant, imply that modification of MCIG may possibly alleviate these risk factors? harmful impacts on increasing IGD. These mediation hypotheses were tested in this study for the first time. Objective: This study tested the mediation effects of MCIG between intrapersonal factors (impulsivity and self-control) and IGD, and between interpersonal factors (parental influences and peer influences) and IGD among adolescents in China. Methods: An anonymous, cross-sectional, and self-administered survey was conducted among secondary school students in classroom settings in Guangzhou and Chengdu, China. All grade 7 to 9 students (7 to 9 years of formal education) of 7 secondary schools were invited to join the study, and 3087 completed the survey. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) checklist was used to assess IGD. MCIG was assessed by using the Chinese version of the Revised Internet Gaming Cognition Scale. Impulsivity, self-control, and parental or peer influences were measured by using the motor subscale of the Barratt Impulsiveness Scale, the Brief Self-Control Scale, and the modified interpersonal influence scale, respectively. Structural equation modeling was conducted to examine the mediation effects of MCIG between these risk factors and IGD. Results: The prevalence of IGD was 13.57% (418/3081) and 17.67% (366/2071) among all participants and adolescent internet gamers, respectively. The 3 types of MCIG (perceived rewards of internet gaming, perceived urges for playing internet games, and perceived unwillingness to stop playing without completion of gaming tasks) were positively associated with IGD. Impulsivity, self-control, parental influences, and peer influences were all significantly associated with the 3 types of MCIG and IGD. The 3 types of MCIG partially mediated the associations between the studied factors and IGD (effect size of 30.0% to 37.8%). Conclusions: Impulsivity, self-control, and interpersonal influences had both direct and indirect effects via MCIG on IGD. Modifications of the 3 types of MCIG can potentially reduce the harmful impacts of impulsivity and interpersonal influences on IGD and enhance the protective effect of self-control against IGD. Future longitudinal studies are warranted. UR - https://www.jmir.org/2021/10/e26810 UR - http://dx.doi.org/10.2196/26810 UR - http://www.ncbi.nlm.nih.gov/pubmed/34704960 ID - info:doi/10.2196/26810 ER - TY - JOUR AU - Bente, E. Britt AU - Wentzel, Jobke AU - Groeneveld, GH Rik AU - IJzerman, VH Renée AU - de Buisonjé, R. David AU - Breeman, D. Linda AU - Janssen, R. Veronica AU - Kraaijenhagen, Roderik AU - Pieterse, E. Marcel AU - Evers, WM Andrea AU - van Gemert-Pijnen, EWC Julia PY - 2021/10/22 TI - Values of Importance to Patients With Cardiovascular Disease as a Foundation for eHealth Design and Evaluation: Mixed Methods Study JO - JMIR Cardio SP - e33252 VL - 5 IS - 2 KW - patient values KW - health behavior KW - lifestyle KW - mobile app KW - user-centered design KW - eHealth KW - cardiovascular disease KW - behavior KW - app KW - design KW - cardiovascular KW - evaluation KW - platform KW - support KW - intervention N2 - Background: eHealth interventions are developed to support and facilitate patients with lifestyle changes and self-care tasks after being diagnosed with a cardiovascular disease (CVD). Creating long-lasting effects on lifestyle change and health outcomes with eHealth interventions is challenging and requires good understanding of patient values. Objective: The aim of the study was to identify values of importance to patients with CVD to aid in designing a technological lifestyle platform. Methods: A mixed method?design was applied,?combining?data from usability testing?with an additional online survey study, to validate?the outcomes of the usability tests. Results: A total of 11 relevant patient values were identified, including the need for security, support, not wanting to feel anxious, tailoring of treatment, and personalized, accessible care. The validation survey shows that all values but one (value 9: To have extrinsic motivation to accomplish goals or activities [related to health/lifestyle]) were regarded as important/very important. A rating of very unimportant or unimportant was given by less than 2% of the respondents (value 1: 4/641, 0.6%; value 2: 10/641, 1.6%; value 3: 9/641, 1.4%; value 4: 5/641, 0.8%; value 5: 10/641, 1.6%; value 6: 4/641, 0.6%; value 7: 10/639, 1.6%; value 8: 4/639, 0.6%; value 10: 3/636, 0.5%; value 11: 4/636, 0.6%) to all values except but one (value 9: 56/636, 8.8%). Conclusions: There is a high consensus among patients regarding the identified values reflecting goals and themes central to their lives, while living with or managing their CVD. The identified values can serve as a foundation for future research to translate and integrate these values into the design of the eHealth technology. This may call for prioritization of values, as not all values can be met equally. UR - https://cardio.jmir.org/2021/2/e33252 UR - http://dx.doi.org/10.2196/33252 UR - http://www.ncbi.nlm.nih.gov/pubmed/34677130 ID - info:doi/10.2196/33252 ER - TY - JOUR AU - Wu, S. Monica AU - Chen, Shih-Yin AU - Wickham, E. Robert AU - O?Neil-Hart, Shane AU - Chen, Connie AU - Lungu, Anita PY - 2021/10/21 TI - Outcomes of a Blended Care Coaching Program for Clients Presenting With Moderate Levels of Anxiety and Depression: Pragmatic Retrospective Study JO - JMIR Ment Health SP - e32100 VL - 8 IS - 10 KW - blended care KW - coaching KW - cognitive KW - behavior KW - depression KW - anxiety KW - digital health KW - retrospective KW - mental health KW - CBT KW - cognitive behavioral therapy KW - outcome KW - video conference N2 - Background: Depression and anxiety are leading causes of disability worldwide, but access to quality mental health care is limited by myriad factors. Cognitive-behavioral coaching is rooted in evidence-based principles and has the potential to address some of these unmet care needs. Harnessing technology to facilitate broader dissemination within a blended care model shows additional promise for overcoming barriers to care. Objective: The aim of this study is to evaluate the outcomes of a blended care coaching (BCC) program for clients presenting with moderate levels of anxiety and depression in real-world settings. Methods: This study examined retrospective data from US-based individuals (N=1496) who presented with moderate levels of depression and anxiety symptoms and who received blended care coaching services. Using a short-term framework, clients met with coaches via a secure video conference platform and also received digital video lessons and exercises. To evaluate the effectiveness of the BCC program, mixed effects modeling was used to examine growth trajectories of anxiety and depression scores over the course of care. Results: Out of the total sample of 1496 clients, 75.9% (n=1136) demonstrated reliable improvement, and 88.6% (n=1326) recovered based on either the Generalized Anxiety Disorder-7 scale (anxiety) or Patient Health Questionnaire-9 (depression). On average, clients exhibited a significant decline in anxiety and depression symptoms during the initial weeks of coaching, with a continued decline over subsequent weeks at a lower rate. Engaging in a coaching session was associated with lower anxiety (b=?1.04) and depression (b=?0.79) symptoms in the same week, as well as lower anxiety (b=?0.74) and depression (b=?0.91) symptoms the following week (P<.001). Conclusions: The BCC program demonstrated strong outcomes in decreasing symptomology for clients presenting with moderate levels of anxiety and depression. When clients received coaching sessions, significant decreases in symptoms were observed, reflecting the importance of session attendance. Additionally, the steepest declines in symptoms tended to occur during the initial weeks of coaching, emphasizing the importance of client buy-in and early engagement. Collectively, these findings have implications for addressing unmet mental health care needs in a more accessible, cost-effective manner. UR - https://mental.jmir.org/2021/10/e32100 UR - http://dx.doi.org/10.2196/32100 UR - http://www.ncbi.nlm.nih.gov/pubmed/34673534 ID - info:doi/10.2196/32100 ER - TY - JOUR AU - Porter, Gwenndolyn AU - Michaud, L. Tzeyu AU - Schwab, J. Robert AU - Hill, L. Jennie AU - Estabrooks, A. Paul PY - 2021/10/20 TI - Reach Outcomes and Costs of Different Physician Referral Strategies for a Weight Management Program Among Rural Primary Care Patients: Type 3 Hybrid Effectiveness-Implementation Trial JO - JMIR Form Res SP - e28622 VL - 5 IS - 10 KW - weight management KW - rural KW - RE-AIM KW - hybrid effectiveness-implementation KW - primary care KW - obesity KW - physicians KW - digital health KW - health technology KW - mobile phone N2 - Background: Rural residents are at high risk for obesity; however, little resources exist to address this disproportional burden of disease. Primary care may provide an opportunity to connect primary care patients with overweight and obesity to effective weight management programming. Objective: The purpose of this study is to examine the utility of different physician referral and engagement processes for improving the reach of an evidence-based and technology-delivered weight management program with counseling support for rural primary care patients. Methods: A total of 5 rural primary care physicians were randomly assigned a sequence of four referral strategies: point-of-care (POC) referral with active telephone follow-up (ATF); POC referral, no ATF; a population health registry?derived letter referral with ATF; and letter referral, no ATF. For registry-derived referrals, physicians screened a list of patients with BMI ?25 and approved patients for participation to receive a personalized referral letter via mail. Results: Out of a potential 991 referrals, 573 (57.8%) referrals were made over 16 weeks, and 98 (9.9%) patients were enrolled in the program (58/98, 59.2% female). Differences based on letter (485/991, 48.9%) versus POC (506/991, 51.1%) referrals were identified for completion (100% vs 7%; P<.001) and for proportion screened (36% vs 12%; P<.001) but not for proportion enrolled (12% vs 8%; P=.10). Patients receiving ATF were more likely to be screened (47% vs 7%; P<.001) and enrolled (15% vs 7%; P<.001) than those not receiving ATF. On the basis of the number of referrals made in each condition, we found variations in the proportion and number of enrollees (POC with ATF: 27/190, 50%; POC no ATF: 14/316, 41%; letter ATF: 30/199; 15.1%; letter no ATF: 27/286, 9.4%). Across all conditions, participants were representative of the racial and ethnic characteristics of the region (60% female, P=.15; 94% White individuals, P=.60; 94% non-Hispanic, P=.19). Recruitment costs totaled US $6192, and the overall recruitment cost per enrolled participant was US $63. Cost per enrolled participant ranged from POC with ATF (US $47), registry-derived letter without ATF (US $52), and POC without ATF (US $56) to registry-derived letter with ATF (US $91). Conclusions: Letter referral with ATF appears to be the best option for enrolling a large number of patients in a digitally delivered weight management program; however, POC with ATF and letters without ATF yielded similar numbers at a lower cost. The best referral option is likely dependent on the best fit with clinical resources. Trial Registration: ClinicalTrials.gov NCT03690557; http://clinicaltrials.gov/ct2/show/NCT03690557 UR - https://formative.jmir.org/2021/10/e28622 UR - http://dx.doi.org/10.2196/28622 UR - http://www.ncbi.nlm.nih.gov/pubmed/34668873 ID - info:doi/10.2196/28622 ER - TY - JOUR AU - Aguiar, A. AU - Pinto, M. AU - Duarte, R. PY - 2021/10/19 TI - Psychological Impact of the COVID-19 Pandemic and Social Determinants on the Portuguese Population: Protocol for a Web-Based Cross-sectional Study JO - JMIR Res Protoc SP - e28071 VL - 10 IS - 10 KW - COVID-19 KW - public health KW - mental health KW - study protocol KW - psychological impact KW - anxiety KW - depression KW - grief KW - behavior change N2 - Background: The COVID-19 outbreak and consequent physical distance measures implemented worldwide have caused significant stress, anxiety, and mental health implications among the general population. Unemployment, working from home, and day-to-day changes may lead to a greater risk of poor mental health outcomes. Objective: This paper describes the protocol for a web-based cross-sectional study that aims to address the impact of the COVID-19 pandemic on mental health. Methods: Individuals from the general population aged 18 years or more and living in Portugal were included in this study. Data collection took place between November 10, 2020, and February 10, 2021. An exponential, nondiscriminative, snowball sampling method was applied to recruit participants. A web-based survey was developed and shared on social media platforms (eg, Facebook, Instagram, Twitter, LinkedIn, and WhatsApp groups) and through e-mail lists for recruitment of the seeds. Results: Data analysis will be performed in accordance with the different variables and outcomes of interest by using quantitative methods, qualitative methods, or mixed methods, as applicable. A total of 929 individuals had completed the web-based survey during the 3-month period; thus, our final sample comprised 929 participants. Results of the survey will be disseminated in national and international scientific journals in 2021-2022. Conclusions: We believe that the findings of this study will have broad implications for understanding the psychological impact of the COVID-19 pandemic on Portuguese residents, as well as aspects related to the informal economy. We also hope that the findings of this study are able to provide insights and guidelines for the Portuguese government to implement action. Finally, we expect this protocol to provide a roadmap for other countries and researchers that would like to implement a similar questionnaire considering the related conclusions. International Registered Report Identifier (IRRID): DERR1-10.2196/28071 UR - https://www.researchprotocols.org/2021/10/e28071 UR - http://dx.doi.org/10.2196/28071 UR - http://www.ncbi.nlm.nih.gov/pubmed/34516387 ID - info:doi/10.2196/28071 ER - TY - JOUR AU - Vera Cruz dos Santos, Daniela AU - Coelho de Soárez, Patrícia AU - Cavero, Victoria AU - U Rocha, I. Thaís AU - Aschar, Suzana AU - Daley, Louise Kate AU - Garcia Claro, Heloísa AU - Abud Scotton, George AU - Fernandes, Ivan AU - Diez-Canseco, Francisco AU - Brandt, Rebeca Lena AU - Toyama, Mauricio AU - Martins Castro, Carolina Hellen AU - Miranda, Jaime J. AU - Araya, Ricardo AU - Quayle, Julieta AU - Rossi Menezes, Paulo PY - 2021/10/13 TI - A Mobile Health Intervention for Patients With Depressive Symptoms: Protocol for an Economic Evaluation Alongside Two Randomized Trials in Brazil and Peru JO - JMIR Res Protoc SP - e26164 VL - 10 IS - 10 KW - cost-effectiveness KW - depression KW - diabetes KW - hypertension KW - noncommunicable diseases KW - randomized trials KW - low- and middle-income countries KW - mHealth KW - task shifting KW - behavioral activation N2 - Background: Mobile health interventions provide significant strategies for improving access to health services, offering a potential solution to reduce the mental health treatment gap. Economic evaluation of this intervention is needed to help inform local mental health policy and program development. Objective: This paper presents the protocol for an economic evaluation conducted alongside 2 randomized controlled trials (RCTs) to evaluate the cost-effectiveness of a psychological intervention delivered through a technological platform (CONEMO) to treat depressive symptoms in people with diabetes, hypertension, or both. Methods: The economic evaluation uses a within-trial analysis to evaluate the incremental costs and health outcomes of CONEMO plus enhanced usual care in comparison with enhanced usual care from public health care system and societal perspectives. Participants are patients of the public health care services for hypertension, diabetes, or both conditions in São Paulo, Brazil (n=880) and Lima, Peru (n=432). Clinical effectiveness will be measured by reduction in depressive symptoms and gains in health-related quality of life. We will conduct cost-effectiveness and cost-utility analyses, providing estimates of the cost per at least 50% reduction in 9-item Patient Health Questionnaire scores, and cost per quality-adjusted life year gained. The measurement of clinical effectiveness and resource use will take place over baseline, 3-month follow-up, and 6-month follow-up in the intervention and control groups. We will use a mixed costing methodology (ie, a combination of top?down and bottom?up approaches) considering 4 cost categories: intervention (CONEMO related) costs, health care costs, patient and family costs, and productivity costs. We will collect unit costs from the RCTs and national administrative databases. The multinational economic evaluations will be fully split analyses with a multicountry costing approach. We will calculate incremental cost-effectiveness ratios and present 95% CIs from nonparametric bootstrapping (1000 replicates). We will perform deterministic and probabilistic sensitivity analyses. Finally, we will present cost-effectiveness acceptability curves to compare a range of possible cost-effectiveness thresholds. Results: The economic evaluation project had its project charter in June 2018 and is expected to be completed in September 2021. The final results will be available in the second half of 2021. Conclusions: We expect to assess whether CONEMO plus enhanced usual care is a cost-effective strategy to improve depressive symptoms in this population compared with enhanced usual care. This study will contribute to the evidence base for health managers and policy makers in allocating additional resources for mental health initiatives. It also will provide a basis for further research on how this emerging technology and enhanced usual care can improve mental health and well-being in low- and middle-income countries. Trial Registration: ClinicalTrials.gov NCT12345678 (Brazil) and NCT03026426 (Peru); https://clinicaltrials.gov/ct2/show/NCT02846662 and https://clinicaltrials.gov/ct2/show/NCT03026426 International Registered Report Identifier (IRRID): DERR1-10.2196/26164 UR - https://www.researchprotocols.org/2021/10/e26164 UR - http://dx.doi.org/10.2196/26164 UR - http://www.ncbi.nlm.nih.gov/pubmed/34643538 ID - info:doi/10.2196/26164 ER - TY - JOUR AU - Watt, Makayla AU - Spence, C. John AU - Tandon, Puneeta PY - 2021/10/8 TI - Development of a Theoretically Informed Web-Based Mind-Body Wellness Intervention for Patients With Primary Biliary Cholangitis: Formative Study JO - JMIR Form Res SP - e29064 VL - 5 IS - 10 KW - liver disease KW - meditation KW - yoga KW - breathwork KW - behavior theory KW - COM-B model KW - behaviour change wheel KW - behaviour change taxonomy KW - internet KW - digital N2 - Background: Mind-body interventions have the potential to positively impact the symptom burden associated with primary biliary cholangitis (PBC). Interventions are more likely to be effective if they are informed by a theoretical framework. The Behaviour Change Wheel (BCW) and the behaviour change technique taxonomy version 1 (BCTv1) provide frameworks for intervention development. Objective: This study describes how theory has guided the development of a 12-week multicomponent mind-body wellness intervention for PBC. Methods: The steps involved in developing the BCW intervention included specifying the target behavior; explaining barriers and facilitators using the Capability, Opportunity, Motivation, and Behaviour and the theoretical domains framework; identifying intervention functions to target explanatory domains; and selecting relevant behavior change techniques to address intervention functions. Qualitative data from patients with inflammatory bowel disease using an earlier version of the program and feedback from a PBC patient advisory team were used to guide intervention development. Results: Barriers and facilitators to intervention participation associated with capability, opportunity, and motivation were identified. Intervention functions and behavior change techniques were identified to target each barrier and facilitator. Conclusions: The Peace Power Pack PBC intervention was developed to help individuals with PBC manage their symptom burden. The theoretical frameworks employed in this intervention provide direction on targeting antecedents of behavior and allow standardized reporting of intervention components. Trial Registration: ClinicalTrials.gov NCT04791527; https://clinicaltrials.gov/ct2/show/NCT04791527 UR - https://formative.jmir.org/2021/10/e29064 UR - http://dx.doi.org/10.2196/29064 UR - http://www.ncbi.nlm.nih.gov/pubmed/34623317 ID - info:doi/10.2196/29064 ER - TY - JOUR AU - Meyer, Björn AU - Utter, Geri-Lynn AU - Hillman, Catherine PY - 2021/10/8 TI - A Personalized, Interactive, Cognitive Behavioral Therapy?Based Digital Therapeutic (MODIA) for Adjunctive Treatment of Opioid Use Disorder: Development Study JO - JMIR Ment Health SP - e31173 VL - 8 IS - 10 KW - MODIA KW - opioid use disorder KW - digital therapeutic KW - cognitive behavioral therapy KW - medication-assisted treatment KW - Broca N2 - Background: Opioid use disorder (OUD) is characterized by the inability to control opioid use despite attempts to stop use and negative consequences to oneself and others. The burden of opioid misuse and OUD is a national crisis in the United States with substantial public health, social, and economic implications. Although medication-assisted treatment (MAT) has demonstrated efficacy in the management of OUD, access to effective counseling and psychosocial support is a limiting factor and a significant problem for many patients and physicians. Digital therapeutics are an innovative class of interventions that help prevent, manage, or treat diseases by delivering therapy using software programs. These applications can circumvent barriers to uptake, improve treatment adherence, and enable broad delivery of evidence-based management strategies to meet service gaps. However, few digital therapeutics specifically targeting OUD are available, and additional options are needed. Objective: To this end, we describe the development of the novel digital therapeutic MODIA. Methods: MODIA was developed by an international, multidisciplinary team that aims to provide effective, accessible, and sustainable management for patients with OUD. Although MODIA is aligned with principles of cognitive behavioral therapy, it was not designed to present any 1 specific treatment and uses a broad range of evidence-based behavior change techniques drawn from cognitive behavioral therapy, mindfulness, acceptance and commitment therapy, and motivational interviewing. Results: MODIA uses proprietary software that dynamically tailors content to the users? responses. The MODIA program comprises 24 modules or ?chats? that patients are instructed to work through independently. Patient responses dictate subsequent content, creating a ?simulated dialogue? experience between the patient and program. MODIA also includes brief motivational text messages that are sent regularly to prompt patients to use the program and help them transfer therapeutic techniques into their daily routines. Thus, MODIA offers individuals with OUD a custom-tailored, interactive digital psychotherapy intervention that maximizes the personal relevance and emotional impact of the interaction. Conclusions: As part of a clinician-supervised MAT program, MODIA will allow more patients to begin psychotherapy concurrently with opioid maintenance treatment. We expect access to MODIA will improve the OUD management experience and provide sustainable positive outcomes for patients. UR - https://mental.jmir.org/2021/10/e31173 UR - http://dx.doi.org/10.2196/31173 UR - http://www.ncbi.nlm.nih.gov/pubmed/34623309 ID - info:doi/10.2196/31173 ER - TY - JOUR AU - Summers, Charlotte AU - Wu, Philip AU - Taylor, G. Alisdair J. PY - 2021/10/6 TI - Supporting Mental Health During the COVID-19 Pandemic Using a Digital Behavior Change Intervention: An Open-Label, Single-Arm, Pre-Post Intervention Study JO - JMIR Form Res SP - e31273 VL - 5 IS - 10 KW - stress KW - mental health KW - COVID-19 KW - digital therapy KW - mHealth KW - support KW - behavior KW - intervention KW - online intervention KW - outcome KW - wellbeing KW - sleep KW - activity KW - nutrition N2 - Background: The COVID-19 pandemic is taking a toll on people?s mental health, particularly as people are advised to adhere to social distancing, self-isolation measures, and government-imposed national lockdowns. Digital health technologies have an important role to play in keeping people connected and in supporting their mental health and well-being. Even before the COVID-19 pandemic, mental health and social services were already strained. Objective: Our objective was to evaluate the 12-week outcomes of the digitally delivered Gro Health intervention, a holistic digital behavior change app designed for self-management of mental well-being, sleep, activity, and nutrition. Methods: The study used a quasi-experimental research design consisting of an open-label, single-arm, pre-post intervention engagement using a convenience sample. Adults who had joined the Gro Health app (intervention) and had a complete baseline dataset (ie, 7-item Generalized Anxiety Disorder scale, Perceived Stress Scale, and 9-item Patient Health Questionnaire) were followed up at 12 weeks (n=273), including 33 (12.1%) app users who reported a positive COVID-19 diagnosis during the study period. User engagement with the Gro Health platform was tracked by measuring total minutes of app engagement. Paired t tests were used to compare pre-post intervention scores. Linear regression analysis was performed to assess the relationship between minutes of active engagement with the Gro Health app and changes in scores across the different mental health measures. Results: Of the 347 study participants, 273 (78.67%) completed both the baseline and follow-up surveys. Changes in scores for anxiety, perceived stress, and depression were predicted by app engagement, with the strongest effect observed for changes in perceived stress score (F1,271=251.397; R2=0.479; P<.001). Conclusions: A digital behavior change platform that provides remote mental well-being support can be effective in managing depression, anxiety, and perceived stress during times of crisis such as the current COVID-19 pandemic. The outcomes of this study may also support the implementation of remote digital health apps supporting behavior change and providing support for low levels of mental health within the community. UR - https://formative.jmir.org/2021/10/e31273 UR - http://dx.doi.org/10.2196/31273 UR - http://www.ncbi.nlm.nih.gov/pubmed/34459740 ID - info:doi/10.2196/31273 ER - TY - JOUR AU - Miller, Sascha AU - Ainsworth, Ben AU - Weal, Mark AU - Smith, Peter AU - Little, Paul AU - Yardley, Lucy AU - Morrison, Leanne PY - 2021/10/5 TI - A Web-Based Intervention (Germ Defence) to Increase Handwashing During a Pandemic: Process Evaluations of a Randomized Controlled Trial and Public Dissemination JO - J Med Internet Res SP - e26104 VL - 23 IS - 10 KW - behavior KW - infection KW - prevention KW - respiratory tract infection KW - internet KW - evaluation studies KW - pandemic KW - COVID-19 KW - transmission KW - virus KW - influenza KW - respiratory KW - intervention KW - digital intervention KW - dissemination N2 - Background: Washing hands helps prevent transmission of seasonal and pandemic respiratory viruses. In a randomized controlled trial (RCT) during the swine flu outbreak, participants with access to a fully automated, digital intervention promoting handwashing reported washing their hands more often and experienced fewer respiratory tract infections than those without access to the intervention. Based on these findings, the intervention was adapted, renamed as ?Germ Defence,? and a study was designed to assess the preliminary dissemination of the intervention to the general public to help prevent the spread of seasonal colds and flu. Objective: This study compares the process evaluations of the RCT and Germ Defence dissemination to examine (1) how web-based research enrollment procedures affected those who used the intervention, (2) intervention usage in the 2 contexts, and (3) whether increased intentions to wash hands are replicated once disseminated. Methods: The RCT ran between 2010 and 2012 recruiting participants offline from general practices, with restricted access to the intervention (N=9155). Germ Defence was disseminated as an open access website for use by the general public from 2016 to 2019 (N=624). The process evaluation plan was developed using Medical Research Council guidance and the framework for Analyzing and Measuring Usage and Engagement Data. Both interventions contained a goal-setting section where users self-reported current and intended handwashing behavior across 7 situations. Results: During web-based enrolment, 54.3% (17,511/32,250) of the RCT participants dropped out of the study compared to 36.5% (358/982) of Germ Defence users. Having reached the start of the intervention, 93.8% (8586/9155) of RCT users completed the core section, whereas 65.1% (406/624) of Germ Defence users reached the same point. Users across both studies selected to increase their handwashing in 5 out of 7 situations, including before eating snacks (RCT mean difference 1.040, 95% CI 1.016-1.063; Germ Defence mean difference 0.949, 95% CI 0.766-1.132) and after blowing their nose, sneezing, or coughing (RCT mean difference 0.995, 95% CI 0.972-1.019; Germ Defence mean difference 0.842, 95% CI 0.675-1.008). Conclusions: By comparing the preliminary dissemination of Germ Defence to the RCT, we were able to examine the potential effects of the research procedures on uptake and attrition such as the sizeable dropout during the RCT enrolment procedure that may have led to a more motivated sample. The Germ Defence study highlighted the points of attrition within the intervention. Despite sample bias in the trial context, the intervention replicated increases in intentions to handwash when used ?in the wild.? This preliminary dissemination study informed the adaptation of the intervention for the COVID-19 health emergency, and it has now been disseminated globally. Trial Registration: ISRCTN Registry ISRCTN75058295; https://www.isrctn.com/ISRCTN75058295 UR - https://www.jmir.org/2021/10/e26104 UR - http://dx.doi.org/10.2196/26104 UR - http://www.ncbi.nlm.nih.gov/pubmed/34519661 ID - info:doi/10.2196/26104 ER - TY - JOUR AU - O'Dell, M. Sean AU - Fisher, R. Heidi AU - Schlieder, Victoria AU - Klinger, Tracey AU - Kininger, L. Rachel AU - Cosottile, McKenna AU - Cummings, Stacey AU - DeHart, Kathy PY - 2021/10/5 TI - Engaging Parents and Health Care Stakeholders to Inform Development of a Behavioral Intervention Technology to Promote Pediatric Behavioral Health: Mixed Methods Study JO - JMIR Pediatr Parent SP - e27551 VL - 4 IS - 4 KW - primary care KW - parenting KW - targeted prevention KW - behavioral intervention technology KW - behavioral health N2 - Background: Despite effective psychosocial interventions, gaps in access to care persist for youth and families in need. Behavioral intervention technologies (BITs) that apply psychosocial intervention strategies using technological features represent a modality for targeted prevention that is promising for the transformation of primary care behavioral health by empowering parents to take charge of the behavioral health care of their children. To realize the potential of BITs for parents, research is needed to understand the status quo of parental self-help and parent-provider collaboration to address behavioral health challenges and unmet parental needs that could be addressed by BITs. Objective: The aim of this study is to conduct foundational research with parents and health care stakeholders (HCS) to discover current practices and unmet needs related to common behavioral health challenges to inform the design, build, and testing of BITs to address these care gaps within a predominantly rural health system. Methods: We conducted a convergent mixed-parallel study within a large, predominantly rural health system in which the BITs will be developed and implemented. We analyzed data from parent surveys (N=385) on current practices and preferences related to behavioral health topics to be addressed in BITs along with focus group data of 48 HCS in 9 clinics regarding internal and external contextual factors contributing to unmet parental needs and current practices. By comparing and relating the findings, we formed interpretations that will inform subsequent BIT development activities. Results: Parents frequently endorsed several behavioral health topics, and several topics were relatively more or less frequently endorsed based on the child?s age. The HCS suggested that BITs may connect families with evidence-based guidance sooner and indicated that a web-based platform aligns with how parents already seek behavioral health guidance. Areas of divergence between parents and HCS were related to internalizing problems and cross-cutting issues such as parenting stress, which may be more difficult for health care HCS to detect or address because of the time constraints of routine medical visits. Conclusions: These findings provide a rich understanding of the complexity involved in meeting parents? needs for behavioral health guidance in a primary care setting using BITs. User testing studies for BIT prototypes are needed to successfully design, build, and test effective BITs to empower parents to take charge of promoting the behavioral health of their children. UR - https://pediatrics.jmir.org/2021/4/e27551 UR - http://dx.doi.org/10.2196/27551 UR - http://www.ncbi.nlm.nih.gov/pubmed/34609324 ID - info:doi/10.2196/27551 ER - TY - JOUR AU - Snow-Hill, L. Nyssa AU - Donenberg, Geri AU - Feil, G. Edward AU - Smith, R. David AU - Floyd, R. Brenikki AU - Leve, Craig PY - 2021/9/30 TI - A Technology-Based Training Tool for a Health Promotion and Sex Education Program for Justice-Involved Youth: Development and Usability Study JO - JMIR Form Res SP - e31185 VL - 5 IS - 9 KW - health education KW - sexual behavior KW - juvenile delinquency KW - feasibility studies KW - evidence-based practice KW - adolescent health services KW - inservice training KW - implementation science KW - organizational innovation KW - technology KW - risk reduction behavior KW - mobile phone KW - health technology KW - health promotion KW - sexual health N2 - Background: Justice-involved youth are especially vulnerable to mental health distress, substance misuse, and risky sexual activity, amplifying the need for evidence-based programs (EBPs). Yet, uptake of EBPs in the justice system is challenging because staff training is costly in time and effort. Hence, justice-involved youth experience increasing health disparities despite the availability of EBPs. Objective: To counter these challenges, this study develops and pilot-tests a prototype of a technology-based training tool that teaches juvenile justice staff to deliver a uniquely tailored EBP for justice-involved youth?PHAT (Preventing HIV/AIDS Among Teens) Life. PHAT Life is a comprehensive sex education, mental health, and substance use EBP collaboratively designed and tested with guidance from key stakeholders and community members. The training tool addresses implementation barriers that impede uptake and sustainment of EBPs, including staff training and support and implementation costs. Methods: Staff (n=11) from two juvenile justice settings pilot-tested the technology-based training tool, which included five modules. Participants completed measures of HIV and sexually transmitted infection (STI) knowledge, sex education confidence, and implementation outcomes such as training satisfaction, adoption, implementation, acceptability, appropriateness, and sustainability. PHAT Life trainers assessed fidelity through two activity role plays participants submitted upon completing the training modules. Results: Participants demonstrated increases in HIV and STI knowledge (t10=3.07; P=.01), and were very satisfied (mean 4.42, SD 0.36) with the training tool and the PHAT Life curriculum. They believed that the training tool and curriculum could be adopted, implemented, and sustained within their settings as an appropriate and acceptable intervention and training. Conclusions: Overall, the results from this pilot test demonstrate feasibility and support continuing efforts toward completing the training tool and evaluating it within a fully powered randomized controlled trial. Ultimately, this study will provide a scalable option for disseminating an EBP and offers a more cost-effective and sustainable way to train staff in an EBP. UR - https://formative.jmir.org/2021/9/e31185 UR - http://dx.doi.org/10.2196/31185 UR - http://www.ncbi.nlm.nih.gov/pubmed/34591028 ID - info:doi/10.2196/31185 ER - TY - JOUR AU - Guo, Jong-Long AU - Hsu, Hsiao-Pei AU - Lai, Tzu-Ming AU - Lin, Mei-Ling AU - Chung, Chih-Ming AU - Huang, Chiu-Mieh PY - 2021/9/28 TI - Acceptability Evaluation of the Use of Virtual Reality Games in Smoking-Prevention Education for High School Students: Prospective Observational Study JO - J Med Internet Res SP - e28037 VL - 23 IS - 9 KW - behavioral intention KW - ARCS motivation model KW - persuasiveness KW - smoking prevention KW - educational games N2 - Background: Alternative forms of cigarettes, such as electronic cigarettes (e-cigarettes), are becoming increasingly common among adolescents. Many high schools now provide smoking-prevention education in an attempt to minimize the potential negative health effects and illness burdens e-cigarettes may induce in adolescents. However, it is often difficult to motivate young students to engage with traditional education regarding the harmful effects of tobacco; thus, the development of alternative approaches may be required. Objective: In this study, we aimed to conduct an acceptability evaluation of educational virtual reality games designed to support smoking-prevention measures. We based the acceptability evaluation on the following two experience types: game-playing and content-learning experiences. The paths by which these experience types affect the intention to abstain from smoking were also examined. Methods: We applied a prospective observational study design. We developed educational games based on three-dimensional virtual reality technology, in which participants operated joysticks to complete challenge tasks. To increase the possibility of the games fostering motivation to abstain from smoking, the ARCS motivational model (comprising attention, relevance, confidence, and satisfaction) was used as a framework during the games? design. We measured the participants? game-playing experiences by inquiring about the strength of the ARCS elements; content-learning experiences were measured using overall knowledge improvement and the perceived persuasiveness of the content. A total of 130 students participated in the program. Study hypotheses for this evaluation were derived from a literature review. We used partial least squares structural equation modeling to examine the proposed hypotheses. Results: Based on the responses of the students to questionnaire items concerning attention, relevance, confidence, and satisfaction in the context of the games, most students agreed or strongly agreed that the educational games were motivational, and that their game-playing experiences were positive. Regarding content-learning experiences, there was a significant improvement in knowledge (t129=25.67, P<.001), and most students perceived themselves as being persuaded to abstain from smoking. Attention, relevance, and satisfaction significantly influenced perceived persuasiveness (t=3.19, P<.001; t=4.28, P<.001; and t=3.49, P<.001, respectively); however, confidence did not (t=0.42, P=.67). Perceived persuasiveness, relevance, and satisfaction significantly influenced the intention to abstain from smoking (t=3.57, P<.001). In addition to directly affecting the intention to abstain from smoking, indirect effects were observed from both relevance and satisfaction to intention via perceived persuasiveness (t=2.87, P=.004 and t=2.11, P=.04, respectively). However, intention was not significantly influenced by knowledge improvement. Conclusions: Our findings revealed that the educational games were positively accepted by the participating students. This indicates that the integration of the ARCS framework and persuasive strategies is applicable for smoking-prevention education. We recommend that the games be included as teaching materials for smoking-prevention education. UR - https://www.jmir.org/2021/9/e28037 UR - http://dx.doi.org/10.2196/28037 UR - http://www.ncbi.nlm.nih.gov/pubmed/34581679 ID - info:doi/10.2196/28037 ER - TY - JOUR AU - Silfee, Valerie AU - Williams, Kelly AU - Leber, Brett AU - Kogan, Jane AU - Nikolajski, Cara AU - Szigethy, Eva AU - Serio, Catherine PY - 2021/9/28 TI - Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study JO - JMIR Form Res SP - e28538 VL - 5 IS - 9 KW - digital health KW - mHealth KW - implementation KW - cognitive behavioral therapy KW - anxiety KW - depression KW - smartphone KW - mobile phone N2 - Background: Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. Objective: This study assessed providers? views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. Methods: Participating providers included BH and physical health (PH) providers from a women?s health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. Results: A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. Conclusions: Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow. UR - https://formative.jmir.org/2021/9/e28538 UR - http://dx.doi.org/10.2196/28538 UR - http://www.ncbi.nlm.nih.gov/pubmed/34529583 ID - info:doi/10.2196/28538 ER - TY - JOUR AU - Suzuki, Yukio AU - Sukegawa, Akiko AU - Ueda, Yutaka AU - Sekine, Masayuki AU - Enomoto, Takayuki AU - Miyagi, Etsuko PY - 2021/9/27 TI - Effect of a Brief Web-Based Educational Intervention on Willingness to Consider Human Papillomavirus Vaccination for Children in Japan: Randomized Controlled Trial JO - J Med Internet Res SP - e28355 VL - 23 IS - 9 KW - human papillomavirus KW - human papillomavirus vaccination KW - behavioral insights KW - behavioral change KW - web-based randomized controlled trial N2 - Background: The human papillomavirus (HPV) vaccination rate in Japan has fallen to nearly zero since the suspension of governmental proactive recommendations in 2013, owing to the development of purported adverse events. Objective: This study aimed to evaluate the effects of a brief web-based educational intervention using the theory of behavioral insights on the willingness of adults to consider the HPV vaccine for their daughters and sons. Methods: We recruited 1660 participants aged 20 years or older in March 2018 via a webpage and provided them with a 10-item questionnaire related to the following aspects: awareness regarding HPV infection and vaccination, willingness for immunization, and actions for prevention. We randomly stratified participants based on sex and age with or without a brief educational intervention involving scientific information presented in an easy-to-read format. Results: Only 484 (29.2%) of the respondents were aware of the benefits of HPV vaccination. Although only 352 (21.2%) of the respondents displayed a willingness for immunization of their daughters, there were 40 (4.8%) more respondents in the intervention group with this willingness (adjusted odds ratio [aOR] 1.32, 95% CI 1.04-1.69). In a subanalysis, the willingness toward vaccination for daughters in men was significantly higher in the intervention group (aOR 1.46, 95% CI 1.05-2.02). However, such a difference was not observed among women (aOR 1.20, 95% CI 0.83-1.73). Conclusions: This study suggests that a brief web-based educational intervention increases the willingness of adults to consider the HPV vaccine for their children, especially among men. Thus, providing adequate information to men may be a useful strategy to improve the currently low rates of HPV vaccination. Trial Registration: UMIN Clinical Trials Registry UMIN000049745 (UMIN-CTR); https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049745 UR - https://www.jmir.org/2021/9/e28355 UR - http://dx.doi.org/10.2196/28355 UR - http://www.ncbi.nlm.nih.gov/pubmed/34569941 ID - info:doi/10.2196/28355 ER - TY - JOUR AU - Cross, J. Troy AU - Isautier, J. Jennifer M. AU - Morris, J. Sarah AU - Johnson, D. Bruce AU - Wheatley-Guy, M. Courtney AU - Taylor, J. Bryan PY - 2021/9/24 TI - The Influence of Social Distancing Behaviors and Psychosocial Factors on Physical Activity During the COVID-19 Pandemic: Cross-sectional Survey Study JO - JMIR Public Health Surveill SP - e31278 VL - 7 IS - 9 KW - physical activity KW - COVID-19 KW - mental health KW - social distancing KW - public health KW - pandemic KW - physical health KW - exercise N2 - Background: The COVID-19 pandemic has arguably facilitated a shift toward increased sedentariness and reduced physical activity. Moreover, there is mounting evidence that mental health has also declined during the pandemic. However, it remains unknown to what extent social distancing (SD) behaviors and mental health have affected the physical activity levels of the general population. Objective: The purpose of this study was to determine the influence of SD behaviors and prevailing mental health on the odds of being physically active during the early COVID-19 pandemic response. Methods: A total of 4819 adults (2474/4819, 51.3%, female) from the US population with a median age of 46 (IQR 35-59) completed an online survey during the early pandemic response (April-June 2020). The survey included questions on adherence to 11 SD behaviors, and validated questionnaires which assessed self-reported physical activity, depression, anxiety, and mental well-being. Respondents were categorized into 2 physical activity groups: inactive (0-599 metabolic equivalent of task [MET]-minutes/week) and active (?600 MET-minutes/week). A logistic generalized additive model (GAM) was used to determine which SD factors and mental health outcomes were associated with physical activity level. Results: The GAM analysis revealed that wearing a facemask in public (odds ratio [OR] 1.46, 95% CI 1.14-1.79; P=.003), limiting the use of public transport (OR 1.47, 95% CI 1.19-1.83; P=.001), and restricting travel outside the house (OR 1.56, 95% CI 1.19-2.05; P=.002) were SD behaviors associated with higher odds of being more physically active. Conversely, avoiding physical activity outside the house was associated with higher odds of being inactive (OR 0.52, 95% CI 0.46-0.63; P<.001). Leaving the house more frequently, and a higher mental well-being were associated with increasing odds of being physically active (P<.001). Engaging with a moderate number of SD behaviors (3-7 total) was positively associated with physical activity, whereas a very high SD vigilance (ie, engaging with ?10 total behaviors) decreased the odds of being active during the early pandemic response. Conclusions: Based on the findings of our study, we suggest that future public health messaging of SD guidelines should include (1) a clear portrayal of the benefits of regular exercise on mental health; and (2) a specific focus on how to be physically active outdoors in a COVID-safe manner. UR - https://publichealth.jmir.org/2021/9/e31278 UR - http://dx.doi.org/10.2196/31278 UR - http://www.ncbi.nlm.nih.gov/pubmed/34509976 ID - info:doi/10.2196/31278 ER - TY - JOUR AU - Thabrew, Hiran AU - Stasiak, Karolina AU - Kumar, Harshali AU - Naseem, Tarique AU - Frampton, Christopher AU - Merry, Sally PY - 2021/9/24 TI - A Cognitive Behavioral Therapy?, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial JO - JMIR Serious Games SP - e26084 VL - 9 IS - 3 KW - long-term physical conditions KW - chronic illness KW - anxiety KW - eHealth KW - gaming KW - young people KW - treatment KW - cognitive behavioral therapy KW - biofeedback N2 - Background: Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues. Objective: This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions. Methods: Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale. Results: Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (?4.6; P<.001), Spence Child Anxiety Scale (?9.6; P=.005), and the Likert visual analog scales (?2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up. Conclusions: This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial. Trial Registration: Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443 UR - https://games.jmir.org/2021/3/e26084 UR - http://dx.doi.org/10.2196/26084 UR - http://www.ncbi.nlm.nih.gov/pubmed/34559053 ID - info:doi/10.2196/26084 ER - TY - JOUR AU - Feng, Shan AU - Mäntymäki, Matti AU - Dhir, Amandeep AU - Salmela, Hannu PY - 2021/9/21 TI - How Self-tracking and the Quantified Self Promote Health and Well-being: Systematic Review JO - J Med Internet Res SP - e25171 VL - 23 IS - 9 KW - self-tracking KW - quantified self KW - health KW - well-being KW - systematic literature review KW - literature review N2 - Background: Self-tracking technologies are widely used in people?s daily lives and health care. Academic research on self-tracking and the quantified self has also accumulated rapidly in recent years. Surprisingly, there is a paucity of research that reviews, classifies, and synthesizes the state of the art with respect to self-tracking and the quantified self. Objective: Our objective was to identify the state of the art of self-tracking and the quantified self in terms of health and well-being. Methods: We have undertaken a systematic literature review on self-tracking and the quantified self in promoting health and well-being. After a rigorous literature search, followed by inclusions, exclusions, and the application of article quality assessment protocols, 67 empirical studies qualified for the review. Results: Our results demonstrate that prior research has focused on 3 stakeholders with respect to self-tracking and the quantified self, namely end users, patients and people with illnesses, and health care professionals and caregivers. We used these stakeholder groups to cluster the research themes of the reviewed studies. We identified 11 research themes. There are 6 themes under the end-user cluster: user motivation and goal setting, usage and effects of self-tracking, continuance intention and long-term usage, management of personal data, rejection and discontinuance, and user characteristics. The patient and people with illnesses cluster contains three themes: usage experience of patients and people with illnesses, management of patient-generated data, and advantages and disadvantages in the clinical context. The health care professional and caregiver cluster contains two themes: collaboration among patients, health care professionals, and caregivers, and changes in the roles of patients and professionals. Moreover, we classified the future research suggestions given in the literature into 5 directions in terms of research designs and research topics. Finally, based on our reflections on the observations from the review, we suggest four future research directions: (1) users? cognitions and emotions related to processing and interpreting the information produced by tracking devices and apps; (2) the dark side of self-tracking (eg, its adverse psychosocial consequences); (3) self-tracking as a societal phenomenon; and (4) systemic impacts of self-tracking on health care and the actors involved. Conclusions: This systematic literature review contributes to research and practice by assisting future research activities and providing practitioners with a concise overview of the state of the art of self-tracking and the quantified self. UR - https://www.jmir.org/2021/9/e25171 UR - http://dx.doi.org/10.2196/25171 UR - http://www.ncbi.nlm.nih.gov/pubmed/34546176 ID - info:doi/10.2196/25171 ER - TY - JOUR AU - Choi, Michael AU - Raeside, Rebecca AU - Hyun, Karice AU - Partridge, R. Stephanie AU - Thiagalingam, Aravinda AU - Redfern, Julie PY - 2021/9/20 TI - Understanding Preferences for Lifestyle-Focused Visual Text Messages in Patients With Cardiovascular and Chronic Respiratory Disease: Discrete Choice Experiment JO - J Med Internet Res SP - e26224 VL - 23 IS - 9 KW - mHealth KW - cardiovascular disease KW - respiratory disease KW - visual communication KW - lifestyle change KW - consumer preferences KW - secondary prevention KW - rehabilitation KW - persuasive health technology N2 - Background: Supporting healthy lifestyle changes is a key aim of cardiovascular and pulmonary rehabilitation programs. SMS text messaging programs have demonstrated effectiveness in cardiovascular disease risk reduction, weight loss, increasing physical activity, and smoking cessation. The optimization of SMS text messaging programs may deliver greater population benefits as mobile phone use becomes ubiquitous. Visual messaging (ie, image-based messages) has the potential to communicate health messages via digital technology and result in enhanced engagement. Objective: This study aims to determine and understand patient preferences for lifestyle-focused visual text messages that support cardiovascular and pulmonary rehabilitation. Methods: A discrete choice experiment was conducted in a 4-stage iterative process to elicit patient preferences for visual message features. Attribute and level development yielded 3 attributes (purpose, image type, and web address), and 16 choice sets were subsequently constructed according to a full factorial design. Patients participating in cardiovascular and pulmonary rehabilitation were surveyed (on the web) for their preferences regarding the visual message choice sets. Respondents were asked to choose among 16 pairs of visual messages regarding key lifestyle behaviors, namely, physical activity and nutrition. The data were analyzed using a conditional logit model. Results: There was a total of 1728 observations from 54 unique respondents. Two factors that were associated with patient preference were gain-framed purpose compared with no purpose (odds ratio [OR] 1.93, 95% CI 1.40-2.65) and real images compared with cartoon images (OR 1.26, 95% CI 1.04-1.54). A loss-framed purpose was less preferred than no purpose (OR 0.55, 95% CI 0.42-0.74). Overall, patients preferred positive images that were colorful and engaged with text that supported the image and had a preference for images of real people rather than cartoons. Conclusions: A discrete choice experiment is a scientific method for eliciting patient preferences for a visual messaging intervention that is designed to support changes in lifestyle behaviors. SMS text messaging programs that use visual aids may result in greater patient satisfaction by using a gain frame, using real images, and avoiding a loss frame. Further research is needed to explore the feasibility of implementation and the health and behavioral outcomes associated with such visual messaging programs. UR - https://www.jmir.org/2021/9/e26224 UR - http://dx.doi.org/10.2196/26224 UR - http://www.ncbi.nlm.nih.gov/pubmed/34542413 ID - info:doi/10.2196/26224 ER - TY - JOUR AU - Isse, Naohi AU - Tachibana, Yuki AU - Kinoshita, Makiko AU - Fetters, D. Michael PY - 2021/9/20 TI - Evaluating Outcomes of a Social Media?Based Peer and Clinician-Supported Smoking Cessation Program in Preventing Smoking Relapse: Mixed Methods Case Study JO - JMIR Form Res SP - e25883 VL - 5 IS - 9 KW - communication KW - mixed methods case study research KW - online social networking KW - smoking cessation KW - smoking relapse N2 - Background: Smoking relapse prevention after completion of a smoking cessation program is highly germane to reducing smoking rates. Objective: The purpose of this study was to evaluate the 1-year outcomes of a social media?based and peer and clinician-supported smoking cessation program on Facebook and examine communication patterns that could support smoking cessation and identify risk of relapse. Methods: We used a mixed methods case study evaluation approach featuring a single-case holistic design. We recruited volunteers who signed up after successful completion of a 12-week clinical smoking cessation program in a general medicine department in Japan. Participants contemporaneously accessed a closed Facebook page, and we analyzed their posts including text and emoticons. We used joint display analysis, which involved iterative structuring and restructuring construct-specific tables with both types of data to find the most effective approach for integrating the quantitative results with the qualitative results of content analysis. Results: One successful participant and 2 relapsed participants were analyzed to explore the specific patterns of postings prior to relapse. Decisive comments about quitting smoking were common among participants, but encouraging messages for peers were more common from the successful participant. Comments seeking social support and reassurance were warning signs of relapse. Conflicted comments also may be a warning sign of relapse risk. Conclusions: These findings based on a mixed methods case study of a social media platform supporting smoking cessation could be used to guide messaging in other online social networking service communities after a smoking cessation program to help reduce smoking relapse. Trial Registration: UMIN Clinical Trials Registry UMIN000031172; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000035595 UR - https://formative.jmir.org/2021/9/e25883 UR - http://dx.doi.org/10.2196/25883 UR - http://www.ncbi.nlm.nih.gov/pubmed/34542412 ID - info:doi/10.2196/25883 ER - TY - JOUR AU - Keijsers, Merel AU - Vega-Corredor, Cecilia Maria AU - Tomintz, Melanie AU - Hoermann, Simon PY - 2021/9/17 TI - Virtual Reality Technology Use in Cigarette Craving and Smoking Interventions (I ?Virtually? Quit): Systematic Review JO - J Med Internet Res SP - e24307 VL - 23 IS - 9 KW - virtual reality technology KW - nicotine dependency KW - nicotine addiction KW - smoking addiction KW - smoking intervention KW - smoking therapy KW - Electronic Nicotine Delivery Systems N2 - Background: Over the last 2 decades, virtual reality technologies (VRTs) have been proposed as a way to enhance and improve smoking cessation therapy. Objective: This systematic review aims to evaluate and summarize the current knowledge on the application of VRT in various smoking cessation therapies, as well as to explore potential directions for future research and intervention development. Methods: A literature review of smoking interventions using VRT was conducted. Results: Not all intervention studies included an alternative therapy or a placebo condition against which the effectiveness of the intervention could be benchmarked, or a follow-up measure to ensure that the effects were lasting. Virtual reality (VR) cue exposure therapy was the most extensively studied intervention, but its effect on long-term smoking behavior was inconsistent. Behavioral therapies such as a VR approach-avoidance task or gamified interventions were less common but reported positive results. Notably, only 1 study combined Electronic Nicotine Delivery Devices with VRT. Conclusions: The inclusion of a behavioral component, as is done in the VR approach-avoidance task and gamified interventions, may be an interesting avenue for future research on smoking interventions. As Electronic Nicotine Delivery Devices are still the subject of much controversy, their potential to support smoking cessation remains unclear. For future research, behavioral or multicomponent interventions are promising avenues of exploration. Future studies should improve their validity by comparing their intervention group with at least 1 alternative or placebo control group, as well as incorporating follow-up measures. UR - https://www.jmir.org/2021/9/e24307 UR - http://dx.doi.org/10.2196/24307 UR - http://www.ncbi.nlm.nih.gov/pubmed/34533471 ID - info:doi/10.2196/24307 ER - TY - JOUR AU - Ainiwaer, Abidan AU - Zhang, Shuai AU - Ainiwaer, Xiayiabasi AU - Ma, Feicheng PY - 2021/9/16 TI - Effects of Message Framing on Cancer Prevention and Detection Behaviors, Intentions, and Attitudes: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e27634 VL - 23 IS - 9 KW - gain framing KW - loss framing KW - attitude KW - intention KW - behaviors KW - cancer prevention KW - cancer detection N2 - Background: With the increasing health care burden of cancer, public health organizations are increasingly emphasizing the importance of calling people to engage in long-term prevention and periodical detection. How to best deliver behavioral recommendations and health outcomes in messaging is an important issue. Objective: This study aims to disaggregate the effects of gain-framed and loss-framed messages on cancer prevention and detection behaviors and intentions and attitudes, which has the potential to inform cancer control programs. Methods: A search of three electronic databases (Web of Science, Scopus, and PubMed) was conducted for studies published between January 2000 and December 2020. After a good agreement achieved on a sample by two authors, the article selection (?=0.8356), quality assessment (?=0.8137), and data extraction (?=0.9804) were mainly performed by one author. The standardized mean difference (attitude and intention) and the odds ratio (behaviors) were calculated to evaluate the effectiveness of message framing (gain-framed message and loss-framed message). Calculations were conducted, and figures were produced by Review Manager 5.3. Results: The title and abstract of 168 unique citations were scanned, of which 53 were included for a full-text review. A total of 24 randomized controlled trials were included, predominantly examining message framing on cancer prevention and detection behavior change interventions. There were 9 studies that used attitude to predict message framing effect and 16 studies that used intention, whereas 6 studies used behavior to examine the message framing effect directly. The use of loss-framed messages improved cancer detection behavior (OR 0.76, 95% CI 0.64-0.90; P=.001), and the results from subgroup analysis indicated that the effect would be weak with time. No effect of framing was found when effectiveness was assessed by attitudes (prevention: SMD=0.02, 95% CI ?0.13 to 0.17; P=.79; detection: SMD=?0.05, 95% CI ?0.15 to 0.05; P=.32) or intentions (prevention: SMD=?0.05, 95% CI ?0.19 to 0.09; P=.48; detection: SMD=0.02, 95% CI ?0.26 to 0.29; P=.92) among studies encouraging cancer prevention and cancer detection. Conclusions: Research has shown that it is almost impossible to change people's attitudes or intentions about cancer prevention and detection with a gain-framed or loss-framed message. However, loss-framed messages have achieved preliminary success in persuading people to adopt cancer detection behaviors. Future studies could improve the intervention design to achieve better intervention effectiveness. UR - https://www.jmir.org/2021/9/e27634 UR - http://dx.doi.org/10.2196/27634 UR - http://www.ncbi.nlm.nih.gov/pubmed/34528887 ID - info:doi/10.2196/27634 ER - TY - JOUR AU - Xin, Meiqi AU - Coulson, S. Neil AU - Jiang, Li Crystal AU - Sillence, Elizabeth AU - Chidgey, Andrew AU - Kwan, Man Norman Nok AU - Mak, S. Winnie W. AU - Goggins, William AU - Lau, Fai Joseph Tak AU - Mo, Han Phoenix Kit PY - 2021/9/16 TI - Web-Based Behavioral Intervention Utilizing Narrative Persuasion for HIV Prevention Among Chinese Men Who Have Sex With Men (HeHe Talks Project): Intervention Development JO - J Med Internet Res SP - e22312 VL - 23 IS - 9 KW - narrative persuasion KW - firsthand experiential stories KW - online intervention KW - HIV prevention KW - sexual behavior KW - men who have sex with men N2 - Background: In the era of potent antiretroviral therapy, a high level of condomless anal intercourse continues to drive increases in HIV incidence in recent years among men who have sex with men. Effective behavior change strategies for promoting HIV-preventive behaviors are warranted. Narrative persuasion is a novel health communication approach that has demonstrated its persuasive advantages in overcoming resistance to counterattitudinal messages. The efficacy of narrative persuasion in promoting health behavior changes has been well documented, but critical research gaps exist for its application to HIV prevention. Objective: In this study, we aimed to (1) capitalize on narrative persuasion to design a web-based multisession intervention for reducing condomless anal intercourse among men who have sex with men in Hong Kong (the HeHe Talks Project) by following a systematic development process; and (2) describe the main components of the narrative intervention that potentially determine its persuasiveness. Methods: Persuasive themes and subtopics related to reducing condomless anal intercourse were initially proposed based on epidemiological evidence. The biographic narrative interview method was used to elicit firsthand experiential stories from a maximum variation sample of local men who have sex with men with diverse backgrounds and experiences related to HIV prevention; different types of role models were established accordingly. Framework analysis was used to aggregate the original quotations from narrators into collective narratives under 6 intervention themes. A dedicated website was finally developed for intervention delivery. Results: A series of video-based intervention messages in biographic narrative format (firsthand experiential stories shared by men who have sex with men) combined with topic-equivalent argumentative messages were produced and programmed into 6 intervention sessions. The 6-week intervention program can be automatically delivered and monitored online. Conclusions: We systematically created a web-based HIV prevention intervention derived from peer-generated stories. Strategies used to enhance the efficacy of the narrative intervention have been discussed within basic communication components. This paper describes the methods and experiences of the rigorous development of a narrative communication intervention for HIV prevention, which enables replication of the intervention in the future. UR - https://www.jmir.org/2021/9/e22312 UR - http://dx.doi.org/10.2196/22312 UR - http://www.ncbi.nlm.nih.gov/pubmed/34528889 ID - info:doi/10.2196/22312 ER - TY - JOUR AU - Luo, Christina Tiffany AU - Aguilera, Adrian AU - Lyles, Rees Courtney AU - Figueroa, Astrid Caroline PY - 2021/9/14 TI - Promoting Physical Activity Through Conversational Agents: Mixed Methods Systematic Review JO - J Med Internet Res SP - e25486 VL - 23 IS - 9 KW - physical activity KW - health behavior KW - behavior change KW - conversational agent KW - virtual agent KW - chatbot KW - digital health KW - eHealth KW - mHealth KW - mobile health KW - mobile phone N2 - Background: Regular physical activity (PA) is crucial for well-being; however, healthy habits are difficult to create and maintain. Interventions delivered via conversational agents (eg, chatbots or virtual agents) are a novel and potentially accessible way to promote PA. Thus, it is important to understand the evolving landscape of research that uses conversational agents. Objective: This mixed methods systematic review aims to summarize the usability and effectiveness of conversational agents in promoting PA, describe common theories and intervention components used, and identify areas for further development. Methods: We conducted a mixed methods systematic review. We searched seven electronic databases (PsycINFO, PubMed, Embase, CINAHL, ACM Digital Library, Scopus, and Web of Science) for quantitative, qualitative, and mixed methods studies that conveyed primary research on automated conversational agents designed to increase PA. The studies were independently screened, and their methodological quality was assessed using the Mixed Methods Appraisal Tool by 2 reviewers. Data on intervention impact and effectiveness, treatment characteristics, and challenges were extracted and analyzed using parallel-results convergent synthesis and narrative summary. Results: In total, 255 studies were identified, 7.8% (20) of which met our inclusion criteria. The methodological quality of the studies was varied. Overall, conversational agents had moderate usability and feasibility. Those that were evaluated through randomized controlled trials were found to be effective in promoting PA. Common challenges facing interventions were repetitive program content, high attrition, technical issues, and safety and privacy concerns. Conclusions: Conversational agents hold promise for PA interventions. However, there is a lack of rigorous research on long-term intervention effectiveness and patient safety. Future interventions should be based on evidence-informed theories and treatment approaches and should address users? desires for program variety, natural language processing, delivery via mobile devices, and safety and privacy concerns. UR - https://www.jmir.org/2021/9/e25486 UR - http://dx.doi.org/10.2196/25486 UR - http://www.ncbi.nlm.nih.gov/pubmed/34519653 ID - info:doi/10.2196/25486 ER - TY - JOUR AU - Stephenson, Callum AU - Malakouti, Niloufar AU - Nashed, Y. Joseph AU - Salomons, Tim AU - Cook, J. Douglas AU - Milev, Roumen AU - Alavi, Nazanin PY - 2021/9/14 TI - Using Electronically Delivered Therapy and Brain Imaging to Understand Obsessive-Compulsive Disorder Pathophysiology: Protocol for a Pilot Study JO - JMIR Res Protoc SP - e30726 VL - 10 IS - 9 KW - mental health KW - obsessive-compulsive disorder KW - cognitive behavioral therapy KW - exposure ritual prevention KW - electronic KW - functional magnetic resonance imaging KW - eHealth KW - brain imaging N2 - Background: Obsessive-compulsive disorder (OCD) is a debilitating and prevalent anxiety disorder. Although the basal ganglia and frontal cortex are the brain regions that are most commonly hypothesized to be involved in OCD, the exact pathophysiology is unknown. By observing the effects of proven treatments on brain activation levels, the cause of OCD can be better understood. Currently, the gold standard treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response prevention. However, this is often temporally and geographically inaccessible, time consuming, and costly. Fortunately, CBT can be effectively delivered using the internet (electronically delivered CBT [e-CBT]) because of its structured nature, thus addressing these barriers. Objective: The aims of this study are to implement an e-CBT program for OCD and to observe its effects on brain activation levels using functional magnetic resonance imaging (MRI). It is hypothesized that brain activation levels in the basal ganglia and frontal cortex will decrease after treatment. Methods: Individuals with OCD will be offered a 16-week e-CBT program with exposure and response prevention mirroring in-person CBT content and administered through a secure web-based platform. The efficacy of the treatment will be evaluated using clinically validated symptomology questionnaires at baseline, at week 8, and after treatment (week 16). Using functional MRI at baseline and after treatment, brain activation levels will be assessed in the resting state and while exposed to anxiety-inducing images (eg, dirty dishes if cleanliness is an obsession). The effects of treatment on brain activation levels and the correlation between symptom changes and activation levels will be analyzed. Results: The study received initial ethics approval in December 2020, and participant recruitment began in January 2021. Participant recruitment has been conducted through social media advertisements, physical advertisements, and physician referrals. To date, 5 participants have been recruited. Data collection is expected to conclude by January 2022, and data analysis is expected to be completed by February 2022. Conclusions: The findings from this study can further our understanding of the causation of OCD and help develop more effective treatments for this disorder. Trial Registration: ClinicalTrials.gov NCT04630197; https://clinicaltrials.gov/ct2/show/NCT04630197. International Registered Report Identifier (IRRID): PRR1-10.2196/30726 UR - https://www.researchprotocols.org/2021/9/e30726 UR - http://dx.doi.org/10.2196/30726 UR - http://www.ncbi.nlm.nih.gov/pubmed/34348889 ID - info:doi/10.2196/30726 ER - TY - JOUR AU - Daryabeygi-Khotbehsara, Reza AU - Shariful Islam, Mohammed Sheikh AU - Dunstan, David AU - McVicar, Jenna AU - Abdelrazek, Mohamed AU - Maddison, Ralph PY - 2021/9/13 TI - Smartphone-Based Interventions to Reduce Sedentary Behavior and Promote Physical Activity Using Integrated Dynamic Models: Systematic Review JO - J Med Internet Res SP - e26315 VL - 23 IS - 9 KW - smartphone KW - mobile phone KW - physical activity KW - sedentary behavior KW - computational models KW - control systems KW - systematic review N2 - Background: Traditional psychological theories are inadequate to fully leverage the potential of smartphones and improve the effectiveness of physical activity (PA) and sedentary behavior (SB) change interventions. Future interventions need to consider dynamic models taken from other disciplines, such as engineering (eg, control systems). The extent to which such dynamic models have been incorporated in the development of interventions for PA and SB remains unclear. Objective: This review aims to quantify the number of studies that have used dynamic models to develop smartphone-based interventions to promote PA and reduce SB, describe their features, and evaluate their effectiveness where possible. Methods: Databases including PubMed, PsycINFO, IEEE Xplore, Cochrane, and Scopus were searched from inception to May 15, 2019, using terms related to mobile health, dynamic models, SB, and PA. The included studies involved the following: PA or SB interventions involving human adults; either developed or evaluated integrated psychological theory with dynamic theories; used smartphones for the intervention delivery; the interventions were adaptive or just-in-time adaptive; included randomized controlled trials (RCTs), pilot RCTs, quasi-experimental, and pre-post study designs; and were published from 2000 onward. Outcomes included general characteristics, dynamic models, theory or construct integration, and measured SB and PA behaviors. Data were synthesized narratively. There was limited scope for meta-analysis because of the variability in the study results. Results: A total of 1087 publications were screened, with 11 publications describing 8 studies included in the review. All studies targeted PA; 4 also included SB. Social cognitive theory was the major psychological theory upon which the studies were based. Behavioral intervention technology, control systems, computational agent model, exploit-explore strategy, behavioral analytic algorithm, and dynamic decision network were the dynamic models used in the included studies. The effectiveness of quasi-experimental studies involved reduced SB (1 study; P=.08), increased light PA (1 study; P=.002), walking steps (2 studies; P=.06 and P<.001), walking time (1 study; P=.02), moderate-to-vigorous PA (2 studies; P=.08 and P=.81), and nonwalking exercise time (1 study; P=.31). RCT studies showed increased walking steps (1 study; P=.003) and walking time (1 study; P=.06). To measure activity, 5 studies used built-in smartphone sensors (ie, accelerometers), 3 of which used the phone?s GPS, and 3 studies used wearable activity trackers. Conclusions: To our knowledge, this is the first systematic review to report on smartphone-based studies to reduce SB and promote PA with a focus on integrated dynamic models. These findings highlight the scarcity of dynamic model?based smartphone studies to reduce SB or promote PA. The limited number of studies that incorporate these models shows promising findings. Future research is required to assess the effectiveness of dynamic models in promoting PA and reducing SB. Trial Registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42020139350; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=139350. UR - https://www.jmir.org/2021/9/e26315 UR - http://dx.doi.org/10.2196/26315 UR - http://www.ncbi.nlm.nih.gov/pubmed/34515637 ID - info:doi/10.2196/26315 ER - TY - JOUR AU - Ziadni, S. Maisa AU - Gonzalez-Castro, Lluvia AU - Anderson, Steven AU - Krishnamurthy, Parthasarathy AU - Darnall, D. Beth PY - 2021/9/10 TI - Efficacy of a Single-Session ?Empowered Relief? Zoom-Delivered Group Intervention for Chronic Pain: Randomized Controlled Trial Conducted During the COVID-19 Pandemic JO - J Med Internet Res SP - e29672 VL - 23 IS - 9 KW - single-session KW - empowered relief KW - Zoom-delivered KW - pain catastrophizing KW - pain intensity KW - randomized-controlled trial KW - chronic pain N2 - Background: Cognitive behavioral therapy?pain is an evidence-based treatment for chronic pain that can have significant patient burden, including health care cost, travel, multiple sessions, and lack of access in remote areas. Objective: The study aims to pilot test the efficacy of a single-session videoconference-delivered empowered relief (ER) intervention compared to waitlist control (WLC) conditions among individuals with chronic pain. We hypothesized that ER would be superior to WLC in reducing pain catastrophizing, pain intensity, and other pain-related outcomes at 1-3 months posttreatment. Methods: We conducted a randomized controlled trial involving a web-based sample of adults (N=104) aged 18-80 years with self-reported chronic pain. Participants were randomized (1:1) to 1 of 2 unblinded study groups: ER (50/104, 48.1%) and WLC (54/104, 51.9%). Participants allocated to ER completed a Zoom-delivered class, and all participants completed follow-up surveys at 2 weeks and 1, 2, and 3 months posttreatment. All the study procedures were performed remotely and electronically. The primary outcome was pain catastrophizing 1-month posttreatment, with pain intensity, pain bothersomeness, and sleep disruption as secondary outcomes. We also report a more rigorous test of the durability of treatment effects at 3 months posttreatment. Data were collected from September 2020 to February 2021 and analyzed using intention-to-treat analysis. The analytic data set included participants (18/101, 17.8% clinic patients; 83/101, 82.1% community) who completed at least one study survey: ER (50/101, 49.5%) and WLC (51/104, 49%). Results: Participants (N=101) were 69.3% (70/101) female, with a mean age of 49.76 years (SD 13.90; range 24-78); 32.7% (33/101) had an undergraduate degree and self-reported chronic pain for 3 months. Participants reported high engagement (47/50, 94%), high satisfaction with ER (mean 8.26, SD 1.57; range 0-10), and high satisfaction with the Zoom platform (46/50, 92%). For the between-groups factor, ER was superior to WLC for all primary and secondary outcomes at 3 months posttreatment (highest P<.001), and between-groups Cohen d effect sizes ranged from 0.45 to 0.79, indicating that the superiority was of moderate to substantial clinical importance. At 3 months, clinically meaningful pain catastrophizing scale (PCS) reductions were found for ER but not for WLC (ER: PCS ?8.72, 42.25% reduction; WLC: PCS ?2.25, 11.13% reduction). ER resulted in significant improvements in pain intensity, sleep disturbance, and clinical improvements in pain bothersomeness. Conclusions: Zoom-delivered ER had high participant satisfaction and very high engagement. Among adults with chronic pain, this single-session, Zoom-delivered, skills-based pain class resulted in clinically significant improvement across a range of pain-related outcomes that was sustained at 3 months. Web-based delivery of ER could allow greater accessibility of home-based pain treatment and could address the inconveniences and barriers faced by patients when attempting to receive in-person care. Trial Registration: ClinicalTrials.gov NCT04546685; https://clinicaltrials.gov/ct2/show/NCT04546685 UR - https://www.jmir.org/2021/9/e29672 UR - http://dx.doi.org/10.2196/29672 UR - http://www.ncbi.nlm.nih.gov/pubmed/34505832 ID - info:doi/10.2196/29672 ER - TY - JOUR AU - Zengul, Ayse AU - Evans, Eric AU - Hall, Allyson AU - Qu, Haiyan AU - Willig, Amanda AU - Cherrington, Andrea AU - Thirumalai, Mohanraj PY - 2021/9/10 TI - Telehealth Behavioral Intervention for Diabetes Management in Adults With Physical Disabilities: Intervention Fidelity Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e31695 VL - 10 IS - 9 KW - telehealth KW - health coaching KW - artificial intelligence KW - diabetes mellitus KW - intervention fidelity KW - mobile phone N2 - Background: Diabetes mellitus is a major health problem among people with physical disabilities. Health coaching has been proven to be an effective approach in terms of behavioral changes, patient self-efficacy, adherence to treatment, health service use, and health outcomes. Telehealth systems combined with health coaching have the potential to improve the quality of health care by increasing access to services. Treatment fidelity is particularly important for behavior change studies; however, fidelity protocols are inadequately administered and reported in the literature. Objective: The aim of this study is to outline all the intervention fidelity strategies and procedures of a telecoaching intervention?artificial intelligence for diabetes management (AI4DM)?which is a randomized controlled trial to evaluate the feasibility, acceptability, and preliminary efficacy of a telehealth platform in adults with type 2 diabetes and permanent impaired mobility. AI4DM aims to create a web-based disability-inclusive diabetes self-management program. We selected the National Institutes of Health Behavior Change Consortium (NIH BCC) fidelity framework to describe strategies to ensure intervention fidelity in our research. Methods: We have developed fidelity strategies based on the five fidelity domains outlined by the NIH BCC?focusing on study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. The design of the study is grounded in the social cognitive theory and is intended to ensure that both arms would receive the same amount of attention from the intervention. All providers will receive standardized training to deliver consistent health coaching to the participants. The intervention will be delivered through various controlling and monitoring strategies to reduce differences within and between treatment groups. The content and structure of the study are delivered to ensure comprehension and participation among individuals with low health literacy. By constantly reviewing and monitoring participant progress and protocol adherence, we intend to ensure that participants use cognitive and behavioral skills in real-world settings to engage in health behavior. Results: Enrollment for AI4DM will begin in October 2021 and end in October 2022. The results of this study will be reported in late 2022. Conclusions: Developing and using fidelity protocols in behavior change studies is essential to ensure the internal and external validity of interventions. This study incorporates NIH BCC recommendations into an artificial intelligence embedded telecoaching platform for diabetes management designed for people with physical disabilities. The developed fidelity protocol can provide guidance for other researchers conducting telehealth interventions within behavioral health settings to present more consistent and reproducible research. Trial Registration: ClinicalTrials.gov NCT04927377; http://clinicaltrials.gov/ct2/show/NCT04927377. International Registered Report Identifier (IRRID): PRR1-10.2196/31695 UR - https://www.researchprotocols.org/2021/9/e31695 UR - http://dx.doi.org/10.2196/31695 UR - http://www.ncbi.nlm.nih.gov/pubmed/34505835 ID - info:doi/10.2196/31695 ER - TY - JOUR AU - Chen, Hao AU - Li, Xiaomei AU - Gao, Junling AU - Liu, Xiaoxi AU - Mao, Yimeng AU - Wang, Ruru AU - Zheng, Pinpin AU - Xiao, Qianyi AU - Jia, Yingnan AU - Fu, Hua AU - Dai, Junming PY - 2021/9/6 TI - Health Belief Model Perspective on the Control of COVID-19 Vaccine Hesitancy and the Promotion of Vaccination in China: Web-Based Cross-sectional Study JO - J Med Internet Res SP - e29329 VL - 23 IS - 9 KW - COVID-19 pandemic KW - vaccination behavior KW - vaccine hesitancy KW - health belief model N2 - Background: The control of vaccine hesitancy and the promotion of vaccination are key protective measures against COVID-19. Objective: This study assesses the prevalence of vaccine hesitancy and the vaccination rate and examines the association between factors of the health belief model (HBM) and vaccination. Methods: A convenience sample of 2531 valid participants from 31 provinces and autonomous regions of mainland China were enrolled in this online survey study from January 1 to 24, 2021. Multivariable logistic regression was used to identify the associations of the vaccination rate and HBM factors with the prevalence of vaccine hesitancy after other covariates were controlled. Results: The prevalence of vaccine hesitancy was 44.3% (95% CI 42.3%-46.2%), and the vaccination rate was 10.4% (9.2%-11.6%). The factors that directly promoted vaccination behavior were a lack of vaccine hesitancy (odds ratio [OR] 7.75, 95% CI 5.03-11.93), agreement with recommendations from friends or family for vaccination (OR 3.11, 95% CI 1.75-5.52), and absence of perceived barriers to COVID-19 vaccination (OR 0.51, 95% CI 0.35-0.75). The factors that were directly associated with a higher vaccine hesitancy rate were a high level of perceived barriers (OR 1.63, 95% CI 1.36-1.95) and perceived benefits (OR 0.51, 95% CI 0.32-0.79). A mediating effect of self-efficacy, influenced by perceived barriers (standardized structure coefficient [SSC]=?0.71, P<.001), perceived benefits (SSC=0.58, P<.001), agreement with recommendations from authorities (SSC=0.27, P<.001), and agreement with recommendations from friends or family (SSC=0.31, P<.001), was negatively associated with vaccination (SSC=?0.45, P<.001) via vaccine hesitancy (SSC=?0.32, P<.001). Conclusions: It may be possible to increase the vaccination rate by reducing vaccine hesitancy and perceived barriers to vaccination and by encouraging volunteers to advocate for vaccination to their friends and family members. It is also important to reduce vaccine hesitancy by enhancing self-efficacy for vaccination, due to its crucial mediating function. UR - https://www.jmir.org/2021/9/e29329 UR - http://dx.doi.org/10.2196/29329 UR - http://www.ncbi.nlm.nih.gov/pubmed/34280115 ID - info:doi/10.2196/29329 ER - TY - JOUR AU - Meyerhoff, Jonah AU - Liu, Tony AU - Kording, P. Konrad AU - Ungar, H. Lyle AU - Kaiser, M. Susan AU - Karr, J. Chris AU - Mohr, C. David PY - 2021/9/3 TI - Evaluation of Changes in Depression, Anxiety, and Social Anxiety Using Smartphone Sensor Features: Longitudinal Cohort Study JO - J Med Internet Res SP - e22844 VL - 23 IS - 9 KW - mHealth KW - personal sensing KW - digital phenotyping KW - passive sensing KW - ecological momentary assessment KW - depression KW - anxiety KW - digital biomarkers KW - mental health assessment KW - mobile device KW - mobile phone KW - internet technology KW - psychiatric disorders N2 - Background: The assessment of behaviors related to mental health typically relies on self-report data. Networked sensors embedded in smartphones can measure some behaviors objectively and continuously, with no ongoing effort. Objective: This study aims to evaluate whether changes in phone sensor?derived behavioral features were associated with subsequent changes in mental health symptoms. Methods: This longitudinal cohort study examined continuously collected phone sensor data and symptom severity data, collected every 3 weeks, over 16 weeks. The participants were recruited through national research registries. Primary outcomes included depression (8-item Patient Health Questionnaire), generalized anxiety (Generalized Anxiety Disorder 7-item scale), and social anxiety (Social Phobia Inventory) severity. Participants were adults who owned Android smartphones. Participants clustered into 4 groups: multiple comorbidities, depression and generalized anxiety, depression and social anxiety, and minimal symptoms. Results: A total of 282 participants were aged 19-69 years (mean 38.9, SD 11.9 years), and the majority were female (223/282, 79.1%) and White participants (226/282, 80.1%). Among the multiple comorbidities group, depression changes were preceded by changes in GPS features (Time: r=?0.23, P=.02; Locations: r=?0.36, P<.001), exercise duration (r=0.39; P=.03) and use of active apps (r=?0.31; P<.001). Among the depression and anxiety groups, changes in depression were preceded by changes in GPS features for Locations (r=?0.20; P=.03) and Transitions (r=?0.21; P=.03). Depression changes were not related to subsequent sensor-derived features. The minimal symptoms group showed no significant relationships. There were no associations between sensor-based features and anxiety and minimal associations between sensor-based features and social anxiety. Conclusions: Changes in sensor-derived behavioral features are associated with subsequent depression changes, but not vice versa, suggesting a directional relationship in which changes in sensed behaviors are associated with subsequent changes in symptoms. UR - https://www.jmir.org/2021/9/e22844 UR - http://dx.doi.org/10.2196/22844 UR - http://www.ncbi.nlm.nih.gov/pubmed/34477562 ID - info:doi/10.2196/22844 ER - TY - JOUR AU - van der Windt, Melissa AU - Schoenmakers, Sam AU - Willemsen, Sten AU - van Rossem, Lenie AU - Steegers-Theunissen, Régine PY - 2021/9/3 TI - Optimizing the Periconception Lifestyle of Women With Overweight Using a Blended Personalized Care Intervention Combining eHealth and Face-to-face Counseling (eFUSE): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e28600 VL - 10 IS - 9 KW - eHealth KW - periconception period KW - lifestyle intervention KW - maternal and child health KW - pregnancy KW - birth outcomes KW - healthy lifestyle KW - psychotherapy KW - obesity KW - randomized controlled trial KW - behavior change N2 - Background: Maternal overweight has a substantial impact on reproductive, maternal, pregnancy, and neonatal outcomes with long-term and transgenerational health consequences. Interventions that aim to optimize periconception maternal lifestyle can improve maternal and fetal health during pregnancy and throughout the life course. However, it remains difficult to change and adopt adequate lifestyle behaviors. We hypothesize that additional psychological therapy targeting cognitive and affective factors substantially contribute to the effectiveness of these interventions. Objective: The proposed study aims to examine the feasibility and effectiveness of a blended personalized periconception lifestyle care intervention with additional psychological therapy aimed at women with a BMI?25 and who are contemplating pregnancy or are already pregnant (?12 weeks) in reducing inadequate lifestyle behaviors and improving early and late pregnancy outcome. Methods: The eHealth and Face-to-face Counseling (eFUSE) study follows a single-center two-arm randomized controlled trial design at the Erasmus MC, University Medical Center, with a multicenter regional referral. The female patients with overweight (BMI?25), together with their male partner, will be stratified by pregnancy status (preconception vs pregnant) and randomized to receive either the blended personalized periconception lifestyle care intervention with additional psychological therapy (n=313) or usual care (n=313). The primary outcome is a change in the lifestyle risk score (between baseline and 24 weeks) between the randomization arms (difference in differences). Secondary outcomes include measurements defined as most relevant by the International Consortium for Health Outcomes Measurement, including behavioral determinants, patient satisfaction, provider feasibility, and maternal pregnancy and neonatal complications. Results: The study will be open for recruitment from Fall 2021 onward. Data collection is expected to be completed by the beginning of 2023, and the results are expected to be published by Fall 2023. Conclusions: This study will evaluate the feasibility and effectiveness of a blended periconception lifestyle intervention with additional psychological therapy, aimed at women with a BMI?25. Positive results of this innovative care approach will be used for implementation in routine medical care of all women with overweight, with the ultimate aim to improve clinical outcomes of these high-risk pregnancies. Trial Registration: Netherlands Trial Register NL9264; https://www.trialregister.nl/trial/9264 International Registered Report Identifier (IRRID): PRR1-10.2196/28600 UR - https://www.researchprotocols.org/2021/9/e28600 UR - http://dx.doi.org/10.2196/28600 UR - http://www.ncbi.nlm.nih.gov/pubmed/34477561 ID - info:doi/10.2196/28600 ER - TY - JOUR AU - Anderson, Pamela AU - Coyle, Karin AU - Guinosso, Stephanie AU - Ferrand, L. John AU - Owora, Arthur AU - Houghton, F. Rebecca AU - Walsh-Buhi, Eric PY - 2021/9/1 TI - Promoting Adolescent Healthy Relationships (The About Us Program): Protocol for a Randomized Clinical Trial JO - JMIR Res Protoc SP - e30499 VL - 10 IS - 9 KW - adolescents KW - youth KW - teens KW - healthy relationships KW - unintended pregnancy KW - teen pregnancy KW - sexually transmitted infections KW - sexually transmitted diseases KW - sexual health education KW - school-based health center KW - randomized controlled trial N2 - Background: Romantic relationships play a critical role in adolescent development, and by middle adolescence, most young people have been involved in at least one romantic relationship, a context in which most sexual interactions occur. Research suggests adolescents lack positive models and skills related to building healthy relationships. Objective: This project aims to test the impact of an innovative healthy relationships intervention, called About Us, implemented in school-based health centers (SBHCs) in California in a randomized controlled trial. Methods: About Us is being tested using a 7-site, 2-group, parallel randomized controlled trial with a treatment versus control allocation ratio of 3:2 to assess the impact of the intervention relative to the standard of care among adolescents aged 14 to 18 years. Adolescents with active parental consent provide study assent at each of the 3 survey time points: baseline, 3 months postintervention, and 9 months postintervention. A stratified randomization procedure was used to ensure balance in key covariates and screening criteria across intervention groups. Through benchmark intent-to-treat analyses, we will examine the primary outcome of this study?the impact of About Us relative to the standard of care 9 months following the end of the intervention on the prevalence of vaginal or anal sex without condoms in the past 3 months. The secondary outcomes are four-fold: what is the impact of About Us relative to the standard of care 3 and 9 months following the end of the intervention, on (1) the prevalence of abstinence from vaginal or anal sex in the past 3 months, (2) composite scores of relationship communication and positive conflict resolution among participants involved in a relationship at baseline, (3) the prevalence of SBHC service use or information receipt in the past 3 months, and (4) composite scores of condom use intentions and attitudes regarding condoms and other birth control? Additionally, as part of our sensitivity analyses, two additional analyses will be implemented: modified intent-to-treat and complete case analysis. Results: This project (ClinicalTrials.gov #NCT03736876) was funded in 2016 through the Family Youth Services Bureau as part of the Personal Responsibility Education Innovative Strategies program. Baseline data collection took place between February 2018 and March 2020, yielding a total of 5 cohorts and 533 study participants: 316 assigned to treatment and 217 assigned to control. Ongoing follow-up data collection continued through May 2021. Conclusions: About Us draws on developmental science to create a contextually and developmentally relevant program that addresses motivation and emotional influences in sexual decision-making. The intervention was designed for implementation within SBHCs, an understudied venue for relationship and sexual health promotion interventions. Unfortunately, COVID-19 pandemic restrictions led to school closures, interrupting ongoing programming, and in-person follow-up data collection, which has affected study attrition. Trial Registration: ClinicalTrials.gov NCT03736876; https://clinicaltrials.gov/ct2/show/NCT03736876 International Registered Report Identifier (IRRID): DERR1-10.2196/30499 UR - https://www.researchprotocols.org/2021/9/e30499 UR - http://dx.doi.org/10.2196/30499 UR - http://www.ncbi.nlm.nih.gov/pubmed/34468330 ID - info:doi/10.2196/30499 ER - TY - JOUR AU - Gomes, Antunes Luís AU - Gregório, João Maria AU - Iakovleva, A. Tatiana AU - Sousa, de Rute Dinis AU - Bessant, John AU - Oliveira, Pedro AU - Branco, C. Jaime AU - Canhão, Helena AU - Rodrigues, Maria Ana PY - 2021/8/31 TI - A Home-Based eHealth Intervention for an Older Adult Population With Food Insecurity: Feasibility and Acceptability Study JO - J Med Internet Res SP - e26871 VL - 23 IS - 8 KW - food insecurity KW - eHealth KW - television app KW - elderly people KW - vulnerable population KW - cognitive behavioral strategy KW - health innovation KW - multidisciplinary program N2 - Background: Food insecurity is a global public health challenge, affecting predominately the most vulnerable people in society, including older adults. For this population, eHealth interventions represent an opportunity for promoting healthy lifestyle habits, thus mitigating the consequences of food insecurity. However, before their widespread dissemination, it is essential to evaluate the feasibility and acceptability of these interventions among end users. Objective: This study aims to explore the feasibility and acceptability of a home-based eHealth intervention focused on improving dietary and physical activity through an interactive television (TV) app among older adults with food insecurity. Methods: A pilot noncontrolled quasi-experimental study was designed with baseline and 3-month follow-up assessments. Older adult participants with food insecurity were recruited from 17 primary health care centers in Portugal. A home-based intervention program using an interactive TV app aimed at promoting healthy lifestyle behaviors was implemented over 12 weeks. Primary outcomes were feasibility (self-reported use and interest in eHealth) and acceptability (affective attitude, burden, ethicality, perceived effectiveness, and self-efficacy), which were evaluated using a structured questionnaire with a 7-point Likert scale. Secondary outcomes were changes in food insecurity (Household Food Insecurity Scale), quality of life (European Quality of Life Questionnaire with five dimensions and three levels and Functional Assessment of Chronic Illness Therapy-Fatigue), physical function (Health Assessment Questionnaire, Elderly Mobility Scale, grip strength, and regularity of exercise), and nutritional status (adherence to the Mediterranean diet). Results: A sample of 31 older adult individuals with food insecurity was enrolled in the 12-week intervention program with no dropouts. A total of 10 participants self-reported low use of the TV app. After the intervention, participants were significantly more interested in using eHealth to improve food insecurity (baseline median 1.0, IQR 3.0; 3-month median 5.0, IQR 5.0; P=.01) and for other purposes (baseline median 1.0, IQR 2.0; 3-month median 6.0, IQR 2.0; P=.03). High levels of acceptability were found both before and after (median range 7.0-7.0, IQR 2.0-0.0 and 5.0-7.0, IQR 2.0-2.0, respectively) the intervention, with no significant changes for most constructs. Clinically, there was a reduction of 40% in food insecurity (P=.001), decreased fatigue (mean ?3.82, SD 8.27; P=.02), and improved physical function (Health Assessment Questionnaire: mean ?0.22, SD 0.38; P=.01; Elderly Mobility Scale: mean ?1.50, SD 1.08; P=.01; regularity of exercise: baseline 10/31, 32%; 3 months 18/31, 58%; P=.02). No differences were found for the European Quality of Life Questionnaire with five dimensions and three levels, grip strength, or adherence to the Mediterranean diet. Conclusions: The home-based eHealth intervention was feasible and highly acceptable by participants, thus supporting a future full-scale trial. The intervention program not only reduced the proportion of older adults with food insecurity but also improved participants? fatigue and physical function. International Registered Report Identifier (IRRID): RR2-10.2196/resprot.6626 UR - https://www.jmir.org/2021/8/e26871 UR - http://dx.doi.org/10.2196/26871 UR - http://www.ncbi.nlm.nih.gov/pubmed/34463638 ID - info:doi/10.2196/26871 ER - TY - JOUR AU - Swanston, Emma AU - Pulman, Andy AU - Dogan, Huseyin AU - Murphy, Jane AU - Bitters, Fiona PY - 2021/8/31 TI - Scoping the Need for a Tailored mHealth App to Improve Health and Well-being Behavioral Transformation in the Police: Exploring the Views of UK Police Workers via Web-Based Surveys and Client Meetings JO - JMIR Form Res SP - e28075 VL - 5 IS - 8 KW - nutrition KW - food KW - behavior change KW - mobile health KW - police KW - lifestyle management KW - well-being KW - mobile phone N2 - Background: Police officers often work long, unsocial hours in a highly pressurized environment and may experience difficulties in managing their health and well-being. Their jobs can be highly stressful and feature unusual working hours and multiple shift patterns. When considering the policing environment of 2021, many roles that were previously the domain of warranted officers are now being carried out by nonwarranted police staff equivalents. These police staff roles are relatively new to policing but put staff under some of the same stresses as police officers. A UK police force requested help to investigate technologies that could be used to improve health and well-being and research how these technologies could be used to measure and track health behavior change. Objective: Historical research studies need to be appraised in light of this new policing environment, and new research also needs to include this shift in dynamics when considering aspects of policing, including their health and well-being. This study explores police officer and staff attitudes toward and their use of existing health-related technology, highlights existing practices, and gathers views about how technology could be used more effectively. Methods: A web-based survey was completed by police officers and staff (N=213) during the initial period of the UK lockdown in 2020. The survey was designed to find the solutions that participants used outside of those supplied by their employer, identify issues or problems, and find what they would like a hypothetical app to focus on. Additional requirements data were captured through client meetings, including discussions concerning previously attempted solutions and those currently in place. Thematic analysis was undertaken to identify the key themes. Results: Attitudes toward and uses of existing health-related technology were captured, and existing practices were highlighted. Participants identified a need for an app to consider that a user was on shift?an important point, as many issues and problems with elements of their health and well-being involved shift work. Data also highlighted that a multifunctional tool would be more beneficial to participants than focusing on just 1 element. The key features and four domains were identified for app coverage. The prioritized order of importance of the four domains was activity, food and diet, sleep, and fluid intake. Conclusions: For police officers and staff, research data suggest that there is a previously unidentified requirement for a mobile app that could provide an easily accessible platform for them to use, regardless of the current location; one that could provide guidelines on diet, lifestyle habits, and health behavior to help the user make informed decisions to assist in personalized behavior change. Notably, one which is multifunctional and which also aligns effectively with the irregular shift patterns of its users. UR - https://formative.jmir.org/2021/8/e28075 UR - http://dx.doi.org/10.2196/28075 UR - http://www.ncbi.nlm.nih.gov/pubmed/34463625 ID - info:doi/10.2196/28075 ER - TY - JOUR AU - MacPherson, Megan AU - Cranston, Kaela AU - Johnston, Cara AU - Locke, Sean AU - Jung, E. Mary PY - 2021/8/27 TI - Evaluation and Refinement of a Bank of SMS Text Messages to Promote Behavior Change Adherence Following a Diabetes Prevention Program: Survey Study JO - JMIR Form Res SP - e28163 VL - 5 IS - 8 KW - text messaging KW - prediabetic state KW - telemedicine KW - telecommunications KW - exercise KW - diet KW - preventive medicine KW - mHealth KW - intervention development KW - behavior change KW - mobile phone N2 - Background: SMS text messaging is a low-cost and far-reaching modality that can be used to augment existing diabetes prevention programs and improve long-term diet and exercise behavior change adherence. To date, little research has been published regarding the process of SMS text message content development. Understanding how interventions are developed is necessary to evaluate their evidence base and to guide the implementation of effective and scalable mobile health interventions in public health initiatives and in future research. Objective: This study aims to describe the development and refinement of a bank of SMS text messages targeting diet and exercise behavior change to be implemented following a diabetes prevention program. Methods: A bank of 124 theory-based SMS text messages was developed using the Behaviour Change Wheel and linked to active intervention components (behavior change techniques [BCTs]). The Behaviour Change Wheel is a theory-based framework that provides structure to intervention development and can guide the use of evidence-based practices in behavior change interventions. Once the messages were written, 18 individuals who either participated in a diabetes prevention program or were a diabetes prevention coach evaluated the messages on their clarity, utility, and relevance via survey using a 5-point Likert scale. Messages were refined according to participant feedback and recoded to obtain an accurate representation of BCTs in the final bank. Results: 76/124 (61.3%) messages were edited, 4/124 (3.2%) were added, and 8/124 (6.5%) were removed based on participant scores and feedback. Of the edited messages, 43/76 (57%) received minor word choice and grammar alterations while retaining their original BCT code; the remaining 43% (33/76, plus the 4 newly written messages) were recoded by a reviewer trained in BCT identification. Conclusions: This study outlines the process used to develop and refine a bank of SMS text messages to be implemented following a diabetes prevention program. This resulted in a bank of 120 theory-based, user-informed SMS text messages that were overall deemed clear, useful, and relevant by both individuals who will be receiving and delivering them. This formative development process can be used as a blueprint in future SMS text messaging development to ensure that message content is representative of the evidence base and is also grounded in theory and evaluated by key knowledge users. UR - https://formative.jmir.org/2021/8/e28163 UR - http://dx.doi.org/10.2196/28163 UR - http://www.ncbi.nlm.nih.gov/pubmed/34448713 ID - info:doi/10.2196/28163 ER - TY - JOUR AU - Swain, Dharitri AU - Begum, Jasmina AU - Parida, Prangnan Swayam PY - 2021/8/16 TI - Effect of Preconception Care Intervention on Maternal Nutritional Status and Birth Outcome in a Low-Resource Setting: Proposal for a Nonrandomized Controlled Trial JO - JMIR Res Protoc SP - e28148 VL - 10 IS - 8 KW - preconception care KW - maternal nutritional status KW - birth outcome KW - paternal preconception health KW - childbirth KW - birth outcomes KW - maternal and child health KW - maternal health KW - maternal and child nutrition KW - health education KW - pediatrics N2 - Background: The provision of preconception care approaches such as maternal assessments and education on healthy lifestyle (including physical activity, nutrition, and dietary supplements such as folic acid), general and sexual health, avoidance of high-risk behavior, and immunizations has been shown to identify and reduce the risk of adverse birth outcomes through appropriate management and preventive measures. Objective: The goal of the study is to determine the effect of an integrated preconception care intervention on delivery outcomes, which is a novel challenge for lowering unfavorable birth outcomes in India?s low-resource setting. The main objectives are to investigate the relationship of birth outcomes to both maternal and paternal preconception health and determine the effect of preconception care intervention on improvement of maternal nutritional status and reduction of the risk of adverse birth outcomes such as prematurity, low birth weight, and maternal and neonatal complications. Methods: A nonrandomized controlled trial design will be used for comparing 2 groups: preconception care with a standard maternal health care (MHC) program and an integrated MHC program (without preconception care). Two rural field areas of Khordha district, Odisha, will be selected for conducting the study. The study will enroll 782 married women between the ages of 18 and 35 years with their spouses, with 391 women in each group. The couples will receive preconception care based on their health circumstances, and they will be followed up at 3-month intervals before pregnancy. Following pregnancy, they will be followed up for 8 prenatal monitoring and care visits as well as 6 weeks after delivery as part of the standard MCH program. The preconception care intervention package includes couples counseling, contraceptive education and distribution, sex education, lifestyle modification, and nutritional supplementation of iron and folic acid, along with multivitamins if needed. Results: The proposal was approved by the institutional ethical committee for conducting the study in June 2020 (Ref No: T/EMF/Nursing/20/6). Participants were enrolled in phase 1 in April 2021, phase 2 of offering preconception services will begin in August 2021, and study outcomes will be measured from 2023 to 2024. Conclusions: Through preconception care and counseling, the eligible couples will recognize, embrace, and implement the actions to improve their preconception health. Finally, it is expected that maternal and paternal health will have a significant impact on enhancing maternal nutritional status and birth outcomes. Trial Registration: Clinical Trials Registry?India CTRI/2021/04/032836; http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=48239&EncHid=&userName=CTRI/2021/04/032836 International Registered Report Identifier (IRRID): PRR1-10.2196/28148 UR - https://www.researchprotocols.org/2021/8/e28148 UR - http://dx.doi.org/10.2196/28148 UR - http://www.ncbi.nlm.nih.gov/pubmed/34398798 ID - info:doi/10.2196/28148 ER - TY - JOUR AU - Albers, Eline AU - Nijhof, N. Linde AU - Berkelbach van der Sprenkel, E. Emma AU - van de Putte, M. Elise AU - Nijhof, L. Sanne AU - Knoop, Hans PY - 2021/8/13 TI - Effectiveness of Internet-Based Cognitive Behavior Therapy (Fatigue in Teenagers on the Internet) for Adolescents With Chronic Fatigue Syndrome in Routine Clinical Care: Observational Study JO - J Med Internet Res SP - e24839 VL - 23 IS - 8 KW - Fatigue in Teenagers on the Internet KW - cognitive behavior therapy KW - fatigue KW - chronic fatigue syndrome KW - adolescents KW - implementation N2 - Background: Internet-based cognitive behavior therapy (I-CBT) for adolescents with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has been shown to be effective in a randomized controlled trial (RCT; Fatigue in Teenagers on the Internet [FITNET]). FITNET can cause a significant reduction in fatigue and disability. Objective: We aimed to investigate whether FITNET treatment implemented in routine clinical care (IMP-FITNET) was as effective, using the outcomes of the FITNET RCT as the benchmark. Methods: Outcomes of CFS/ME adolescents who started IMP-FITNET between October 2012 and March 2018 as part of routine clinical care were compared to the outcomes in the FITNET RCT. The primary outcome was fatigue severity assessed posttreatment. The secondary outcomes were self-reported physical functioning, school attendance, and recovery rates. Clinically relevant deterioration was assessed posttreatment, and for this outcome, a face-to-face CBT trial was used as the benchmark. The attitude of therapists toward the usability of IMP-FITNET was assessed through semistructured interviews. The number of face-to-face consultations during IMP-FITNET was registered. Results: Of the 384 referred adolescents with CFS/ME, 244 (63.5%) started IMP-FITNET, 84 (21.9%) started face-to-face CBT, and 56 (14.6%) were not eligible for CBT. Posttreatment scores for fatigue severity (mean 26.0, SD 13.8), physical functioning (mean 88.2, SD 15.0), and full school attendance (mean 84.3, SD 26.5) fell within the 95% CIs of the FITNET RCT. Deterioration of fatigue and physical functioning after IMP-FITNET was observed at rates of 1.2% (n=3) and 4.1% (n=10), respectively, which is comparable to a waiting list condition (fatigue: 1.2% vs 5.7%, ?21=3.5, P=.06; physical functioning: 4.1% vs 11.4%, ?21=3.3, P=.07). Moreover, 41 (16.8%) IMP-FITNET patients made use of face-to-face consultations. Conclusions: IMP-FITNET is an effective and safe treatment for adolescents with CFS/ME in routine clinical care. UR - https://www.jmir.org/2021/8/e24839 UR - http://dx.doi.org/10.2196/24839 UR - http://www.ncbi.nlm.nih.gov/pubmed/34397389 ID - info:doi/10.2196/24839 ER - TY - JOUR AU - Arietaleanizbeaskoa, Soledad Maria AU - Gil Rey, Erreka AU - Mendizabal Gallastegui, Nere AU - García-Álvarez, Arturo AU - De La Fuente, Ibon AU - Domínguez-Martinez, Silvia AU - Pablo, Susana AU - Coca, Aitor AU - Gutiérrez Santamaría, Borja AU - Grandes, Gonzalo PY - 2021/8/9 TI - Implementing Exercise in Standard Cancer Care (Bizi Orain Hybrid Exercise Program): Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e24835 VL - 10 IS - 8 KW - patients with cancer KW - physical activity KW - primary care KW - behavioral change KW - randomized controlled trial KW - overall survival N2 - Background: Despite the established benefits of regular exercise for patients with cancer to counteract the deleterious effects of the disease itself and treatment-related adverse effects, most of them do not engage in sufficient levels of physical activity and there is a paucity of data on the integration of efficacious exercise programs that are accessible and generalizable to a large proportion of patients with cancer into routine cancer care. Objective: We intend to examine the effects attributable to the implementation of a community-based exercise program on cardiorespiratory functional capacity and quality of life for patients with cancer. Methods: This will be a hybrid study. In the first experimental phase, patients diagnosed with any type of cancer will be randomized into two parallel groups. One group immediately performs Bizi Orain, a 3-month supervised exercise program (3 times a week), in addition to behavioral counseling in a primary health care setting; the other is a reference group that starts the exercise program 3 months later (delayed treatment). In the second observational phase, the entire cohort of participants will be followed-up for 5 years. Any person diagnosed with cancer in the previous 2 years is eligible for the program. The program evaluation involves the uptake, safety, adherence, and effectiveness assessed after completion of the program and with follow-ups at 3, 6, 12, 24, 36, 48, and 60 months. The primary outcomes of the experimental study, to be compared between groups, are improved physical function and quality of life, whereas overall survival is the main objective of the prospective study. To analyze the association between changes in physical activity levels and overall survival, longitudinal mixed-effects models will be used for repeated follow-up measures. Results: A total of 265 patients have been enrolled into the study since January 2019, with 42 patients from the hematology service and 223 from the oncology service. Conclusions: Bizi Orain is the first population-based exercise program in Spain that will offer more insight into the implementation of feasible, generalizable, and sustainable supportive care services involving structured exercise to extend survival of patients with cancer, improve their physical function and quality of life, and reverse the adverse effects of their disease and related treatments, thereby reducing the clinical burden. Trial Registration: ClinicalTrials.gov NCT03819595; http://clinicaltrials.gov/ct2/show/NCT03819595 International Registered Report Identifier (IRRID): DERR1-10.2196/24835 UR - https://www.researchprotocols.org/2021/8/e24835 UR - http://dx.doi.org/10.2196/24835 UR - http://www.ncbi.nlm.nih.gov/pubmed/34383676 ID - info:doi/10.2196/24835 ER - TY - JOUR AU - Derksen, E. Marloes AU - Jaspers, WM Monique AU - van Strijp, Sander AU - Fransen, P. Mirjam PY - 2021/8/4 TI - Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study JO - JMIR Form Res SP - e24112 VL - 5 IS - 8 KW - think aloud KW - heuristic evaluation KW - usability KW - mHealth KW - game elements KW - smoking prevention KW - user-centered design KW - mobile phone N2 - Background: Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation. Objective: This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation. Methods: Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society. Results: Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon). Conclusions: The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing. UR - https://formative.jmir.org/2021/8/e24112 UR - http://dx.doi.org/10.2196/24112 UR - http://www.ncbi.nlm.nih.gov/pubmed/34346895 ID - info:doi/10.2196/24112 ER - TY - JOUR AU - Holdnack, A. James AU - Brennan, Flatley Patricia PY - 2021/8/4 TI - Usability and Effectiveness of Immersive Virtual Grocery Shopping for Assessing Cognitive Fatigue in Healthy Controls: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e28073 VL - 10 IS - 8 KW - cognitive fatigue KW - immersive VR KW - user experience KW - virtual grocery shopping KW - instrumental activity of daily living N2 - Background: Cognitive fatigue (CF) is a human response to stimulation and stress and is a common comorbidity in many medical conditions that can result in serious consequences; however, studying CF under controlled conditions is difficult. Immersive virtual reality provides an experimental environment that enables the precise measurement of the response of an individual to complex stimuli in a controlled environment. Objective: We aim to examine the development of an immersive virtual shopping experience to measure subjective and objective indicators of CF induced by instrumental activities of daily living. Methods: We will recruit 84 healthy participants (aged 18-75 years) for a 2-phase study. Phase 1 is a user experience study for testing the software functionality, user interface, and realism of the virtual shopping environment. Phase 2 uses a 3-arm randomized controlled trial to determine the effect that the immersive environment has on fatigue. Participants will be randomized into 1 of 3 conditions exploring fatigue response during a typical human activity (grocery shopping). The level of cognitive and emotional challenges will change during each activity. The primary outcome of phase 1 is the experience of user interface difficulties. The primary outcome of phase 2 is self-reported CF. The core secondary phase 2 outcomes include subjective cognitive load, change in task performance behavior, and eye tracking. Phase 2 uses within-subject repeated measures analysis of variance to compare pre- and postfatigue measures under 3 conditions (control, cognitive challenge, and emotional challenge). Results: This study was approved by the scientific review committee of the National Institute of Nursing Research and was identified as an exempt study by the institutional review board of the National Institutes of Health. Data collection will begin in spring 2021. Conclusions: Immersive virtual reality may be a useful research platform for simulating the induction of CF associated with the cognitive and emotional challenges of instrumental activities of daily living. Trial Registration: ClinicalTrials.gov NCT04883359; http://clinicaltrials.gov/ct2/show/NCT04883359 International Registered Report Identifier (IRRID): PRR1-10.2196/28073 UR - https://www.researchprotocols.org/2021/8/e28073 UR - http://dx.doi.org/10.2196/28073 UR - http://www.ncbi.nlm.nih.gov/pubmed/34346898 ID - info:doi/10.2196/28073 ER - TY - JOUR AU - Martinengo, Laura AU - Stona, Anne-Claire AU - Griva, Konstadina AU - Dazzan, Paola AU - Pariante, Maria Carmine AU - von Wangenheim, Florian AU - Car, Josip PY - 2021/7/30 TI - Self-guided Cognitive Behavioral Therapy Apps for Depression: Systematic Assessment of Features, Functionality, and Congruence With Evidence JO - J Med Internet Res SP - e27619 VL - 23 IS - 7 KW - cognitive behavioral therapy KW - CBT KW - depression KW - mobile applications KW - apps KW - telemedicine KW - mHealth KW - self-guided CBT-based apps KW - self-management KW - mobile phone N2 - Background: Mental health disorders affect 1 in 10 people globally, of whom approximately 300 million are affected by depression. At least half of the people affected by depression remain untreated. Although cognitive behavioral therapy (CBT) is an effective treatment, access to mental health specialists, habitually challenging, has worsened because of the COVID-19 pandemic. Internet-based CBT is an effective and feasible strategy to increase access to treatment for people with depression. Mental health apps may further assist in facilitating self-management for people affected by depression; however, accessing the correct app may be cumbersome given the large number and wide variety of apps offered by public app marketplaces. Objective: This study aims to systematically assess the features, functionality, data security, and congruence with evidence of self-guided CBT-based apps targeting users affected by depression that are available in major app stores. Methods: We conducted a systematic assessment of self-guided CBT-based apps available in Google Play and the Apple App Store. Apps launched or updated since August 2018 were identified through a systematic search in the 42matters database using CBT-related terms. Apps meeting the inclusion criteria were downloaded and assessed using a Samsung Galaxy J7 Pro (Android 9) and iPhone 7 (iOS 13.3.1). Apps were appraised using a 182-question checklist developed by the research team, assessing their general characteristics, technical aspects and quality assurance, and CBT-related features, including 6 evidence-based CBT techniques (ie, psychoeducation, behavioral activation, cognitive restructuring, problem solving, relaxation, and exposure for comorbid anxiety) as informed by a CBT manual, CBT competence framework, and a literature review of internet-based CBT clinical trial protocols. The results were reported as a narrative review using descriptive statistics. Results: The initial search yielded 3006 apps, of which 98 met the inclusion criteria and were systematically assessed. There were 20 well-being apps; 65 mental health apps, targeting two or more common mental health disorders, including depression; and 13 depression apps. A total of 28 apps offered at least four evidence-based CBT techniques, particularly depression apps. Cognitive restructuring was the most common technique, offered by 79% (77/98) of the apps. Only one-third of the apps offered suicide risk management resources, whereas 17% (17/98) of the apps offered COVID-19?related information. Although most apps included a privacy policy, only a third of the apps presented it before account creation. In total, 82% (74/90) of privacy policies stated sharing data with third-party service providers. Half of the app development teams included academic institutions or health care providers. Conclusions: Only a few self-guided CBT-based apps offer comprehensive CBT programs or suicide risk management resources. Sharing of users? data is widespread, highlighting shortcomings in health app market governance. To fulfill their potential, self-guided CBT-based apps should follow evidence-based clinical guidelines, be patient centered, and enhance users? data security. UR - https://www.jmir.org/2021/7/e27619 UR - http://dx.doi.org/10.2196/27619 UR - http://www.ncbi.nlm.nih.gov/pubmed/34328431 ID - info:doi/10.2196/27619 ER - TY - JOUR AU - Vasiloglou, F. Maria AU - Christodoulidis, Stergios AU - Reber, Emilie AU - Stathopoulou, Thomai AU - Lu, Ya AU - Stanga, Zeno AU - Mougiakakou, Stavroula PY - 2021/7/30 TI - Perspectives and Preferences of Adult Smartphone Users Regarding Nutrition and Diet Apps: Web-Based Survey Study JO - JMIR Mhealth Uhealth SP - e27885 VL - 9 IS - 7 KW - dietary assessment KW - end-users KW - mHealth KW - mobile apps KW - smartphone KW - survey KW - apps KW - nutrition KW - diet KW - mobile health KW - users KW - behavior KW - behavior change N2 - Background: Digital technologies have evolved dramatically in recent years, finding applications in a variety of aspects of everyday life. Smartphones and mobile apps are being used for a steadily increasing number of tasks, including health monitoring. A large number of nutrition and diet apps are available, and some of them are very popular in terms of user downloads, highlighting a trend toward diet monitoring and assessment. Objective: We sought to explore the perspectives of end users on the features, current use, and acceptance of nutrition and diet mHealth apps with a survey. We expect that this study can provide user insights to assist researchers and developers in achieving innovative dietary assessments. Methods: A multidisciplinary team designed and compiled the survey. Before its release, it was pilot-tested by 18 end users. A 19-question survey was finally developed and was translated into six languages: English, German, French, Spanish, Italian, and Greek. The participants were mainly recruited via social media platforms and mailing lists of universities, university hospitals, and patient associations. Results: A total of 2382 respondents (1891 female, 79.4%; 474 male, 19.9%; and 17 neither, 0.7%) with a mean age of 27.2 years (SD 8.5) completed the survey. Approximately half of the participants (1227/2382, 51.5%) had used a nutrition and diet app. The primary criteria for selecting such an app were ease of use (1570/2382, 65.9%), free cost (1413/2382, 59.3%), and ability to produce automatic readings of caloric content (1231/2382, 51.7%) and macronutrient content (1117/2382, 46.9%) (ie, food type and portion size are estimated by the system without any contribution from the user). An app was less likely to be selected if it incorrectly estimated portion size, calories, or nutrient content (798/2382, 33.5%). Other important limitations included the use of a database that does not include local foods (655/2382, 27.5%) or that may omit major foods (977/2382, 41%). Conclusions: This comprehensive study in a mostly European population assessed the preferences and perspectives of potential nutrition and diet app users. Understanding user needs will benefit researchers who develop tools for innovative dietary assessment as well as those who assist research on behavioral changes related to nutrition. UR - https://mhealth.jmir.org/2021/7/e27885 UR - http://dx.doi.org/10.2196/27885 UR - http://www.ncbi.nlm.nih.gov/pubmed/34328425 ID - info:doi/10.2196/27885 ER - TY - JOUR AU - Pettersson, Beatrice AU - Janols, Rebecka AU - Wiklund, Maria AU - Lundin-Olsson, Lillemor AU - Sandlund, Marlene PY - 2021/7/30 TI - Older Adults? Experiences of Behavior Change Support in a Digital Fall Prevention Exercise Program: Qualitative Study Framed by the Self-determination Theory JO - J Med Internet Res SP - e26235 VL - 23 IS - 7 KW - accidental falls KW - aged KW - exercise KW - qualitative research KW - eHealth KW - self-management KW - fall prevention KW - behavior change KW - self-determination theory KW - classification of motivation and behavior change techniques N2 - Background: Exercise is an effective intervention to prevent falls in older adults; however, long-term adherence is often poor. To increase adherence, additional support for behavior change has been advocated. However, consistency in the reporting of interventions using behavior change techniques is lacking. Recently, a classification system has been developed to increase consistency in studies using behavior change techniques within the self-determination theory. Objective: This study aimed to explore expressions of self-determination among community-dwelling older adults using a self-managed digital fall prevention exercise program comprising behavior change support (the Safe Step program), which was developed in co-creation with intended users. Methods: The qualitative study design was based on open-ended responses to questionnaires, and individual and focus group interviews. A deductive qualitative content analysis was applied using the classification system of motivation and behavior change techniques as an analytical matrix, followed by an inductive analysis. Twenty-five participants took part in a feasibility study and exercised in their homes with the Safe Step program for 4 months. The exercise program was available on computers,smartphones, and tablets, and was fully self-managed. Results: In the deductive analysis, expressions of support were demonstrated for all three basic human psychological needs, namely, autonomy, competence, and relatedness. These expressions were related to 11 of the 21 motivation and behavior change techniques in the classification system. The inductive analysis indicated that autonomy (to be in control) was valued and enabled individual adaptations according to different rationales for realizing exercise goals. However, the experience of autonomy was also two-sided and depended on the participants? competence in exercise and the use of technology. The clarity of the program and exercise videos was seen as key for support in performance and competent choices. Although augmented techniques for social support were requested, support through relatedness was found within the program. Conclusions: In this study, the Safe Step program supported the establishment of new exercise routines, as well as the three basic human psychological needs, with autonomy and competence being expressed as central in this context. Based on the participants? experiences, a proposed addition to the classification system used as an analytical matrix has been presented. Trial Registration: ClinicalTrials.gov NCT02916849; https://clinicaltrials.gov/ct2/show/NCT02916849 UR - https://www.jmir.org/2021/7/e26235 UR - http://dx.doi.org/10.2196/26235 UR - http://www.ncbi.nlm.nih.gov/pubmed/34328438 ID - info:doi/10.2196/26235 ER - TY - JOUR AU - Nuijten, Yannic Raoul Ceasar AU - Van Gorp, Pieter AU - Borghouts, Tom AU - Le Blanc, Pascale AU - Van den Berg, Pauline AU - Kemperman, Astrid AU - Hadian, Ehsan AU - Simons, Monique PY - 2021/7/29 TI - Preadolescent Students? Engagement With an mHealth Intervention Fostering Social Comparison for Health Behavior Change: Crossover Experimental Study JO - J Med Internet Res SP - e21202 VL - 23 IS - 7 KW - mHealth KW - health promotion KW - social comparison KW - competitiveness KW - collaboration KW - gamification KW - preadolescents KW - high school students N2 - Background: Contemporary mobile health (mHealth) interventions use various behavior change techniques to promote healthier lifestyles. Social comparison is one of the techniques that is consensually agreed to be effective in engaging the general population in mHealth interventions. However, it is unclear how this strategy can be best used to engage preadolescents. Nevertheless, this strategy has great potential for this target audience, as they are particularly developing their social skills. Objective: This study aims to evaluate how social comparison drives preadolescents? engagement with an mHealth app. Methods: We designed a 12-week crossover experiment in which we studied 3 approaches to implementing behavior change via social comparison. This study was hosted in a school environment to leverage naturally existing social structures among preadolescents. During the experiment, students and teachers used an mHealth tool that awarded points for performing healthy activities. Participants could read their aggregated scores on a leaderboard and compare their performance with others. In particular, these leaderboards were tweaked to implement 3 approaches of the social comparison technique. The first approach focused on intragroup comparison (ie, students and teachers competing against each other to obtain the most points), whereas the other two approaches focused on intergroup comparison (ie, classes of students and their mentoring teachers collaborating to compete against other classes). Additionally, in the third approach, the performance of teachers was highlighted to further increase students? engagement through teachers? natural exemplary function. To obtain our results, we used linear modeling techniques to analyze the dropout rates and engagement levels for the different approaches. In such analyses, we also considered individual participant traits. Results: Our sample included 313 participants?290 students (92.7%) and 23 teachers (7.3%). It was found that student engagement levels dropped over time and declined during holidays. However, students seemed to monitor the intergroup competitions more closely than the intragroup competitions, as they, on average, checked the mHealth app more often when they were engaged in team-based comparisons. Students, on average, performed the most unique activities when they were engaged in the second intergroup setting, perhaps because their teachers were most active in this setting. Moreover, teachers seemed to play an important role in engaging their students, as their relationship with their students influenced the engagement of the students. Conclusions: When using social comparison to engage preadolescents with an mHealth tool, an intergroup setting, rather than an intragroup competition, motivated them to engage with the app but did not necessarily motivate them to perform more activities. It seems that the number of unique activities that preadolescents perform depends on the activeness of a role model. Moreover, this effect is amplified by preadolescents? perceptions of closeness to that role model. UR - https://www.jmir.org/2021/7/e21202 UR - http://dx.doi.org/10.2196/21202 UR - http://www.ncbi.nlm.nih.gov/pubmed/34326041 ID - info:doi/10.2196/21202 ER - TY - JOUR AU - Martinengo, Laura AU - Lo, W. Nicholas Y. AU - Goh, T. Westin I. W. AU - Tudor Car, Lorainne PY - 2021/7/21 TI - Choice of Behavioral Change Techniques in Health Care Conversational Agents: Protocol for a Scoping Review JO - JMIR Res Protoc SP - e30166 VL - 10 IS - 7 KW - behavior change KW - behavioral change technique KW - chatbot KW - conversational agent KW - health care KW - protocol KW - scoping review KW - long-term outcomes KW - behavior N2 - Background: Conversational agents or chatbots are computer programs that simulate conversations with users. Conversational agents are increasingly used for delivery of behavior change interventions in health care. Behavior change is complex and comprises the use of one or several components collectively known as behavioral change techniques (BCTs). Objective: The objective of this scoping review is to identify the BCTs that are used in behavior change?focused interventions delivered via conversational agents in health care. Methods: This scoping review will be performed in line with the Joanna Briggs Institute methodology and will be reported according to the PRISMA extension for scoping reviews guidelines. We will perform a comprehensive search of electronic databases and grey literature sources, and will check the reference lists of included studies for additional relevant studies. The screening and data extraction will be performed independently and in parallel by two review authors. Discrepancies will be resolved through consensus or discussion with a third review author. We will use a data extraction form congruent with the key themes and aims of this scoping review. BCTs employed in the included studies will be coded in line with BCT Taxonomy v1. We will analyze the data qualitatively and present it in diagrammatic or tabular form, alongside a narrative summary. Results: To date, we have designed the search strategy and performed the search on April 26, 2021. The first round of screening of retrieved articles is planned to begin soon. Conclusions: Using appropriate BCTs in the design and delivery of health care interventions via conversational agents is essential to improve long-term outcomes. Our findings will serve to inform the development of future interventions in this area. International Registered Report Identifier (IRRID): PRR1-10.2196/30166 UR - https://www.researchprotocols.org/2021/7/e30166 UR - http://dx.doi.org/10.2196/30166 UR - http://www.ncbi.nlm.nih.gov/pubmed/34287221 ID - info:doi/10.2196/30166 ER - TY - JOUR AU - Lukas, Aljoscha Christian AU - Eskofier, Bjoern AU - Berking, Matthias PY - 2021/7/20 TI - A Gamified Smartphone-Based Intervention for Depression: Randomized Controlled Pilot Trial JO - JMIR Ment Health SP - e16643 VL - 8 IS - 7 KW - smartphone technology KW - depression KW - cognitive behavioral therapy KW - approach/avoidance KW - gamification N2 - Background: Available smartphone-based interventions for depression predominantly use evidence-based strategies from cognitive-behavioral therapy (CBT), but patient engagement and reported effect sizes are small. Recently, studies have demonstrated that smartphone-based interventions combining CBT with gamified approach-avoidance bias modification training (AAMT) can foster patient engagement and reduce symptoms of several mental health problems. Objective: Based on these findings, we developed a gamified smartphone-based intervention, mentalis Phoenix (MT-Phoenix), and hypothesized the program would both engage patients and produce preliminary evidence for the reduction of depressive symptoms. Methods: To test this hypothesis, we evaluated MT-Phoenix in a randomized controlled pilot trial including 77 individuals with elevated depression scores (Patient Health Questionnaire-9 scores ?5). Participants were either instructed to train for 14 days with MT-Phoenix or assigned to a waitlist control condition. Engagement with the intervention was measured by assessing usage data. The primary outcome was reduction in depressive symptom severity at postassessment. Results: Data from this pilot trial shows that participants in the intervention group used the smartphone-based intervention for 46% of all days (6.4/14) and reported a significantly greater reduction of depressive symptoms than did participants in the control condition (F1,74=19.34; P=.001), with a large effect size (d=1.02). Effects were sustained at a 3-month follow-up. Conclusions: A gamified smartphone-based intervention combining CBT with AAMT may foster patient engagement and effectively target depressive symptoms. Future studies should evaluate the effectiveness of this intervention in a phase 3 trial using clinical samples. Moreover, the intervention should be compared to active control conditions. Trial Registration: German Clinical Trial Registry DRKS00012769; https://tinyurl.com/47mw8du7 UR - https://mental.jmir.org/2021/7/e16643 UR - http://dx.doi.org/10.2196/16643 UR - http://www.ncbi.nlm.nih.gov/pubmed/34283037 ID - info:doi/10.2196/16643 ER - TY - JOUR AU - Moghimi, Elnaz AU - Davis, Caroline AU - Rotondi, Michael PY - 2021/7/20 TI - The Efficacy of eHealth Interventions for the Treatment of Adults Diagnosed With Full or Subthreshold Binge Eating Disorder: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e17874 VL - 23 IS - 7 KW - internet KW - cognitive behavioral therapy KW - guided self-help KW - obesity KW - weight loss KW - eating disorder KW - binge eating KW - mobile phone N2 - Background: There has been a recent rise in the use of eHealth treatments for a variety of psychological disorders, including eating disorders. Objective: This meta-analysis of randomized controlled trials is the first to evaluate the efficacy of eHealth interventions specifically for the treatment of binge eating disorder (characterized by compulsive overconsumption of food, in a relatively short period, and without compensatory behaviors such as purging or fasting). Methods: A search on the electronic databases PubMed, Web of Science, Embase, MEDLINE, and CINAHL was conducted for randomized controlled trials that compared the efficacy of eHealth treatment interventions with waitlist controls. Results: From the databases searched, 3 studies (298 participants in total) met the inclusion criteria. All interventions were forms of internet-based guided cognitive behavioral therapy. The results of the analysis demonstrated that when compared with waitlist controls, individuals enrolled in eHealth interventions experienced a reduction in objective binge episodes (standardized mean difference [SMD] ?0.77, 95% CI ?1.38 to ?0.16) and eating disorder psychopathology (SMD ?0.71, 95% CI ?1.20 to ?0.22), which included shape (SMD ?0.61, 95% CI ?1.01 to ?0.22) and weight concerns (SMD ?0.91, 95% CI ?1.33 to ?0.48). There was no significant difference in BMI between the eHealth interventions and controls (SMD ?0.01, 95% CI ?0.40 to 0.39). Conclusions: These findings provide promising results for the use of internet-based cognitive behavioral therapy for binge eating disorder treatment and support the need for future research to explore the efficacy of these eHealth interventions. UR - https://www.jmir.org/2021/7/e17874 UR - http://dx.doi.org/10.2196/17874 UR - http://www.ncbi.nlm.nih.gov/pubmed/34283028 ID - info:doi/10.2196/17874 ER - TY - JOUR AU - Oehler, Caroline AU - Scholze, Katharina AU - Reich, Hanna AU - Sander, Christian AU - Hegerl, Ulrich PY - 2021/7/16 TI - Intervention Use and Symptom Change With Unguided Internet-Based Cognitive Behavioral Therapy for Depression During the COVID-19 Pandemic: Log Data Analysis of a Convenience Sample JO - JMIR Ment Health SP - e28321 VL - 8 IS - 7 KW - iCBT KW - internet-based cognitive behavioral therapy KW - internet-based treatment KW - internet- and mobile-based intervention KW - depression KW - guidance KW - unguided KW - COVID-19 N2 - Background: Internet- and mobile-based interventions are most efficacious in the treatment of depression when they involve some form of guidance, but providing guidance requires resources such as trained personnel, who might not always be available (eg, during lockdowns to contain the COVID-19 pandemic). Objective: The current analysis focuses on changes in symptoms of depression in a guided sample of patients with depression who registered for an internet-based intervention, the iFightDepression tool, as well as the extent of intervention use, compared to an unguided sample. The objective is to further understand the effects of guidance and adherence on the intervention?s potential to induce symptom change. Methods: Log data from two convenience samples in German routine care were used to assess symptom change after 6-9 weeks of intervention as well as minimal dose (finishing at least two workshops). A linear regression model with changes in Patient Health Questionnaire (PHQ-9) score as a dependent variable and guidance and minimal dose as well as their interaction as independent variables was specified. Results: Data from 1423 people with symptoms of depression (n=940 unguided, 66.1%) were included in the current analysis. In the linear regression model predicting symptom change, a significant interaction of guidance and minimal dose revealed a specifically greater improvement for patients who received guidance and also worked with the intervention content (?=?1.75, t=?2.37, P=.02), while there was little difference in symptom change due to guidance in the group that did not use the intervention. In this model, the main effect of guidance was only marginally significant (?=?.53, t=?1.78, P=.08). Conclusions: Guidance in internet-based interventions for depression is not only an important factor to facilitate adherence, but also seems to further improve results for patients adhering to the intervention compared to those who do the same but without guidance. UR - https://mental.jmir.org/2021/7/e28321 UR - http://dx.doi.org/10.2196/28321 UR - http://www.ncbi.nlm.nih.gov/pubmed/34115604 ID - info:doi/10.2196/28321 ER - TY - JOUR AU - Farage, Gregory AU - Simmons, Courtney AU - Kocak, Mehmet AU - Klesges, C. Robert AU - Talcott, Wayne G. AU - Richey, Phyllis AU - Hare, Marion AU - Johnson, C. Karen AU - Sen, Saunak AU - Krukowski, Rebecca PY - 2021/7/14 TI - Assessing the Contribution of Self-Monitoring Through a Commercial Weight Loss App: Mediation and Predictive Modeling Study JO - JMIR Mhealth Uhealth SP - e18741 VL - 9 IS - 7 KW - weight loss KW - self-monitoring KW - obesity KW - apps KW - behavioral intervention N2 - Background: Electronic self-monitoring technology has the potential to provide unique insights into important behaviors for inducing weight loss. Objective: The aim of this study is to investigate the effects of electronic self-monitoring behavior (using the commercial Lose It! app) and weight loss interventions (with differing amounts of counselor feedback and support) on 4- and 12-month weight loss. Methods: In this secondary analysis of the Fit Blue study, we compared the results of two interventions of a randomized controlled trial. Counselor-initiated participants received consistent support from the interventionists, and self-paced participants received assistance upon request. The participants (N=191), who were active duty military personnel, were encouraged to self-monitor their diet and exercise with the Lose It! app or website. We examined the associations between intervention assignment and self-monitoring behaviors. We conducted a mediation analysis of the intervention assignment for weight loss through multiple mediators?app use (calculated from the first principal component [PC] of electronically collected variables), number of weigh-ins, and 4-month weight change. We used linear regression to predict weight loss at 4 and 12 months, and the accuracy was measured using cross-validation. Results: On average, the counselor-initiated?treatment participants used the app more frequently than the self-paced?treatment participants. The first PC represented app use frequencies, the second represented calories recorded, and the third represented reported exercise frequency and exercise caloric expenditure. We found that 4-month weight loss was partially mediated through app use (ie, the first PC; 60.3%) and the number of weigh-ins (55.8%). However, the 12-month weight loss was almost fully mediated by 4-month weight loss (94.8%). Linear regression using app data from the first 8 weeks, the number of self?weigh-ins at 8 weeks, and baseline data explained approximately 30% of the variance in 4-month weight loss. App use frequency (first PC; P=.001), self-monitored caloric intake (second PC; P=.001), and the frequency of self-weighing at 8 weeks (P=.008) were important predictors of 4-month weight loss. Predictions for 12-month weight with the same variables produced an R2 value of 5%; only the number of self?weigh-ins was a significant predictor of 12-month weight loss. The R2 value using 4-month weight loss as a predictor was 31%. Self-reported exercise did not contribute to either model (4 months: P=.77; 12 months: P=.15). Conclusions: We found that app use and daily reported caloric intake had a substantial impact on weight loss prediction at 4 months. Our analysis did not find evidence of an association between participant self-monitoring exercise information and weight loss. As 12-month weight loss was completely mediated by 4-month weight loss, intervention targets should focus on promoting early and frequent dietary intake self-monitoring and self-weighing to promote early weight loss, which leads to long-term success. Trial Registration: ClinicalTrials.gov NCT02063178; https://clinicaltrials.gov/ct2/show/NCT02063178 UR - https://mhealth.jmir.org/2021/7/e18741 UR - http://dx.doi.org/10.2196/18741 UR - http://www.ncbi.nlm.nih.gov/pubmed/34259635 ID - info:doi/10.2196/18741 ER - TY - JOUR AU - Yang, Yanxiang AU - Koenigstorfer, Joerg PY - 2021/7/13 TI - Determinants of Fitness App Usage and Moderating Impacts of Education-, Motivation-, and Gamification-Related App Features on Physical Activity Intentions: Cross-sectional Survey Study JO - J Med Internet Res SP - e26063 VL - 23 IS - 7 KW - smartphone KW - fitness applications KW - mHealth KW - technology acceptance KW - Unified Theory of Acceptance and Use of Technology 2 KW - physical activity KW - determinants of app usage KW - education-related app features KW - motivation-related app features KW - gamification-related app features KW - mobile phone N2 - Background: Smartphone fitness apps are considered promising tools for promoting physical activity and health. However, it is unclear which user-perceived factors and app features encourage users to download apps with the intention of being physically active. Objective: Building on the second version of the Unified Theory of Acceptance and Use of Technology, this study aims to examine the association of the seven determinants of the second version of the Unified Theory of Acceptance and Use of Technology with the app usage intentions of the individuals and their behavioral intentions of being physically active as well as the moderating effects of different smartphone fitness app features (ie, education, motivation, and gamification related) and individual differences (ie, age, gender, and experience) on these intentions. Methods: Data from 839 US residents who reported having used at least one smartphone fitness app were collected via a web-based survey. A confirmatory factor analysis was performed, and path modeling was used to test the hypotheses and explore the influence of moderators on structural relationships. Results: The determinants explain 76% of the variance in the behavioral intention to use fitness apps. Habit (?=.42; P<.001), performance expectancy (?=.36; P<.001), facilitating conditions (?=.15; P<.001), price value (?=.13; P<.001), and effort expectancy (?=.09; P=.04) were positively related to behavioral intention to use fitness apps, whereas social influence and hedonic motivation were nonsignificant predictors. Behavioral intentions to use fitness apps were positively related to intentions of being physically active (?=.12; P<.001; R2=0.02). Education-related app features moderated the association between performance expectancy and habit and app usage intentions; motivation-related features moderated the association of performance expectancy, facilitating conditions, and habit with usage intentions; and gamification-related features moderated the association between hedonic motivation and usage intentions. Age moderated the association between effort expectancy and usage intentions, and gender moderated the association between performance expectancy and habit and usage intentions. User experience was a nonsignificant moderator. Follow-up tests were used to describe the nature of significant interaction effects. Conclusions: This study identifies the drivers of the use of fitness apps. Smartphone app features should be designed to increase the likelihood of app usage, and hence physical activity, by supporting users in achieving their goals and facilitating habit formation. Target group?specific preferences for education-, motivation-, and gamification-related app features, as well as age and gender differences, should be considered. Performance expectancy had a high predictive power for intended usage for male (vs female) users who appreciated motivation-related features. Thus, apps targeting these user groups should focus on goal achievement?related features (eg, goal setting and monitoring). Future research could examine the mechanisms of these moderation effects and their long-term influence on physical activity. UR - https://www.jmir.org/2021/7/e26063 UR - http://dx.doi.org/10.2196/26063 UR - http://www.ncbi.nlm.nih.gov/pubmed/34255656 ID - info:doi/10.2196/26063 ER - TY - JOUR AU - Odunitan-Wayas, A. Feyisayo AU - Wadende, Pamela AU - Mogo, I. Ebele R. AU - Brugulat-Panés, Anna AU - Micklesfield, K. Lisa AU - Govia, Ishtar AU - Mapa-Tassou, Clarisse AU - Mukoma, Gudani AU - Smith, A. Joanne AU - Motlhalhedi, Molebogeng AU - Wasnyo, Yves AU - Were, Vincent AU - Assah, Felix AU - Okop, J. Kufre AU - Norris, A. Shane AU - Obonyo, Charles AU - Mbanya, Claude Jean AU - Tulloch-Reid, K. Marshall AU - King, C. Abby AU - Lambert, V. Estelle AU - Oni, Tolu PY - 2021/7/13 TI - Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol JO - JMIR Res Protoc SP - e26739 VL - 10 IS - 7 KW - adolescent KW - food intake KW - foodways KW - physical activity KW - noncommunicable diseases KW - socioecological levers KW - low and middle income countries KW - health outcomes N2 - Background: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. Objective: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. Methods: Male and female adolescents (n?150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. Results: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n?150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. Conclusions: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. International Registered Report Identifier (IRRID): DERR1-10.2196/26739 UR - https://www.researchprotocols.org/2021/7/e26739 UR - http://dx.doi.org/10.2196/26739 UR - http://www.ncbi.nlm.nih.gov/pubmed/34255729 ID - info:doi/10.2196/26739 ER - TY - JOUR AU - Ash, I. Garrett AU - Griggs, Stephanie AU - Nally, M. Laura AU - Stults-Kolehmainen, Matthew AU - Jeon, Sangchoon AU - Brandt, Cynthia AU - Gulanski, I. Barbara AU - Spanakis, K. Elias AU - Baker, S. Julien AU - Whittemore, Robin AU - Weinzimer, A. Stuart AU - Fucito, M. Lisa PY - 2021/7/8 TI - Evaluation of Web-Based and In-Person Methods to Recruit Adults With Type 1 Diabetes for a Mobile Exercise Intervention: Prospective Observational Study JO - JMIR Diabetes SP - e28309 VL - 6 IS - 3 KW - type 1 diabetes mellitus KW - exercise KW - behavior and behavior mechanisms KW - mobile phone N2 - Background: Our clinical trial of a mobile exercise intervention for adults 18 to 65 years old with type 1 diabetes (T1D) occurred during COVID-19 social distancing restrictions, prompting us to test web-based recruitment methods previously underexplored for this demographic. Objective: Our objectives for this study were to (1) evaluate the effectiveness and cost of using social media news feed advertisements, a clinic-based approach method, and web-based snowball sampling to reach inadequately active adults with T1D and (2) compare characteristics of enrollees against normative data. Methods: Participants were recruited between November 2019 and August 2020. In method #1, Facebook and Instagram news feed advertisements ran for five 1-to-8-day windows targeting adults (18 to 64 years old) in the greater New Haven and Hartford, Connecticut, areas with one or more diabetes-related profile interest. If interested, participants completed a webform so that the research team could contact them for eligibility screening. In method #2, patients 18 to 24 years old with T1D were approached in person at clinical visits in November and December 2019. Those who were interested immediately completed eligibility screening. Older patients could not be approached due to clinic restrictions. In method #3, snowball sampling was conducted by physically active individuals with T1D contacting their peers on Facebook and via email for 48 days, with details to contact the research staff to express interest and complete eligibility screening. Other methods referred participants to the study similarly to snowball sampling. Results: In method #1, advertisements were displayed to 11,738 unique viewers and attracted 274 clickers (2.33%); 20 participants from this group (7.3%) volunteered, of whom 8 (40%) were eligible. Costs averaged US $1.20 per click and US $95.88 per eligible volunteer. Men had lower click rates than women (1.71% vs 3.17%; P<.001), but their responsiveness and eligibility rates did not differ. In method #2, we approached 40 patients; 32 of these patients (80%) inquired about the study, of whom 20 (63%) volunteered, and 2 of these volunteers (10%) were eligible. Costs including personnel for in-person approaches averaged US $21.01 per inquirer and US $479.79 per eligible volunteer. In method #3, snowball sampling generated 13 inquirers; 12 of these inquirers (92%) volunteered, of whom 8 (67%) were eligible. Incremental costs to attract inquirers were negligible, and total costs averaged US $20.59 per eligible volunteer. Other methods yielded 7 inquirers; 5 of these inquirers (71%) volunteered, of whom 2 (40%) were eligible. Incremental costs to attract inquirers were negligible, and total costs averaged US $34.94 per eligible volunteer. Demographic overrepresentations emerged in the overall cohort (ie, optimal glycemic control, obesity, and low exercise), among those recruited by news feed advertisements (ie, obesity and older age), and among those recruited by snowball sampling (ie, optimal glycemic control and low exercise). Conclusions: Web-based advertising and recruitment strategies are a promising means to attract adults with T1D to clinical trials and exercise interventions, with costs comparing favorably to prior trials despite targeting an uncommon condition (ie, T1D) and commitment to an intervention. These strategies should be tailored in future studies to increase access to higher-risk participants. Trial Registration: ClinicalTrials.gov NCT04204733; https://clinicaltrials.gov/ct2/show/NCT04204733 UR - https://diabetes.jmir.org/2021/3/e28309 UR - http://dx.doi.org/10.2196/28309 UR - http://www.ncbi.nlm.nih.gov/pubmed/34047700 ID - info:doi/10.2196/28309 ER - TY - JOUR AU - Ruf, Alea AU - Koch, Doris Elena AU - Ebner-Priemer, Ulrich AU - Knopf, Monika AU - Reif, Andreas AU - Matura, Silke PY - 2021/7/5 TI - Studying Microtemporal, Within-Person Processes of Diet, Physical Activity, and Related Factors Using the APPetite-Mobile-App: Feasibility, Usability, and Validation Study JO - J Med Internet Res SP - e25850 VL - 23 IS - 7 KW - diet KW - physical activity KW - microtemporal processes KW - within-person factors KW - ecological momentary assessment KW - smartphone-app KW - mobile phone KW - mHealth KW - dietary assessment KW - feasibility KW - usability KW - validity N2 - Background: Diet and physical activity (PA) have a major impact on physical and mental health. However, there is a lack of effective strategies for sustaining these health-protective behaviors. A shift to a microtemporal, within-person approach is needed to capture dynamic processes underlying eating behavior and PA, as they change rapidly across minutes or hours and differ among individuals. However, a tool that captures these microtemporal, within-person processes in daily life is currently not present. Objective: The APPetite-mobile-app is developed for the ecological momentary assessment of microtemporal, within-person processes of complex dietary intake, objectively recorded PA, and related factors. This study aims to evaluate the feasibility and usability of the APPetite-mobile-app and the validity of the incorporated APPetite-food record. Methods: The APPetite-mobile-app captures dietary intake event-contingently through a food record, captures PA continuously through accelerometers, and captures related factors (eg, stress) signal-contingently through 8 prompts per day. Empirical data on feasibility (n=157), usability (n=84), and validity (n=44) were collected within the Eat2beNICE-APPetite-study. Feasibility and usability were examined in healthy participants and psychiatric patients. The relative validity of the APPetite-food record was assessed with a subgroup of healthy participants by using a counterbalanced crossover design. The reference method was a 24-hour recall. In addition, the energy intake was compared with the total energy expenditure estimated from accelerometry. Results: Good feasibility, with compliance rates above 80% for prompts and the accelerometer, as well as reasonable average response and recording durations (prompt: 2.04 min; food record per day: 17.66 min) and latencies (prompts: 3.16 min; food record: 58.35 min) were found. Usability was rated as moderate, with a score of 61.9 of 100 on the System Usability Scale. The evaluation of validity identified large differences in energy and macronutrient intake between the two methods at the group and individual levels. The APPetite-food record captured higher dietary intakes, indicating a lower level of underreporting, compared with the 24-hour recall. Energy intake was assessed fairly accurately by the APPetite-food record at the group level on 2 of 3 days when compared with total energy expenditure. The comparison with mean total energy expenditure (2417.8 kcal, SD 410) showed that the 24-hour recall (1909.2 kcal, SD 478.8) underestimated habitual energy intake to a larger degree than the APPetite-food record (2146.4 kcal, SD 574.5). Conclusions: The APPetite-mobile-app is a promising tool for capturing microtemporal, within-person processes of diet, PA, and related factors in real time or near real time and is, to the best of our knowledge, the first of its kind. First evidence supports the good feasibility and moderate usability of the APPetite-mobile-app and the validity of the APPetite-food record. Future findings in this context will build the foundation for the development of personalized lifestyle modification interventions, such as just-in-time adaptive interventions. UR - https://www.jmir.org/2021/7/e25850 UR - http://dx.doi.org/10.2196/25850 UR - http://www.ncbi.nlm.nih.gov/pubmed/34342268 ID - info:doi/10.2196/25850 ER - TY - JOUR AU - Esmaeilzadeh, Pouyan PY - 2021/7/5 TI - The Influence of Gamification and Information Technology Identity on Postadoption Behaviors of Health and Fitness App Users: Empirical Study in the United States JO - JMIR Serious Games SP - e28282 VL - 9 IS - 3 KW - gamification KW - health and fitness apps KW - IT identity KW - continued intention to use KW - information-sharing tendency KW - mHealth KW - app design KW - user interaction N2 - Background: The use of health and fitness apps has been on the rise to monitor personal fitness and health parameters. However, recent research discovered that many users discontinue using these apps after only a few months. Gamification has been suggested as a technique to increase users? interactions with apps. Nevertheless, it is still not clear how gamification mechanisms encourage continued use and inspire user self-management. Objective: The main objective of this study was to articulate how gamification mechanisms in studies of designing and using health and fitness apps can contribute to the realization of information technology (IT) identity and positive behavioral outcomes. The broader goal was to shed light on how gamification mechanisms will translate into positive use behaviors in the context of mobile health apps. Methods: Data were collected from 364 users of health and fitness apps through an online survey to empirically examine the proposed model. Results: Based on identity theories, this study suggests the fully mediating role of IT identity to describe how gamification elements can lead to continued intention to use health and fitness apps, and increase users? tendency for information sharing through the apps. The findings indicate that perceived gamification can increase users? IT identity. In turn, a higher IT identity would encourage users to continue using the apps and share more personal health information with others through the apps. Conclusions: The results of this study can have practical implications for app designers to use gamification elements to increase users? dependency, relatedness, and emotional energy associated with health apps. Moreover, the findings can have theoretical contributions for researchers to help better articulate the process in which gamification can be translated into positive use behaviors. UR - https://games.jmir.org/2021/3/e28282/ UR - http://dx.doi.org/10.2196/28282 UR - http://www.ncbi.nlm.nih.gov/pubmed/34812736 ID - info:doi/10.2196/28282 ER - TY - JOUR AU - Walsh, C. Jane AU - Richmond, Janice AU - Mc Sharry, Jenny AU - Groarke, AnnMarie AU - Glynn, Liam AU - Kelly, Grace Mary AU - Harney, Owen AU - Groarke, M. Jenny PY - 2021/7/5 TI - Examining the Impact of an mHealth Behavior Change Intervention With a Brief In-Person Component for Cancer Survivors With Overweight or Obesity: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e24915 VL - 9 IS - 7 KW - cancer survivors KW - overweight KW - obesity KW - health behavior KW - goals KW - accelerometry KW - text messaging KW - technology KW - Ireland KW - self-management KW - mobile phone N2 - Background: Cancer survivorship in Ireland is increasing in both frequency and longevity. However, a significant proportion of cancer survivors do not reach the recommended physical activity levels and have overweight. This has implications for both physical and psychological health, including an increased risk of subsequent and secondary cancers. Mobile health (mHealth) interventions demonstrate potential for positive health behavior change, but there is little evidence for the efficacy of mobile technology in improving health outcomes in cancer survivors with overweight or obesity. Objective: This study aims to investigate whether a personalized mHealth behavior change intervention improves physical and psychological health outcomes in cancer survivors with overweight or obesity. Methods: A sample of 123 cancer survivors (BMI?25 kg/m2) was randomly assigned to the standard care control (n=61) or intervention (n=62) condition. Group allocation was unblinded. The intervention group attended a 4-hour tailored lifestyle education and information session with physiotherapists, a dietician, and a clinical psychologist to support self-management of health behavior. Over the following 12 weeks, participants engaged in personalized goal setting to incrementally increase physical activity (with feedback and review of goals through SMS text messaging contact with the research team). Direct measures of physical activity were collected using a Fitbit accelerometer. Data on anthropometric, functional exercise capacity, dietary behavior, and psychological measures were collected at face-to-face assessments in a single hospital site at baseline (T0), 12 weeks (T1; intervention end), and 24 weeks (T2; follow-up). Results: The rate of attrition was 21% (13/61) for the control condition and 14% (9/62) for the intervention condition. Using intent-to-treat analysis, significant reductions in BMI (F2,242=4.149; P=.02; ?p2=0.033) and waist circumference (F2,242=3.342; P=.04; ?p2=0.027) were observed in the intervention group. Over the 24-week study, BMI was reduced by 0.52 in the intervention condition, relative to a nonsignificant reduction of 0.11 in the control arm. Waist circumference was reduced by 3.02 cm in the intervention condition relative to 1.82 cm in the control condition. Physical activity level was significantly higher in the intervention group on 8 of the 12 weeks of the intervention phase and on 5 of the 12 weeks of the follow-up period, accounting for up to 2500 additional steps per day (mean 2032, SD 270). Conclusions: The results demonstrate that for cancer survivors with a BMI?25 kg/m2, lifestyle education and personalized goal setting using mobile technology can yield significant changes in clinically relevant health indicators. Further research is needed to elucidate the mechanisms of behavior change and explore the capacity for mHealth interventions to improve broader health and well-being outcomes in the growing population of cancer survivors. Trial Registration: ISRCTN Registry ISRCTN18676721; https://www.isrctn.com/ISRCTN18676721 International Registered Report Identifier (IRRID): RR2-10.2196/13214 UR - https://mhealth.jmir.org/2021/7/e24915 UR - http://dx.doi.org/10.2196/24915 UR - http://www.ncbi.nlm.nih.gov/pubmed/36260394 ID - info:doi/10.2196/24915 ER - TY - JOUR AU - Kim, Meelim AU - Yang, Jaeyeong AU - Ahn, Woo-Young AU - Choi, Jin Hyung PY - 2021/6/24 TI - Machine Learning Analysis to Identify Digital Behavioral Phenotypes for Engagement and Health Outcome Efficacy of an mHealth Intervention for Obesity: Randomized Controlled Trial JO - J Med Internet Res SP - e27218 VL - 23 IS - 6 KW - digital phenotype KW - clinical efficacy KW - in-app engagement KW - machine learning analysis KW - mobile phone N2 - Background: The digital health care community has been urged to enhance engagement and clinical outcomes by analyzing multidimensional digital phenotypes. Objective: This study aims to use a machine learning approach to investigate the performance of multivariate phenotypes in predicting the engagement rate and health outcomes of digital cognitive behavioral therapy. Methods: We leveraged both conventional phenotypes assessed by validated psychological questionnaires and multidimensional digital phenotypes within time-series data from a mobile app of 45 participants undergoing digital cognitive behavioral therapy for 8 weeks. We conducted a machine learning analysis to discriminate the important characteristics. Results: A higher engagement rate was associated with higher weight loss at 8 weeks (r=?0.59; P<.001) and 24 weeks (r=?0.52; P=.001). Applying the machine learning approach, lower self-esteem on the conventional phenotype and higher in-app motivational measures on digital phenotypes commonly accounted for both engagement and health outcomes. In addition, 16 types of digital phenotypes (ie, lower intake of high-calorie food and evening snacks and higher interaction frequency with mentors) predicted engagement rates (mean R2 0.416, SD 0.006). The prediction of short-term weight change (mean R2 0.382, SD 0.015) was associated with 13 different digital phenotypes (ie, lower intake of high-calorie food and carbohydrate and higher intake of low-calorie food). Finally, 8 measures of digital phenotypes (ie, lower intake of carbohydrate and evening snacks and higher motivation) were associated with a long-term weight change (mean R2 0.590, SD 0.011). Conclusions: Our findings successfully demonstrated how multiple psychological constructs, such as emotional, cognitive, behavioral, and motivational phenotypes, elucidate the mechanisms and clinical efficacy of a digital intervention using the machine learning method. Accordingly, our study designed an interpretable digital phenotype model, including multiple aspects of motivation before and during the intervention, predicting both engagement and clinical efficacy. This line of research may shed light on the development of advanced prevention and personalized digital therapeutics. Trial Registration: ClinicalTrials.gov NCT03465306; https://clinicaltrials.gov/ct2/show/NCT03465306 UR - https://www.jmir.org/2021/6/e27218/ UR - http://dx.doi.org/10.2196/27218 UR - http://www.ncbi.nlm.nih.gov/pubmed/34184991 ID - info:doi/10.2196/27218 ER - TY - JOUR AU - van der Haar, Sandra AU - Hoevenaars, M. Femke P. AU - van den Brink, J. Willem AU - van den Broek, Tim AU - Timmer, Mariëlle AU - Boorsma, André AU - Doets, L. Esmée PY - 2021/6/24 TI - Exploring the Potential of Personalized Dietary Advice for Health Improvement in Motivated Individuals With Premetabolic Syndrome: Pretest-Posttest Study JO - JMIR Form Res SP - e25043 VL - 5 IS - 6 KW - personalized nutrition KW - metabolic syndrome KW - dietary behavior KW - diet KW - metabolic KW - metabolic health KW - dietary advice KW - dietary feedback KW - digital health N2 - Background: Dietary quality plays an essential role in the prevention and management of metabolic syndrome (MetS). Objective: The aim of this pilot study is to organize personalized dietary advice in a real-life setting and to explore the effects on dietary intake, metabolic health, and perceived health. Methods: We followed a one-group pretest-posttest design and included 37 individuals at risk of MetS, who indicated motivation to change dietary behavior. For a period of 16 weeks, participants received personalized advice (t=0 and t=8) and feedback (t=0, t=4, t=8, t=12 and t=16) on dietary quality and metabolic health (ie, waist circumference, BMI, blood pressure, lipid profile, fasting glucose levels, and C-peptide). Personalized advice was generated in a two-stage process. In stage 1, an automated algorithm generated advice per food group, integrating data on individual dietary quality (Dutch Healthy Diet Index; total score 8-80) and metabolic health parameters. Stage 2 included a telephone consultation with a trained dietitian to define a personal dietary behavior change strategy and to discuss individual preferences. Dietary quality and metabolic health markers were assessed at t=0, t=8, and t=16. Self-perceived health was evaluated on 7-point Likert scales at t=0 and t=16. Results: At the end of the study period, dietary quality was significantly improved compared with the baseline (Dutch Healthy Diet Index +4.3; P<.001). In addition, lipid profile (triglycerides, P=.02; total cholesterol, P=.01; high-density lipoprotein, P<.001; and low-density lipoprotein, P<.001), BMI (P<.001), waist circumference (P=.01), and C-peptide (P=.01) were all significantly improved, whereas plasma glucose increased by 0.23 nmol/L (P=.04). In line with these results, self-perceived health scores were higher at t=16 weeks than at baseline (+0.67; P=.005). Conclusions: This exploratory study showed that personalized dietary advice resulted in positive effects on dietary behavior, metabolic health, and self-perceived health in motivated pre-MetS adults. The study was performed in a do-it-yourself setting, highlighting the potential of at-home health improvement through dietary changes. Trial Registration: ClinicalTrials.gov NCT04595669; https://clinicaltrials.gov/ct2/show/NCT04595669 UR - https://formative.jmir.org/2021/6/e25043/ UR - http://dx.doi.org/10.2196/25043 UR - http://www.ncbi.nlm.nih.gov/pubmed/34185002 ID - info:doi/10.2196/25043 ER - TY - JOUR AU - Zhang, Hongjie Thomas AU - Tham, Sern Jen PY - 2021/6/21 TI - Calls to Action (Mobilizing Information) on Cancer in Online News: Content Analysis JO - J Med Internet Res SP - e26019 VL - 23 IS - 6 KW - mobilizing information KW - online cancer news KW - quantitative content analysis KW - Malaysia KW - online news KW - cancer KW - infodemiology KW - media KW - digital media KW - digital health KW - health information KW - cancer health information N2 - Background: The health belief model explains that individual intentions and motivation of health behaviors are mostly subject to externalcues to action, such as from interpersonal communications and media consumptions. The concept of mobilizing information (MI) refers to a type of mediated information that could call individuals to carry out particular health actions. Different media channels, especially digital media outlets, play an essential role as a health educator to disseminate cancer health information and persuade and mobilize cancer prevention in the community. However, little is known about calls to action (or MI) in online cancer news, especially from Asian media outlets. Objective: This study aimed at analyzing cancer news articles that contain MI and their news components on the selected Malaysian English and Chinese newspapers with online versions. Methods: The Star Online and Sin Chew Online were selected for analysis because the two newspaper websites enjoy the highest circulation and readership in the English language and the Chinese language streams, respectively. Two bilingual coders searched the cancer news articles based on sampling keywords and then read and coded each news article accordingly. Five coding variables were conceptualized from previous studies (ie, cancer type, news source, news focus, cancer risk factors, and MI), and a good consistency using Cohen kappa was built between coders. Descriptive analysis was used to examine the frequency and percentage of each coding item; chi-square test (confidence level at 95%) was applied to analyze the differences between two newspaper websites, and the associations between variables and the presence of MI were examined through binary logistic regression. Results: Among 841 analyzed news articles, 69.6% (585/841) presented MI. News distributions were unbalanced throughout the year in both English and Chinese newspaper websites; some months occupied peaks (ie, February and October), but cancer issues and MI for cancer prevention received minimal attention in other months. The news articles from The Star Online and Sin Chew Online were significantly different in several news components, such as the MI present rates (?2=9.25, P=.003), providing different types of MI (interactive MI: ?2=12.08, P=.001), interviewing different news sources (government agency: ?2=12.05, P=.001), concerning different news focus (primary cancer prevention: ?2=10.98, P=.001), and mentioning different cancer risks (lifestyle risks: ?2=7.43, P=.007). Binary logistic regression results reported that online cancer news articles were more likely to provide MI when interviewing nongovernmental organizations, focusing on topics related to primary cancer prevention, and highlighting lifestyle risks (odds ratio [OR] 2.77, 95% CI 1.89-4.05; OR 97.70, 95% CI 46.97-203.24; OR 186.28; 95% CI 44.83-773.96; P=.001, respectively). Conclusions: This study provided new understandings regarding MI in cancer news coverage. This could wake and trigger individuals? preexisting attitudes and intentions on cancer prevention. Thus, health professionals, health journalists, and health campaign designers should concentrate on MI when distributing health information to the community. UR - https://www.jmir.org/2021/6/e26019 UR - http://dx.doi.org/10.2196/26019 UR - http://www.ncbi.nlm.nih.gov/pubmed/34152283 ID - info:doi/10.2196/26019 ER - TY - JOUR AU - Yokotani, Kenji PY - 2021/6/21 TI - A Change Talk Model for Abstinence Based on Web-Based Anonymous Gambler Chat Meeting Data by Using an Automatic Change Talk Classifier: Development Study JO - J Med Internet Res SP - e24088 VL - 23 IS - 6 KW - problem gambling KW - web-based anonymous gambler chat meetings KW - self-help group KW - change talk classifier KW - computerized text analysis KW - long-term data with dropout gamblers KW - recovery gradient KW - gradient descent method KW - gambling KW - addiction KW - abstinence N2 - Background: Change and sustain talks (negative and positive comments) on gambling have been relevant for determining gamblers? outcomes but they have not been used to clarify the abstinence process in anonymous gambler meetings. Objective: The aim of this study was to develop a change talk model for abstinence based on data extracted from web-based anonymous gambler chat meetings by using an automatic change talk classifier. Methods: This study used registry data from the internet. The author accessed web-based anonymous gambler chat meetings in Japan and sampled 1.63 million utterances (two-sentence texts) from 267 abstinent gamblers who have remained abstinent for at least three years and 1625 nonabstinent gamblers. The change talk classifier in this study automatically classified gamblers? utterances into change and sustain talks. Results: Abstinent gamblers showed higher proportions of change talks and lower probability of sustain talks compared with nonabstinent gamblers. The change talk model for abstinence, involving change and sustain talks, classified abstinent and nonabstinent gamblers through the use of a support vector machine with a radial basis kernel function. The model also indicated individual evaluation scores for abstinence and the ideal proportion of change talks for all participants according to their previous utterances. Conclusions: Abstinence likelihood among gamblers can be increased by providing personalized evaluation values and indicating the optimal proportion of change talks. Moreover, this may help to prevent severe mental, social, and financial problems caused by the gambling disorder. UR - https://www.jmir.org/2021/6/e24088 UR - http://dx.doi.org/10.2196/24088 UR - http://www.ncbi.nlm.nih.gov/pubmed/34152282 ID - info:doi/10.2196/24088 ER - TY - JOUR AU - March, Sonja AU - Batterham, J. Philip AU - Rowe, Arlen AU - Donovan, Caroline AU - Calear, L. Alison AU - Spence, H. Susan PY - 2021/6/18 TI - Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial JO - JMIR Ment Health SP - e27981 VL - 8 IS - 6 KW - iCBT KW - child KW - adolescent KW - anxiety KW - online KW - trajectories of change N2 - Background: Although evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed). Objective: This study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help). Methods: This study?s participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session. Results: The results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements. Conclusions: These findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary. UR - https://mental.jmir.org/2021/6/e27981 UR - http://dx.doi.org/10.2196/27981 UR - http://www.ncbi.nlm.nih.gov/pubmed/34142971 ID - info:doi/10.2196/27981 ER - TY - JOUR AU - Fulford, Daniel AU - Gard, E. David AU - Mueser, T. Kim AU - Mote, Jasmine AU - Gill, Kathryn AU - Leung, Lawrence AU - Mow, Jessica PY - 2021/6/15 TI - Preliminary Outcomes of an Ecological Momentary Intervention for Social Functioning in Schizophrenia: Pre-Post Study of the Motivation and Skills Support App JO - JMIR Ment Health SP - e27475 VL - 8 IS - 6 KW - schizophrenia KW - psychosis KW - social functioning KW - social skills KW - motivation KW - mHealth KW - smartphone KW - mobile phone N2 - Background: People with schizophrenia and other serious mental illnesses often lack access to evidence-based interventions, particularly interventions that target meaningful recovery outcomes such as social functioning and quality of life. Mobile technologies, including smartphone apps, have the potential to provide scalable support that places elements of evidence-based interventions at the palm of patients? hands. Objective: We aim to develop a smartphone app?called Motivation and Skills Support?to provide targeted social goal support (eg, making new friends and improving existing relationships) for people with schizophrenia enrolled in a stand-alone open trial. Methods: In this paper, we presented preliminary outcomes of 31 participants who used the Motivation and Skills Support app for 8 weeks, including social functioning pre- to postintervention, and momentary reports of treatment targets (eg, social motivation and appraisals) during the intervention. Results: The findings suggest that the intervention improved self-reported social functioning from baseline to treatment termination, particularly in female participants. Gains were not maintained at the 3-month follow-up. Furthermore, increased social functioning was predicted by momentary reports of social appraisals, including perceived social competence and the extent to which social interactions were worth the effort. Conclusions: The implications of these findings and future directions for addressing social functioning in schizophrenia using mobile technology have been discussed. Trial Registration: ClinicalTrials.gov NCT03404219; https://clinicaltrials.gov/ct2/show/NCT03404219 UR - https://mental.jmir.org/2021/6/e27475 UR - http://dx.doi.org/10.2196/27475 UR - http://www.ncbi.nlm.nih.gov/pubmed/34128812 ID - info:doi/10.2196/27475 ER - TY - JOUR AU - Larsen, Britta AU - Greenstadt, D. Emily AU - Olesen, L. Brittany AU - Marcus, H. Bess AU - Godino, Job AU - Zive, M. Michelle PY - 2021/6/15 TI - An mHealth Physical Activity Intervention for Latina Adolescents: Iterative Design of the Chicas Fuertes Study JO - JMIR Form Res SP - e26195 VL - 5 IS - 6 KW - mobile health KW - human-centered design KW - qualitative research KW - adolescent health KW - health disparities KW - mobile phone N2 - Background: Only 3% of Latina teens meet the national physical activity (PA) guidelines, and these habits appear to persist into adulthood. Developing effective interventions to increase PA in Latina teens is necessary to prevent disease and reduce disparities. Mobile technologies may be especially appropriate for this population, but mobile health (mHealth) intervention content must be designed in collaboration with the target population. Objective: This study aims to develop an mHealth PA intervention for Latina adolescents using a multistage iterative process based on the principles of human-centered design and multiple iterations of the design phase of the IDEAS (Integrate, Design, Assess, Share) framework. Methods: On the basis of the feedback from a previous pilot study, the planned intervention included visual social media posts and text messaging, a commercial wearable tracker, and a primarily visual website. The development of the requested mHealth intervention components was accomplished through the following 2 phases: conducting focus groups with the target population and testing the usability of the final materials with a youth advisory board (YAB) comprising Latina adolescents. Participants for focus groups (N=50) were girls aged 13-18 years who could speak and read in English and who were recruited from local high schools and after-school programs serving a high proportion of Latinos. Facilitated discussions focused on experience with PA and social media apps and specific feedback on intervention material prototypes and possible names and logos. Viable products were designed based on their feedback and then tested for usability by the YAB. YAB members (n=4) were Latinas aged 13-18 years who were not regularly active and were recruited via word of mouth and selected through an application process. Results: The focus group discussions yielded the following findings: PA preferences included walking, running, and group fitness classes, whereas the least popular activities were running, swimming, and biking. Most participants (n=48, 96%) used some form of social media, with Instagram being the most favored. Participants preferred text messages to be sent no more than once per day, be personalized, and be positively worded. The focus group participants preferred an intervention directly targeting Latinas and social media posts that were brightly colored, included girls of all body types, and provided specific tips and information. Modified intervention materials were generally perceived favorably by the YAB members, who provided suggestions for further refinement, including the shortening of texts and the incorporation of some Spanish phrases. Conclusions: Latina teens were generally enthusiastic about an mHealth PA intervention, provided that the materials were targeted specifically to them and their preferences. Through multiple iterations of development and feedback from the target population, we gained insight into the needs of Latina teens and joined with industry partners to build a viable final product. UR - https://formative.jmir.org/2021/6/e26195 UR - http://dx.doi.org/10.2196/26195 UR - http://www.ncbi.nlm.nih.gov/pubmed/34128823 ID - info:doi/10.2196/26195 ER - TY - JOUR AU - Gibson, Bryan AU - Simonsen, Sara AU - Barton, Jonathan AU - Zhang, Yue AU - Altizer, Roger AU - Lundberg, Kelly AU - Wetter, W. David PY - 2021/6/14 TI - Motivation and Problem Solving Versus Mobile 360° Videos to Promote Enrollment in the National Diabetes Prevention Program?s Lifestyle Change Program Among People With Prediabetes: Protocol for a Randomized Trial JO - JMIR Res Protoc SP - e28884 VL - 10 IS - 6 KW - diabetes prevention program KW - mobile video KW - motivation and problem solving KW - program enrollment KW - participant engagement KW - prediabetes N2 - Background: More than 88 million Americans are at risk of developing type 2 diabetes mellitus (T2DM). The National Diabetes Prevention Program?s Lifestyle Change Program (DPP LCP) has been shown to be effective in reducing the risk of progressing from prediabetes to T2DM. However, most individuals who could benefit from the program do not enroll. Objective: The aim of this trial is to test the real-world efficacy of 3 mobile phone?based approaches to increasing enrollment in the DPP LCP including a best-practice condition and 2 novel approaches. Methods: We will conduct a 3-armed randomized clinical trial comparing enrollment and 1-month engagement in the DPP LCP among adults with prediabetes from 2 health care settings. Participants in the best-practice condition will receive SMS-based notifications that they have prediabetes and a link to a website that explains prediabetes, T2DM, and the DPP LCP. This will be followed by a single question survey, ?Would you like the DPP LCP to call you to enroll?? Participants in the 2 intervention arms will receive the same best-practice intervention plus either 2 mobile 360° videos or up to 5 brief phone calls from a health coach trained in a motivational coaching approach known as Motivation and Problem Solving (MAPS). We will collect measures of diabetes-related knowledge, beliefs in the controllability of risk for T2DM, risk perceptions for T2DM, and self-efficacy for lifestyle change pre-intervention and 4 weeks later. The primary outcomes of the study are enrollment in the DPP LCP and 4-week engagement in the DPP LCP. In addition, data on the person-hours needed to deliver the interventions as well as participant feedback about the interventions and their acceptability will be collected. Our primary hypotheses are that the 2 novel interventions will lead to higher enrollment and engagement in the DPP LCP than the best-practice intervention. Secondary hypotheses concern the mechanisms of action of the 2 intervention arms: (1) whether changes in risk perception are associated with program enrollment among participants in the mobile 360° video group and (2) whether changes in self-efficacy for lifestyle change are associated with program enrollment among participants in the MAPS coaching group. Finally, exploratory analyses will examine the cost effectiveness and acceptability of the interventions. Results: The project was funded in September 2020; enrollment began in February 2021 and is expected to continue through July 2022. Conclusions: We are conducting a test of 2 novel, scalable, mobile phone?based interventions to increase enrollment in the DPP LCP. If effective, they have tremendous potential to be scaled up to help prevent T2DM nationwide. Trial Registration: ClinicalTrials.gov NCT04746781; https://clinicaltrials.gov/ct2/show/NCT04746781 International Registered Report Identifier (IRRID): DERR1-10.2196/28884 UR - https://www.researchprotocols.org/2021/6/e28884 UR - http://dx.doi.org/10.2196/28884 UR - http://www.ncbi.nlm.nih.gov/pubmed/34125075 ID - info:doi/10.2196/28884 ER - TY - JOUR AU - van Allen, Zack AU - Bacon, L. Simon AU - Bernard, Paquito AU - Brown, Heather AU - Desroches, Sophie AU - Kastner, Monika AU - Lavoie, Kim AU - Marques, Marta AU - McCleary, Nicola AU - Straus, Sharon AU - Taljaard, Monica AU - Thavorn, Kednapa AU - Tomasone, R. Jennifer AU - Presseau, Justin PY - 2021/6/11 TI - Clustering of Unhealthy Behaviors: Protocol for a Multiple Behavior Analysis of Data From the Canadian Longitudinal Study on Aging JO - JMIR Res Protoc SP - e24887 VL - 10 IS - 6 KW - health behaviors KW - multiple behaviors KW - cluster analysis KW - network analysis KW - CLSA N2 - Background: Health behaviors such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are leading risk factors for noncommunicable chronic diseases and play a central role in limiting health and life satisfaction. To date, however, health behaviors tend to be considered separately from one another, resulting in guidelines and interventions for healthy aging siloed by specific behaviors and often focused only on a given health behavior without considering the co-occurrence of family, social, work, and other behaviors of everyday life. Objective: The aim of this study is to understand how behaviors cluster and how such clusters are associated with physical and mental health, life satisfaction, and health care utilization may provide opportunities to leverage this co-occurrence to develop and evaluate interventions to promote multiple health behavior changes. Methods: Using cross-sectional baseline data from the Canadian Longitudinal Study on Aging, we will perform a predefined set of exploratory and hypothesis-generating analyses to examine the co-occurrence of health and everyday life behaviors. We will use agglomerative hierarchical cluster analysis to cluster individuals based on their behavioral tendencies. Multinomial logistic regression will then be used to model the relationships between clusters and demographic indicators, health care utilization, and general health and life satisfaction, and assess whether sex and age moderate these relationships. In addition, we will conduct network community detection analysis using the clique percolation algorithm to detect overlapping communities of behaviors based on the strength of relationships between variables. Results: Baseline data for the Canadian Longitudinal Study on Aging were collected from 51,338 participants aged between 45 and 85 years. Data were collected between 2010 and 2015. Secondary data analysis for this project was approved by the Ottawa Health Science Network Research Ethics Board (protocol ID #20190506-01H). Conclusions: This study will help to inform the development of interventions tailored to subpopulations of adults (eg, physically inactive smokers) defined by the multiple behaviors that describe their everyday life experiences. International Registered Report Identifier (IRRID): DERR1-10.2196/24887 UR - https://www.researchprotocols.org/2021/6/e24887 UR - http://dx.doi.org/10.2196/24887 UR - http://www.ncbi.nlm.nih.gov/pubmed/34114962 ID - info:doi/10.2196/24887 ER - TY - JOUR AU - Sanatkar, Samineh AU - Heinsch, Milena AU - Baldwin, Andrew Peter AU - Rubin, Mark AU - Geddes, Jenny AU - Hunt, Sally AU - Baker, L. Amanda AU - Woodcock, Kathryn AU - Lewin, J. Terry AU - Brady, Kathleen AU - Deady, Mark AU - Thornton, Louise AU - Teesson, Maree AU - Kay-Lambkin, Frances PY - 2021/6/7 TI - Factors Predicting Trial Engagement, Treatment Satisfaction, and Health-Related Quality of Life During a Web-Based Treatment and Social Networking Trial for Binge Drinking and Depression in Young Adults: Secondary Analysis of a Randomized Controlled Trial JO - JMIR Ment Health SP - e23986 VL - 8 IS - 6 KW - digital mental health KW - personality KW - negative affect KW - study engagement KW - life quality N2 - Background: Mental health and alcohol use problems are among the most common causes of disease burden in young Australians, frequently co-occur (comorbidity), and lead to significant lifetime burden. However, comorbidities remain significantly underdetected and undertreated in health settings. Digital mental health tools designed to identify at-risk individuals, encourage help-seeking, or deliver treatment for comorbidity have the potential to address this service gap. However, despite a strong body of evidence that digital mental health programs provide an effective treatment option for a range of mental health and alcohol use problems in young adults, research shows that uptake rates can be low. Thus, it is important to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e?mental health interventions for comorbidity. Objective: In this study, we seek to understand the factors that influence treatment satisfaction and quality-of-life outcomes for young adults who access e?mental health interventions for comorbid alcohol and mood disorders. The aim is to determine the importance of personality (ie, Big Five personality traits and intervention attitudes), affective factors (ie, depression, anxiety, and stress levels), and baseline alcohol consumption in predicting intervention trial engagement at sign-up, satisfaction with the online tool, and quality of life at the end of the iTreAD (Internet Treatment for Alcohol and Depression) trial. Methods: Australian adults (N=411) aged between 18 and 30 years who screened positive for depression and alcohol use problems signed up for the iTreAD project between August 2014 and October 2015. During registration, participants provided information about their personality, current affective state, alcohol use, treatment expectations, and basic demographic information. Subsequent follow-up surveys were used to gauge the ongoing trial engagement. The last follow-up questionnaire, completed at 64 weeks, assessed participants? satisfaction with web-based treatment and quality-of-life outcomes. Results: Multiple linear regression analyses were used to assess the relative influence of predictor variables on trial engagement, treatment satisfaction, and quality-of-life outcomes. The analyses revealed that the overall predictive effects of personality and affective factors were 20% or lower. Neuroticism constituted a unique predictor of engagement with the iTreAD study in that neuroticism facilitated the return of web-based self-assessments during the study. The return of incentivized follow-up assessments predicted treatment satisfaction, and state-based depression predicted variance in quality-of-life reports at study completion. Conclusions: Our findings suggest that traditional predictors of engagement observed in face-to-face research may not be easily transferable to digital health interventions, particularly those aimed at comorbid mental health concerns and alcohol misuse among young adults. More research is needed to identify what determines engagement in this population to optimally design and execute digital intervention studies with multiple treatment aims. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12614000310662; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365137&isReview=true. International Registered Report Identifier (IRRID): RR2-10.1186/s12889-015-2365-2 UR - https://mental.jmir.org/2021/6/e23986 UR - http://dx.doi.org/10.2196/23986 UR - http://www.ncbi.nlm.nih.gov/pubmed/34096873 ID - info:doi/10.2196/23986 ER - TY - JOUR AU - Boumparis, Nikolaos AU - Schulte, H. Mieke AU - Kleiboer, Annet AU - Huizink, Anja AU - Riper, Heleen PY - 2021/6/7 TI - A Mobile Intervention to Promote Low-Risk Drinking Habits in Young Adults: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e29750 VL - 10 IS - 6 KW - alcohol KW - lifestyle KW - drinking KW - young adults KW - digital KW - mobile app KW - COVID-19 N2 - Background: Young adults? drinking habits commonly exceed recommendations for low-risk drinking, which may have a negative effect on their mental, social, and physical health. As smartphones are highly accessible to young adults, mobile apps could be used to support young adults to develop low-risk drinking habits and improve their general health. Objective: The objective of this study is to evaluate the effectiveness of Boozebuster, a self-guided mobile app based on healthy lifestyle?related components that aim to develop and maintain low-risk drinking habits among young adults. Methods: This two-arm, parallel-group randomized controlled trial will investigate whether a 6-week self-guided mobile intervention (Boozebuster) targeting drinking behavior is more effective than a minimal intervention consisting of an educational website on alcohol use and its consequences for young adults. We will recruit 506 young adults (aged 18-30 years) from the Netherlands via an open recruitment strategy by using an open access website. All outcomes will be self-assessed through questionnaires. The primary outcome is the quantity and frequency of alcohol consumption in standard drinks (10 g ethanol per standard drink) per month (timeline follow-back [TLFB]). Secondary outcomes include binge-drinking sessions per month, alcohol-related problem severity (Rutgers Alcohol Problem Index), cannabis use frequency and quantity in grams (TLFB), depressive symptoms (Center for Epidemiological Studies Depression Scale), perceived stress (Perceived Stress Scale), engagement (Twente Engagement with eHealth Technologies Scale), readiness to change (Readiness to Change Questionnaire), mental well-being (Warwick-Edinburgh Mental Wellbeing Scale), trauma and COVID-19?related trauma (Short-Form Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), impulsivity (Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency Impulsive Behavior Scale), study or work performance (Individual Work Performance Questionnaire), and treatment adherence. Baseline (T0), 6-week postbaseline (T1), and 3-month postbaseline (T2) assessments will be conducted and analyzed on the basis of the intention-to-treat principle using multilevel mixed modeling analyses. Results: Recruitment began in September 2020. We received 933 registrations via our study information website; 506 participants have completed the T0 assessment, 336 participants have completed the T1 assessment, and 308 participants have completed the T2 assessment as of May 2021. The study is still in progress, and results will be reported in 2021 and 2022. Conclusions: Self-guided mobile interventions based on a lifestyle approach might be an attractive approach for young adults due to their preference on self-reliance, healthy living, and increased perceived anonymity. Such interventions are yet understudied, and it is known that interventions addressing solely problem drinking are less appealing to young adults. We hypothesize that the Boozebuster mobile app will effectively reduce drinking levels compared to an alcohol educational website (control condition). If effective, our intervention could be an inexpensive and scalable public health intervention to improve drinking habits in young adults. Trial Registration: Netherlands Trial Register NL8828; https://www.trialregister.nl/trial/8828 International Registered Report Identifier (IRRID): DERR1-10.2196/29750 UR - https://www.researchprotocols.org/2021/6/e29750 UR - http://dx.doi.org/10.2196/29750 UR - http://www.ncbi.nlm.nih.gov/pubmed/34033583 ID - info:doi/10.2196/29750 ER - TY - JOUR AU - Fakolade, Afolasade AU - Cameron, Julie AU - McKenna, Odessa AU - Finlayson, L. Marcia AU - Freedman, S. Mark AU - Latimer-Cheung, E. Amy AU - Pilutti, A. Lara PY - 2021/6/1 TI - Physical Activity Together for People With Multiple Sclerosis and Their Care Partners: Protocol for a Feasibility Randomized Controlled Trial of a Dyadic Intervention JO - JMIR Res Protoc SP - e18410 VL - 10 IS - 6 KW - multiple sclerosis KW - advanced disability KW - care partners KW - physical activity KW - dyadic intervention KW - feasibility randomized controlled trial N2 - Background: Physical activity (PA) is beneficial for all people; however, people affected by multiple sclerosis (MS) find regular PA challenging. These people may include individuals with advanced disabilities and their care partners. Objective: The objective of this study is to determine the feasibility of a dyadic PA intervention for people with advanced MS and their care partners. Methods: This study is a randomized controlled feasibility trial of a 12-week intervention, with 1:1 allocation into an immediate intervention condition or delayed control condition. A target of 20 people with MS?care partner dyads will be included. The outcomes will be indicators of process, resources, management, and scientific feasibility. Participant satisfaction with the intervention components will be evaluated using a satisfaction survey. The subjective experience of participation in the study will be explored using semistructured interviews. Results: The project is funded by the Consortium of Multiple Sclerosis Centers. This protocol was approved by the Ottawa Hospital Research Ethics Board (20190329-01H) and the University of Ottawa Research Ethics Board (H-09-19-4886). The study protocol was registered with ClinicalTrials.gov in February 2020. The findings of this feasibility trial will be disseminated through presentations at community events to engage the MS population in the interpretation of our results and in the next steps. The results will also be published in peer-reviewed journals and presented to the scientific community at national and international MS conferences. Conclusions: The data collected from this feasibility trial will be used to refine the intervention and materials in preparation for a pilot randomized controlled trial. Trial Registration: ClinicalTrials.gov NCT04267185; https://clinicaltrials.gov/ct2/show/NCT04267185. International Registered Report Identifier (IRRID): PRR1-10.2196/18410 UR - https://www.researchprotocols.org/2021/6/e18410 UR - http://dx.doi.org/10.2196/18410 UR - http://www.ncbi.nlm.nih.gov/pubmed/34061040 ID - info:doi/10.2196/18410 ER - TY - JOUR AU - Detweiler Guarino, Isadora AU - Cowan, R. Devin AU - Fellows, M. Abigail AU - Buckey, C. Jay PY - 2021/5/31 TI - Use of a Self-guided Computerized Cognitive Behavioral Tool During COVID-19: Evaluation Study JO - JMIR Form Res SP - e26989 VL - 5 IS - 5 KW - computerized cognitive behavioral therapy KW - interactive media KW - COVID-19 KW - computer-based therapy KW - usability KW - acceptability KW - cognitive behavioral therapy KW - therapy KW - effectiveness KW - digital health KW - depression KW - stress N2 - Background: Internet-based programs can help provide accessible and inexpensive behavioral health care to those in need; however, the evaluation of these interventions has been mostly limited to controlled trials. Data regarding patterns of use and effectiveness of self-referred, open-access online interventions are lacking. We evaluated an online-based treatment designed to address stress, depression, and conflict management, the Dartmouth PATH Program, in a freely available and self-guided format during the COVID-19 pandemic. Objective: The primary aim is to determine users? levels of stress and depression, and the nature of problems and triggers they reported during the COVID-19 pandemic. A secondary objective is to assess the acceptability and usability of the PATH content and determine whether such a program would be useful as a stand-alone open-access resource. The final objective is understanding the high dropout rates associated with online behavioral programs by contrasting the use pattern and program efficacy of individuals who completed session one and did not return to the program with those who came back to complete more sessions. Methods: Cumulative anonymous data from 562 individuals were analyzed. Stress triggers, stress responses, and reported problems were analyzed using qualitative analysis techniques. Scores on usability and acceptability questionnaires were evaluated using the sign test and Wilcoxon signed rank test. Mixed-effects linear modeling was used to evaluate changes in stress and depression over time. Results: A total of 2484 users registered from April through October 2020, most of whom created an account without initiating a module. A total of 562 individuals started the program and were considered in the data analysis. The most common stress triggers individuals reported involved either conflicts with family or spouses and work or workload. The most common problems addressed in the mood module were worry, anxiousness, or stress and difficulty concentrating or procrastination. The attrition rate was high with 13% (21/156) completing the conflict module, 17% (50/289) completing session one of the mood module, and 14% (16/117) completing session one of the stress module. Usability and acceptability scores for the mood and stress modules were significantly better than average. In those who returned to complete sessions, symptoms of stress showed a significant improvement over time (P=.03), and there was a significant decrease in depressive symptoms over all time points (P=.01). Depression severity decreased on average by 20% (SD 35.2%; P=.60) between sessions one and two. Conclusions: Conflicts with others, worry, and difficulty concentrating were some of the most common problems people used the programs to address. Individuals who completed the modules indicated improvements in self-reported stress and depression symptoms. Users also found the modules to be effective and rated the program highly for usability and acceptability. Nevertheless, the attrition rate was very high, as has been found with other freely available online-based interventions. Trial Registration: ClinicalTrials.gov NCT02726061; https://clinicaltrials.gov/ct2/show/NCT02726061 UR - https://formative.jmir.org/2021/5/e26989 UR - http://dx.doi.org/10.2196/26989 UR - http://www.ncbi.nlm.nih.gov/pubmed/33973856 ID - info:doi/10.2196/26989 ER - TY - JOUR AU - Juarascio, Adrienne AU - Srivastava, Paakhi AU - Presseller, Emily AU - Clark, Kelsey AU - Manasse, Stephanie AU - Forman, Evan PY - 2021/5/31 TI - A Clinician-Controlled Just-in-time Adaptive Intervention System (CBT+) Designed to Promote Acquisition and Utilization of Cognitive Behavioral Therapy Skills in Bulimia Nervosa: Development and Preliminary Evaluation Study JO - JMIR Form Res SP - e18261 VL - 5 IS - 5 KW - eating disorders KW - telemedicine KW - mobile phone KW - smartphone KW - technology KW - cognitive behavioral therapy N2 - Background: Cognitive behavioral therapy (CBT) for bulimia nervosa (BN) is most effective when patients demonstrate adequate skill utilization (ie, the frequency with which a patient practices or uses therapeutic skills) and skill acquisition (ie, the ability to successfully perform a skill learned in treatment). However, rates of utilization and acquisition of key treatment skills (eg, regular eating, urge management skills, and mood management skills) by the end of the treatment are frequently low; as a result, outcomes from CBT for BN are affected. Just-in-time adaptive interventions (JITAIs) may improve skill acquisition and utilization by delivering real-time interventions during algorithm-identified opportunities for skill practice. Objective: In this manuscript, we describe a newly developed JITAI system called CBT+ that is designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation. We also present feasibility, acceptability, and preliminary outcomes data from a small proof-of-concept pilot trial (n=5 patients and n=3 clinicians) designed to identify opportunities for iterative development of CBT+ ahead of a larger ongoing randomized controlled trial. Methods: A total of 5 individuals with BN received 16 sessions of outpatient CBT for BN while using the CBT+ app. Data were collected from patients and clinicians to evaluate the feasibility (eg, app use and user adherence), acceptability (eg, qualitative patient and clinician feedback, including usefulness ratings of CBT+ on a 6-point Likert scale ranging from 1=extremely useless to 6=extremely useful), and preliminary outcomes (eg, improvements in skill utilization and acquisition and BN symptoms) of the CBT+ system. Results: Patients reported that CBT+ was a relatively low burden (eg, quick and easy-to-use self-monitoring interface), and adherence to in-app self-monitoring was high (mean entries per day 3.13, SD 1.03). JITAIs were perceived as useful by both patients (median rating 5/6) and clinicians (median rating 5/6) for encouraging the use of CBT skills. Large improvements in CBT skills and clinically significant reductions in BN symptoms were observed post treatment. Although preliminary findings indicated that the CBT+ system was acceptable to most patients and clinicians, the overall study dropout was relatively high (ie, 2/5, 40% patients), which could indicate some moderate concerns regarding feasibility. Conclusions: CBT+, the first-ever JITAI system designed to facilitate the acquisition and utilization of CBT for BN treatment skills when used as a treatment augmentation, was shown to be feasible and acceptable. The results indicate that the CBT+ system should be subjected to more rigorous evaluations with larger samples and should be considered for wider implementation if found effective. Areas for iterative improvement of the CBT+ system ahead of a randomized controlled trial are also discussed. UR - https://formative.jmir.org/2021/5/e18261 UR - http://dx.doi.org/10.2196/18261 UR - http://www.ncbi.nlm.nih.gov/pubmed/34057416 ID - info:doi/10.2196/18261 ER - TY - JOUR AU - Cochran, A. Randyl AU - Feldman, S. Sue AU - Ivankova, V. Nataliya AU - Hall, G. Allyson AU - Opoku-Agyeman, William PY - 2021/5/27 TI - Intention to Use Behavioral Health Data From a Health Information Exchange: Mixed Methods Study JO - JMIR Ment Health SP - e26746 VL - 8 IS - 5 KW - behavioral health KW - integrated care KW - health information exchange KW - behavioral intention KW - patient care KW - mixed methods research N2 - Background: Patients with co-occurring behavioral health and chronic medical conditions frequently overuse inpatient hospital services. This pattern of overuse contributes to inefficient health care spending. These patients require coordinated care to achieve optimal health outcomes. However, the poor exchange of health-related information between various clinicians renders the delivery of coordinated care challenging. Health information exchanges (HIEs) facilitate health-related information sharing and have been shown to be effective in chronic disease management; however, their effectiveness in the delivery of integrated care is less clear. It is prudent to consider new approaches to sharing both general medical and behavioral health information. Objective: This study aims to identify and describe factors influencing the intention to use behavioral health information that is shared through HIEs. Methods: We used a mixed methods design consisting of two sequential phases. A validated survey instrument was emailed to clinical and nonclinical staff in Alabama and Oklahoma. The survey captured information about the impact of predictors on the intention to use behavioral health data in clinical decision making. Follow-up interviews were conducted with a subsample of participants to elaborate on the survey results. Partial least squares structural equation modeling was used to analyze survey data. Thematic analysis was used to identify themes from the interviews. Results: A total of 62 participants completed the survey. In total, 63% (n=39) of the participants were clinicians. Performance expectancy (?=.382; P=.01) and trust (?=.539; P<.001) predicted intention to use behavioral health information shared via HIEs. The interviewees (n=5) expressed that behavioral health information could be useful in clinical decision making. However, privacy and confidentiality concerns discourage sharing this information, which is generally missing from patient records altogether. The interviewees also stated that training for HIE use was not mandatory; the training that was provided did not focus specifically on the exchange of behavioral health information. Conclusions: Despite barriers, individuals are willing to use behavioral health information from HIEs if they believe that it will enhance job performance and if the information being transmitted is trustworthy. The findings contribute to our understanding of the role HIEs can play in delivering integrated care, particularly to vulnerable patients. UR - https://mental.jmir.org/2021/5/e26746 UR - http://dx.doi.org/10.2196/26746 UR - http://www.ncbi.nlm.nih.gov/pubmed/34042606 ID - info:doi/10.2196/26746 ER - TY - JOUR AU - Buntrock, Claudia AU - Lehr, Dirk AU - Smit, Filip AU - Horvath, Hanne AU - Berking, Matthias AU - Spiegelhalder, Kai AU - Riper, Heleen AU - Ebert, Daniel David PY - 2021/5/24 TI - Guided Internet-Based Cognitive Behavioral Therapy for Insomnia: Health-Economic Evaluation From the Societal and Public Health Care Perspective Alongside a Randomized Controlled Trial JO - J Med Internet Res SP - e25609 VL - 23 IS - 5 KW - insomnia KW - internet-based cognitive behavioural therapy KW - iCBT-I KW - economic evaluation KW - cost-effectiveness KW - cost-utility KW - cognitive behavioral therapy KW - behavior KW - sleep KW - economics KW - public health KW - perspective N2 - Background: The evidence base for internet-based cognitive behavioral therapy for insomnia (iCBT-I) is firm; however, little is known about iCBT-I?s health-economic effects. Objective: This study aimed to evaluate the cost-effectiveness and cost?utility of iCBT-I in reducing insomnia among schoolteachers. Methods: Schoolteachers (N=128) with clinically significant insomnia symptoms and work-related rumination were randomized to guided iCBT-I or a wait list control group, both with unrestricted access to treatment as usual. Health care use, patient and family expenditures, and productivity losses were self-assessed and used for costing from a societal and a public health care perspective. Costs were related to symptom-free status (score <8 on the insomnia severity index) and quality-adjusted life years (QALYs) gained. Sampling error was handled using nonparametric bootstrapping. Results: Statistically significant differences favoring the intervention group were found for both health outcomes (symptom-free status yes or no: ?=.30; 95% CI 0.16-0.43; QALYs: ?=.019, 95% CI 0.01-0.03). From a societal perspective, iCBT-I had a 94% probability of dominating the wait list control for both health outcomes. From a public health care perspective, iCBT-I was more effective but also more expensive than the wait list control, resulting in an incremental cost-effectiveness ratio of ?650 per symptom-free individual. In terms of QALYs, the incremental cost-effectiveness ratio was ?11,285. At a willingness-to-pay threshold of ?20,000 per QALY gained, the intervention?s probability of being cost-effective was 89%. Conclusions: Our trial indicates that iCBT could be considered as a good value-for-money intervention for insomnia. Trial Registration: German Clinical Trial Registry: DRKS00004700; https://tinyurl.com/2nnk57jm International Registered Report Identifier (IRRID): RR2-10.1186/1745-6215-14-169 UR - https://www.jmir.org/2021/5/e25609 UR - http://dx.doi.org/10.2196/25609 UR - http://www.ncbi.nlm.nih.gov/pubmed/34028361 ID - info:doi/10.2196/25609 ER - TY - JOUR AU - Manjong, Titu Florence AU - Verla, Siysi Vincent AU - Egbe, Obinchemti Thomas AU - Nsagha, Shey Dickson PY - 2021/5/20 TI - Impact of Nutrition Education on the Nutrition Capacity of Caregivers and Nutrition Outcomes of Indigenous Mbororo Children in the West Region of Cameroon: Protocol for a Cluster Randomized Controlled Trial JO - JMIR Res Protoc SP - e23115 VL - 10 IS - 5 KW - nutrition education KW - caregivers KW - nutrition outcomes KW - indigenous children N2 - Background: Inadequate diets and life-threatening infections have profound adverse implications for child growth, development, and survival, particularly among indigenous peoples. Evidence of the effectiveness of community-based nutrition education interventions in improving child feeding and nutrition outcomes among indigenous Mbororo population in Cameroon is scarce. Objective: This study aims to investigate the impact of culturally tailored community-based nutrition education intervention on caregivers? knowledge, attitude, and practice regarding complementary feeding and on nutrition outcomes of indigenous Mbororo children (aged 3-59 months) in the Foumban and Galim health districts of the West Region of Cameroon. Methods: A two-arm cluster randomized controlled trial will be conducted in the Foumban Health District and Galim Health District. The intervention and control arms will each comprise 5 clusters with 121 child?caregiver pairs. Participants in the intervention arm will be organized into 5 caregivers? peer-support platforms. A total of 12 educational sessions will be assigned to the intervention group by trained female Mbororo nutrition volunteers (n=6) and community health workers (n=6). The control arm will receive routine facility-based nutrition education. Data will be collected at 3-month and 6-month follow-up. Both descriptive statistics and multivariate logistic models will be used to estimate the effect of culturally tailored community-based nutrition education intervention (independent variable) on outcome variables (caregivers? knowledge, attitude, and practice), child growth (weight, height/length, weight for age), and morbidity status (diarrhea, cough, and fever) between both arms. Data assessors will be blinded to the group allocation. Ethical approval (reference no. 2019/1002-07/UB/SG/IRB/FHS) was obtained from the Faculty of Health Sciences Institutional Review Board at the University of Buea. Results: Baseline data were collected in September 2019. In February 2020, 10 Mbororo communities (clusters) with 242 child?caregiver pairs were selected and allocated to the experimental and control arm in a 1:1 ratio. Community nutrition volunteers (n=6) and community health workers (n=6) were selected and trained. Data collection and analysis are ongoing, and results are not available for this manuscript. Conclusions: The findings of this study will provide evidence on the impact of culturally tailored and health belief model?based nutrition education on behavior change as a complementary strategy for strengthening health facility?based approaches in the reduction of malnutrition burden among the study population International Registered Report Identifier (IRRID): DERR1-10.2196/23115 UR - https://www.researchprotocols.org/2021/5/e23115 UR - http://dx.doi.org/10.2196/23115 UR - http://www.ncbi.nlm.nih.gov/pubmed/34014173 ID - info:doi/10.2196/23115 ER - TY - JOUR AU - Mooses, Kerli AU - Taveter, Kuldar PY - 2021/5/19 TI - Agent-Oriented Goal Models in Developing Information Systems Supporting Physical Activity Among Adolescents: Literature Review and Expert Interviews JO - J Med Internet Res SP - e24810 VL - 23 IS - 5 KW - agent-oriented goal models KW - physical activity KW - adolescent N2 - Background: Information and communication technologies (ICTs) are becoming increasingly popular in supporting the fight against low physical activity (PA) levels among adolescents. However, several ICT solutions lack evidence-based content. Therefore, there is a need to identify important features that have the potential to efficiently and consistently support the PA of adolescents using ICT solutions. Objective: This study aims to create evidence-based models of requirements for ICT solutions supporting PA by combining scientific evidence from literature and health experts. In addition, we test the suitability of agent-oriented goal models in this type of modeling process. Methods: A literature search of PubMed, Web of Science, and Scopus databases was conducted to identify evidence-based functional, quality, and emotional goals that have previously been proven to be relevant in supporting PAs among youth using ICT solutions. The identified goals were presented in the form of goal models. These models were used to collaborate with health experts to receive their input on the topic and suggestions for improvement. The initial goal models were improved based on the feedback from the experts. Results: The results indicated that agent-oriented goal modeling is a suitable method for merging information from the literature and experts. One strength of agent-oriented goal models is that they present emotional requirements together with quality and functional requirements. Another strength is the possibility of presenting results from a literature review in a systematic manner and using them thereafter in the communication process with stakeholders. Agent-oriented goal models that were created were easy to understand for health experts without previous experience in requirements engineering, which facilitates and supports collaboration with nontechnical stakeholders. Conclusions: The proposed agent-oriented goal models effectively merged information from scientific literature and experts in the field and presented early functional, quality, and emotional requirements in a holistic and coherent manner. We believe that the created models have high potential to help requirements engineers and developers to provide more efficient ICT solutions that support PA among adolescents in the future. UR - https://www.jmir.org/2021/5/e24810 UR - http://dx.doi.org/10.2196/24810 UR - http://www.ncbi.nlm.nih.gov/pubmed/34009127 ID - info:doi/10.2196/24810 ER - TY - JOUR AU - Badawy, M. Sherif AU - Abebe, Z. Kaleab AU - Reichman, A. Charlotte AU - Checo, Grace AU - Hamm, E. Megan AU - Stinson, Jennifer AU - Lalloo, Chitra AU - Carroll, Patrick AU - Saraf, L. Santosh AU - Gordeuk, R. Victor AU - Desai, Payal AU - Shah, Nirmish AU - Liles, Darla AU - Trimnell, Cassandra AU - Jonassaint, R. Charles PY - 2021/5/14 TI - Comparing the Effectiveness of Education Versus Digital Cognitive Behavioral Therapy for Adults With Sickle Cell Disease: Protocol for the Cognitive Behavioral Therapy and Real-time Pain Management Intervention for Sickle Cell via Mobile Applications (CaRISMA) Study JO - JMIR Res Protoc SP - e29014 VL - 10 IS - 5 KW - sickle cell anemia KW - sickle cell disease KW - pain KW - depression KW - depressive symptoms KW - quality of life KW - digital KW - mHealth KW - eHealth KW - CBT KW - cognitive behavioral therapy KW - education KW - mobile phone N2 - Background: Patients with sickle cell disease (SCD) experience significant medical and psychological stressors that affect their mental health, well-being, and disease outcomes. Digital cognitive behavioral therapy (CBT) has been used in other patient populations and has demonstrated clinical benefits. Although evidence-based, nonpharmacological interventions for pain management are widely used in other populations, these treatments have not been well studied in SCD. Currently, there are no adequately powered large-scale clinical trials to evaluate the effectiveness and dissemination potential of behavioral pain management for adults with SCD. Furthermore, some important details regarding behavioral therapies in SCD remain unclear?in particular, what works best for whom and when. Objective: Our primary goal is to compare the effectiveness of two smartphone?delivered programs for reducing SCD pain symptoms: digital CBT versus pain and SCD education (Education). Our secondary goal is to assess whether baseline depression symptoms moderate the effect of interventions on pain outcomes. We hypothesize that digital CBT will confer greater benefits on pain outcomes and depressive symptoms at 6 months and a greater reduction in health care use (eg, opioid prescriptions or refills or acute care visits) over 12 months. Methods: The CaRISMA (Cognitive Behavioral Therapy and Real-time Pain Management Intervention for Sickle Cell via Mobile Applications) study is a multisite comparative effectiveness trial funded by the Patient-Centered Outcomes Research Institute. CaRISMA is conducted at six clinical academic sites, in partnership with four community-based organizations. CaRISMA will evaluate the effectiveness of two 12-week health coach?supported digital health programs with a total of 350 participants in two groups: CBT (n=175) and Education (n=175). Participants will complete a series of questionnaires at baseline and at 3, 6, and 12 months. The primary outcome will be the change in pain interference between the study arms. We will also evaluate changes in pain intensity, depressive symptoms, other patient-reported outcomes, and health care use as secondary outcomes. We have 80% power to detect a difference of 0.37 SDs between study arms on 6-month changes in the outcomes with 15% expected attrition at 6 months. An exploratory analysis will examine whether baseline depression symptoms moderate the effect of the intervention on pain interference. Results: This study will be conducted from March 2021 through February 2022, with results expected to be available in February 2023. Conclusions: Patients with SCD experience significant disease burden, psychosocial stress, and impairment of their quality of life. CaRISMA proposes to leverage digital technology and overcome barriers to the routine use of behavioral treatments for pain and depressive symptoms in the treatment of adults with SCD. The study will provide data on the comparative effectiveness of digital CBT and Education approaches and evaluate the potential for implementing evidence-based behavioral interventions to manage SCD pain. Trial Registration: ClinicalTrials.gov NCT04419168; https://clinicaltrials.gov/ct2/show/NCT04419168. International Registered Report Identifier (IRRID): PRR1-10.2196/29014 UR - https://www.researchprotocols.org/2021/5/e29014 UR - http://dx.doi.org/10.2196/29014 UR - http://www.ncbi.nlm.nih.gov/pubmed/33988517 ID - info:doi/10.2196/29014 ER - TY - JOUR AU - Elling, Mathis Jan AU - Crutzen, Rik AU - Talhout, Reinskje AU - de Vries, Hein PY - 2021/5/14 TI - Effects of Providing Tailored Information About e-Cigarettes in a Web-Based Smoking Cessation Intervention: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e27088 VL - 10 IS - 5 KW - digital health KW - eHealth KW - mHealth KW - electronic cigarette KW - e-cigarette KW - electronic nicotine delivery system KW - ENDS KW - smoking KW - smoking cessation KW - computer tailoring N2 - Background: There is an ongoing debate whether electronic cigarettes (e-cigarettes) should be advocated for smoking cessation. Because of this uncertainty, information about the use of e-cigarettes for smoking cessation is usually not provided in governmental smoking cessation communications. However, there is an information need among smokers because despite this uncertainty, e-cigarettes are used by many smokers to reduce and quit tobacco smoking. Objective: The aim of this study is to describe the protocol of a randomized controlled trial that assesses the effect of providing tailored information about e-cigarettes compared to not providing this information on determinants of decision making and smoking reduction and abstinence. This information is provided in the context of a digital smoking cessation intervention. Methods: A randomized controlled trial with a 6-month follow-up period will be conducted among adult smokers motivated to quit smoking within 5 years. Participants will be 1:1 randomized into either the intervention condition or control condition. In this trial, which is grounded on the I-Change model, participants in both conditions will receive tailored feedback on attitude, social influence, preparatory plans, self-efficacy, and coping plans. Information on 6 clusters of smoking cessation methods (face-to-face counselling, eHealth interventions, telephone counselling, group-based programs, nicotine replacement therapy, and prescription medication) will be provided in both conditions. Smokers in the intervention condition will also receive detailed tailored information on e-cigarettes, while smokers in the control condition will not receive this information. The primary outcome measure will be the number of tobacco cigarettes smoked in the past 7 days. Secondary outcome measures will include 7-day point prevalence tobacco abstinence, 7-day point prevalence e-cigarette abstinence, and determinants of decision making (ie, knowledge and attitude regarding e-cigarettes). All outcomes will be self-assessed through web-based questionnaires. Results: This project is supported by a research grant of the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu). Ethical approval was granted by the Ethics Review Committee Health, Medicine and Life Sciences at Maastricht University (FHML-REC/2019/072). Recruitment began in March 2020 and was completed by July 2020. We enrolled 492 smokers in this study. The results are expected to be published in June 2021. Conclusions: The experimental design of this study allows conclusions to be formed regarding the effects of tailored information about e-cigarettes on decision making and smoking behavior. Our findings can inform the development of future smoking cessation interventions. Trial Registration: Dutch Trial Register Trial NL8330; https://www.trialregister.nl/trial/8330 International Registered Report Identifier (IRRID): DERR1-10.2196/27088 UR - https://www.researchprotocols.org/2021/5/e27088 UR - http://dx.doi.org/10.2196/27088 UR - http://www.ncbi.nlm.nih.gov/pubmed/33988520 ID - info:doi/10.2196/27088 ER - TY - JOUR AU - Gold, Natalie AU - Yau, Amy AU - Rigby, Benjamin AU - Dyke, Chris AU - Remfry, Alice Elizabeth AU - Chadborn, Tim PY - 2021/5/14 TI - Effectiveness of Digital Interventions for Reducing Behavioral Risks of Cardiovascular Disease in Nonclinical Adult Populations: Systematic Review of Reviews JO - J Med Internet Res SP - e19688 VL - 23 IS - 5 KW - alcohol KW - behavior change KW - cardiovascular disease KW - diet KW - digital interventions KW - digital medicine KW - internet interventions KW - mHealth KW - mobile interventions KW - physical activity KW - smoking KW - tobacco KW - mobile phone N2 - Background: Digital health interventions are increasingly being used as a supplement or replacement for face-to-face services as a part of predictive prevention. They may be offered to those who are at high risk of cardiovascular disease and need to improve their diet, increase physical activity, stop smoking, or reduce alcohol consumption. Despite the popularity of these interventions, there is no overall summary and comparison of the effectiveness of different modes of delivery of a digital intervention to inform policy. Objective: This review aims to summarize the effectiveness of digital interventions in improving behavioral and health outcomes related to physical activity, smoking, alcohol consumption, or diet in nonclinical adult populations and to identify the effectiveness of different modes of delivery of digital interventions. Methods: We reviewed articles published in the English language between January 1, 2009, and February 25, 2019, that presented a systematic review with a narrative synthesis or meta-analysis of any study design examining digital intervention effectiveness; data related to adults (?18 years) in high-income countries; and data on behavioral or health outcomes related to diet, physical activity, smoking, or alcohol, alone or in any combination. Any time frame or comparator was considered eligible. We searched MEDLINE, Embase, PsycINFO, Cochrane Reviews, and gray literature. The AMSTAR-2 tool was used to assess review confidence ratings. Results: We found 92 reviews from the academic literature (47 with meta-analyses) and 2 gray literature items (1 with a meta-analysis). Digital interventions were typically more effective than no intervention, but the effect sizes were small. Evidence on the effectiveness of digital interventions compared with face-to-face interventions was mixed. Most trials reported that intent-to-treat analysis and attrition rates were often high. Studies with long follow-up periods were scarce. However, we found that digital interventions may be effective for up to 6 months after the end of the intervention but that the effects dissipated by 12 months. There were small positive effects of digital interventions on smoking cessation and alcohol reduction; possible effectiveness in combined diet and physical activity interventions; no effectiveness for interventions targeting physical activity alone, except for when interventions were delivered by mobile phone, which had medium-sized effects; and no effectiveness observed for interventions targeting diet alone. Mobile interventions were particularly effective. Internet-based interventions were generally effective. Conclusions: Digital interventions have small positive effects on smoking, alcohol consumption, and in interventions that target a combination of diet and physical activity. Small effects may have been due to the low efficacy of treatment or due to nonadherence. In addition, our ability to make inferences from the literature we reviewed was limited as those interventions were heterogeneous, many reviews had critically low AMSTAR-2 ratings, analysis was typically intent-to-treat, and follow-up times were relatively short. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019126074; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=126074. UR - https://www.jmir.org/2021/5/e19688 UR - http://dx.doi.org/10.2196/19688 UR - http://www.ncbi.nlm.nih.gov/pubmed/33988126 ID - info:doi/10.2196/19688 ER - TY - JOUR AU - Bustamante, Adriana Luz AU - Gill Ménard, Cédric AU - Julien, Sabrina AU - Romo, Lucia PY - 2021/5/13 TI - Behavior Change Techniques in Popular Mobile Apps for Smoking Cessation in France: Content Analysis JO - JMIR Mhealth Uhealth SP - e26082 VL - 9 IS - 5 KW - smartphone app KW - smoking cessation KW - mHealth KW - app quality KW - user engagement KW - behavior change technique taxonomy N2 - Background: The mobile app market differs from country to country, and to date, no previous review of the content quality of smoking cessation apps has been conducted in France. Objective: This study aimed to examine the general quality of the most popular smoking cessation apps in France and also determine the degree to which apps adhere to established behavioral and cognitive techniques (BCTs) proven effective in clinical practice. Methods: A systematic research of smoking cessation apps was conducted in both the Google Play Store and Apple Store in the French market. The general quality of popular apps was rated with the Mobile App Rating Scale (MARS), and the therapeutic quality was assessed with the ratio of adherence of the behavior change technique taxonomy for smoking cessation treatment. Results: A total of 14 mobile apps met all the inclusion criteria of the content analysis. The interrater reliability varied from ?substantial? (0.79) to ?almost perfect? (0.9) for the two measures. The mean MARS score was 3.5 out of 5 (median 3.6, IQR 0.6 [3.2-3.8]). The findings suggest that popular apps focus primarily on the functionality dimension of the MARS scale (4.2/5). The mean number of BCTs was 22, with a large difference between apps (minimum 4, maximum 38). At least half of the apps addressed motivation (8.8/14, 63%) and advised on using behavioral skills in order to quit smoking or stay a nonsmoker (8.7/14, 62%). However, only a handful of apps gathered important information (5.9/14, 42%) in order to deliver proper advice regarding the use of approved medication or the implementation of behavioral techniques (4.3/14, 31%). The mean MARS score was positively correlated with the price (r=0.70, P=.007) and the number of BCTs used (r=0.67, P=.01). User rating was not correlated with any quality scale (P=.67). Conclusions: The content quality of popular smoking cessation apps in France varied by app type and price. Most popular apps propose in general good quality content but lack implementation of evidence-based BCTs associated with effectiveness on smoking cessation treatment. Further research is needed to evaluate the improvement in the content quality of smoking cessation apps in France. UR - https://mhealth.jmir.org/2021/5/e26082 UR - http://dx.doi.org/10.2196/26082 UR - http://www.ncbi.nlm.nih.gov/pubmed/33983130 ID - info:doi/10.2196/26082 ER - TY - JOUR AU - Piera-Jiménez, Jordi AU - Etzelmueller, Anne AU - Kolovos, Spyros AU - Folkvord, Frans AU - Lupiáñez-Villanueva, Francisco PY - 2021/5/11 TI - Guided Internet-Based Cognitive Behavioral Therapy for Depression: Implementation Cost-Effectiveness Study JO - J Med Internet Res SP - e27410 VL - 23 IS - 5 KW - digital health KW - telemedicine KW - eHealth KW - e?mental health KW - internet-based cognitive behavioral therapy KW - depression KW - iCBT KW - implementation KW - cost-effectiveness KW - cognitive behavioral therapy KW - CBT KW - cost N2 - Background: Major depressive disorder is a chronic condition; its prevalence is expected to grow with the aging trend of high-income countries. Internet-based cognitive-behavioral therapy has proven efficacy in treating major depressive disorder. Objective: The objective of this study was to assess the cost-effectiveness of implementing a community internet-based cognitive behavioral therapy intervention (Super@, the Spanish program for the MasterMind project) for treating major depressive disorder. Methods: The cost-effectiveness of the Super@ program was assessed with the Monitoring and Assessment Framework for the European Innovation Partnership on Active and Healthy Ageing tool, using a 3-state Markov model. Data from the cost and effectiveness of the intervention were prospectively collected from the implementation of the program by a health care provider in Badalona, Spain; the corresponding data for usual care were gathered from the literature. The health states, transition probabilities, and utilities were computed using Patient Health Questionnaire?9 scores. Results: The analysis was performed using data from 229 participants using the Super@ program. Results showed that the intervention was more costly than usual care; the discounted (3%) and nondiscounted incremental cost-effectiveness ratios were ?29,367 and ?26,484 per quality-adjusted life-year, respectively (approximately US $35,299 and $31,833, respectively). The intervention was cost-effective based on the ?30,000 willingness-to-pay threshold typically applied in Spain (equivalent to approximately $36,060). According to the deterministic sensitivity analyses, the potential reduction of costs associated with intervention scale-up would reduce the incremental cost-effectiveness ratio of the intervention, although it remained more costly than usual care. A discount in the incremental effects up to 5% exceeded the willingness-to-pay threshold of ?30,000. Conclusions: The Super@ program, an internet-based cognitive behavioral therapy intervention for treating major depressive disorder, cost more than treatment as usual. Nevertheless, its implementation in Spain would be cost-effective from health care and societal perspectives, given the willingness-to-pay threshold of ?30,000 compared with treatment as usual. UR - https://www.jmir.org/2021/5/e27410 UR - http://dx.doi.org/10.2196/27410 UR - http://www.ncbi.nlm.nih.gov/pubmed/33973857 ID - info:doi/10.2196/27410 ER - TY - JOUR AU - Compernolle, Sofie AU - Van Dyck, Delfien AU - Cardon, Greet AU - Brondeel, Ruben PY - 2021/5/10 TI - Exploring Breaks in Sedentary Behavior of Older Adults Immediately After Receiving Personalized Haptic Feedback: Intervention Study JO - JMIR Mhealth Uhealth SP - e26387 VL - 9 IS - 5 KW - tactile feedback KW - sitting behavior KW - sedentary behavior KW - older adults KW - mHealth intervention KW - self-monitoring N2 - Background: ?Push? components of mobile health interventions may be promising to create conscious awareness of habitual sedentary behavior; however, the effect of these components on the near-time, proximal outcome, being breaks in sedentary behavior immediately after receiving a push notification, is still unknown, especially in older adults. Objective: The aims of this study are to examine if older adults break their sedentary behavior immediately after receiving personalized haptic feedback on prolonged sedentary behavior and if the percentage of breaks differs depending on the time of the day when the feedback is provided. Methods: A total of 26 Flemish older adults (mean age 64.4 years, SD 3.8) wore a triaxial accelerometer (Activator, PAL Technologies Ltd) for 3 weeks. The accelerometer generated personalized haptic feedback by means of vibrations each time a participant sat for 30 uninterrupted minutes. Accelerometer data on sedentary behavior were used to estimate the proximal outcome, which was sedentary behavior breaks immediately (within 1, 3, and 5 minutes) after receiving personalized haptic feedback. Generalized estimating equations were used to investigate whether or not participants broke up their sedentary behavior immediately after receiving haptic feedback. A time-related variable was added to the model to investigate if the sedentary behavior breaks differed depending on the time of day. Results: A total of 2628 vibrations were provided to the participants during the 3-week intervention period. Of these 2628 vibrations, 379 (14.4%), 570 (21.7%), and 798 (30.4%) resulted in a sedentary behavior break within 1, 3 and 5 minutes, respectively. Although the 1-minute interval did not reveal significant differences in the percentage of breaks depending on the time at which the haptic feedback was provided, the 3- and 5-minute intervals did show significant differences in the percentage of breaks depending on the time at which the haptic feedback was provided. Concretely, the percentage of sedentary behavior breaks was significantly higher if personalized haptic feedback was provided between noon and 3 PM compared to if the feedback was provided between 6 and 9 AM (odds ratio 1.58, 95% CI 1.01-2.47, within 3 minutes; odds ratio 1.78, 95% CI 1.11-2.84, within 5 minutes). Conclusions: The majority of haptic vibrations, especially those in the morning, did not result in a break in the sedentary behavior of older adults. As such, simply bringing habitual sedentary behavior into conscious awareness seems to be insufficient to target sedentary behavior. More research is needed to optimize push components in interventions aimed at the reduction of the sedentary behavior of older adults. Trial Registration: ClinicalTrials.gov NCT04003324; https://clinicaltrials.gov/ct2/show/NCT04003324 UR - https://mhealth.jmir.org/2021/5/e26387 UR - http://dx.doi.org/10.2196/26387 UR - http://www.ncbi.nlm.nih.gov/pubmed/33970109 ID - info:doi/10.2196/26387 ER - TY - JOUR AU - Graham, K. Andrea AU - Munson, A. Sean AU - Reddy, Madhu AU - Neubert, W. Sarah AU - Green, A. Emilie AU - Chang, Angela AU - Spring, Bonnie AU - Mohr, C. David AU - Wildes, E. Jennifer PY - 2021/5/10 TI - Integrating User-Centered Design and Behavioral Science to Design a Mobile Intervention for Obesity and Binge Eating: Mixed Methods Analysis JO - JMIR Form Res SP - e23809 VL - 5 IS - 5 KW - obesity KW - binge eating KW - user-centered design KW - mobile intervention KW - engagement KW - experimental therapeutics N2 - Background: Accounting for how end users engage with technologies is imperative for designing an efficacious mobile behavioral intervention. Objective: This mixed methods analysis examined the translational potential of user-centered design and basic behavioral science to inform the design of a new mobile intervention for obesity and binge eating. Methods: A total of 22 adults (7/22, 32% non-Hispanic White; 8/22, 36% male) with self-reported obesity and recurrent binge eating (?12 episodes in 3 months) who were interested in losing weight and reducing binge eating completed a prototyping design activity over 1 week. Leveraging evidence from behavioral economics on choice architecture, participants chose treatment strategies from 20 options (aligned with treatment targets composing a theoretical model of the relation between binge eating and weight) to demonstrate which strategies and treatment targets are relevant to end users. The process by which participants selected and implemented strategies and their change in outcomes were analyzed. Results: Although prompted to select one strategy, participants selected between 1 and 3 strategies, citing perceived achievability, helpfulness, or relevance as selection reasons. Over the week, all practiced a strategy at least once; 82% (18/22) struggled with implementation, and 23% (5/22) added a new strategy. Several themes emerged on successes and challenges with implementation, yielding design implications for supporting users in behavior change. In postexperiment reflections, 82% (18/22) indicated the strategy was helpful, and 86% (19/22) planned to continue use. One-week average within-subject changes in weight (?2.2 [SD ?5.0] pounds) and binge eating (?1.6 [SD ?1.8] episodes) indicated small clinical improvement. Conclusions: Applying user-centered design and basic behavioral science yielded design insights to incorporate personalization through user choice with guidance, which may enhance engagement with and potential efficacy of digital health interventions. UR - https://formative.jmir.org/2021/5/e23809 UR - http://dx.doi.org/10.2196/23809 UR - http://www.ncbi.nlm.nih.gov/pubmed/33970114 ID - info:doi/10.2196/23809 ER - TY - JOUR AU - Hadjistavropoulos, D. Heather AU - McCall, C. Hugh AU - Thiessen, L. David AU - Huang, Ziyin AU - Carleton, Nicholas R. AU - Dear, F. Blake AU - Titov, Nickolai PY - 2021/5/5 TI - Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study JO - J Med Internet Res SP - e27610 VL - 23 IS - 5 KW - internet KW - cognitive behavior therapy KW - anxiety KW - depression KW - posttraumatic stress disorder KW - public safety personnel KW - CBT KW - internet-based cognitive behavioral therapy KW - ICBT KW - PTSD KW - outcome KW - diagnosis KW - longitudinal KW - observational KW - literature KW - effectiveness N2 - Background: Canadian public safety personnel (PSP) experience high rates of mental health disorders and face many barriers to treatment. Internet-delivered cognitive behavioral therapy (ICBT) overcomes many such barriers, and is effective for treating depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. Objective: This study was designed to fill a gap in the literature regarding the use of ICBT tailored specifically for PSP. We examined the effectiveness of a tailored ICBT program for treating depression, anxiety, and PTSD symptoms among PSP in the province of Saskatchewan. Methods: We employed a longitudinal single-group open-trial design (N=83) with outcome measures administered at screening and at 8 weeks posttreatment. Data were collected between December 5, 2019 and September 11, 2020. Primary outcomes included changes in depression, anxiety, and PTSD symptoms. Secondary outcomes included changes in functional impairment; symptoms of panic, social anxiety, and anger; as well as treatment satisfaction, working alliance, and program usage patterns. Results: Clients reported large symptom reductions on measures of depression and anxiety, as well as moderate reductions on measures of PTSD and secondary symptoms, except for social anxiety. Most clients who reported symptoms above clinical cut-offs on measures of depression, anxiety, and PTSD during screening experienced clinically significant symptom reductions. Results suggested good engagement, treatment satisfaction, and working alliance. Conclusions: Tailored, transdiagnostic ICBT demonstrated promising outcomes as a treatment for depression, anxiety, and PTSD among Saskatchewan PSP and warrants further investigation. Trial Registration: Clinicaltrials.gov NCT04127032; https://www.clinicaltrials.gov/ct2/show/NCT04127032 UR - https://www.jmir.org/2021/5/e27610 UR - http://dx.doi.org/10.2196/27610 UR - http://www.ncbi.nlm.nih.gov/pubmed/33949959 ID - info:doi/10.2196/27610 ER - TY - JOUR AU - Fahey, C. Margaret AU - Klesges, C. Robert AU - Kocak, Mehmet AU - Gladney, A. Leslie AU - Talcott, W. Gerald AU - Krukowski, A. Rebecca PY - 2021/5/5 TI - Counselor Efficiency at Providing Feedback in a Technology-Based Behavioral Weight Loss Intervention: Longitudinal Analysis JO - JMIR Form Res SP - e23974 VL - 5 IS - 5 KW - technology-based intervention KW - counselor communication KW - counselor feedback KW - counselor KW - weight loss KW - lifestyle KW - wellness N2 - Background: Feedback for participants? self-monitoring is a crucial and costly component of technology-based weight loss interventions. Detailed examination of interventionist time when reviewing and providing feedback for online self-monitoring data is lacking. Objective: The aim of this study was to longitudinally examine the time counselors spent providing feedback on participant self-monitoring data (ie, diet, physical activity, weight) in a 12-month technology-based weight loss intervention. We hypothesized that counselors would compose feedback for participants more quickly over time. Methods: The time the lay counselors (N=10) spent reviewing self-monitoring records and providing feedback to participants via email was longitudinally examined for all counselors across the three years of study implementation. Descriptives were observed for counselor feedback duration across counselors by 12 annual quarters (ie, 3-month periods). Differences in overall duration times by each consecutive annual quarter were analyzed using Wilcoxon-Mann-Whitney tests. Results: There was a decrease in counselor feedback duration from the first to second quarter (mean 53 to 46 minutes; P<.001), and from the second to third (mean 46 to 30 minutes; P<.001). A trend suggested a decrease from the third to fourth quarter (mean 30 to 26 minutes; P=.053), but no changes were found in subsequent quarters. Consistent with the hypothesis, counselors may be increasing their efficiency in providing feedback; across 12 months, counselors spent less time reviewing participant self-monitoring and composing feedback (decreasing from mean 53 to 26 minutes). Conclusions: Counselors used increasingly less time to review online self-monitoring data and compose feedback after the initial 9 months of study implementation. Results inform counselor costs for future technology-based behavioral weight loss interventions. For example, regardless of increasing counselor efficiency, 25-30 minutes per feedback message is a high cost for interventions. One possibility for reducing costs would be generating computer-automated feedback. Trial Registration: ClinicalTrials.gov NCT02063178; https://clinicaltrials.gov/ct2/show/NCT02063178 UR - https://formative.jmir.org/2021/5/e23974 UR - http://dx.doi.org/10.2196/23974 UR - http://www.ncbi.nlm.nih.gov/pubmed/33949954 ID - info:doi/10.2196/23974 ER - TY - JOUR AU - Bertrand, Romain AU - Vrkljan, Brenda AU - Kühne, Nicolas AU - Charvoz, Linda AU - Vuillerme, Nicolas PY - 2021/5/4 TI - Interpersonal Perception of Time-Use Patterns in Romantic Relationships: Protocol for the IP-COUPLES Study JO - JMIR Res Protoc SP - e21306 VL - 10 IS - 5 KW - behavioral disciplines and activities KW - daily living activities KW - health KW - human activities KW - interpersonal relations KW - social interactions KW - spouses N2 - Background: Perceptual congruence has been defined as the level of agreement between partners on various aspects of their shared lives, including perceived engagement in individual and jointly performed activities. While the level of adjustment made by partners to such activities is thought to contribute to a couple?s sense of mutuality, perceptions of time use concerning activity engagement has yet to be considered. As such, this study will determine the level of perceptual congruence between partners with respect to perceived time use in their respective and shared activities. Objective: The primary objective of the IP-COUPLES study is to determine the similarities and differences between partners in terms of their perceptual congruence with respect to independent and jointly performed activities. This study will also examine the association between independent and joint activities in terms of perceptual congruence of time use and the strength of this association. Methods: This descriptive observational study includes 100 couples from Western Switzerland who are recruited using snowball sampling methods. The Life Balance Inventory (LBI), a self-report questionnaire that captures activity configuration congruence, will measure independent and joint perceptions of both time use allocated to daily activities and corresponding satisfaction. Due to COVID-19, the protocol can be administered virtually by the primary investigator. The mean scores of perceptual congruence variables will be used for analysis, namely perceived congruence of time use in terms of independent and jointly performed activities. For the first objective, an independent t test will be used for each variable to compare the mean score between activities on the LBI. For the second objective, the correlations between the mean scores for these activities will be calculated for each variable using the Pearson correlation. Results: The IP-COUPLES study protocol was developed in 2019 and 2020. Enrollment began in June 2020. Data collection will continue until October 2021 to account for time needed for recruitment due to the COVID-19 pandemic crisis. Analysis and presentation of results are expected in 2022. Conclusions: This study is exploratory, as it is the first to our knowledge to investigate how perceived time-use patterns with respect to independent or jointly performed activities are similar or different among romantic couples. By investigating the interpersonal perception of time-use patterns among couples, the IP-COUPLES study is an important first step to understanding how romantic partners? daily activities are contributing to the level of satisfaction as a partner and as a couple and to the sense of mutuality between partners in a romantic relationship. International Registered Report Identifier (IRRID): DERR1-10.2196/21306 UR - https://www.researchprotocols.org/2021/5/e21306 UR - http://dx.doi.org/10.2196/21306 UR - http://www.ncbi.nlm.nih.gov/pubmed/33944792 ID - info:doi/10.2196/21306 ER - TY - JOUR AU - Ashraf, Sania AU - Bicchieri, Cristina AU - Delea, G. Maryann AU - Das, Upasak AU - Chauhan, Kavita AU - Kuang, Jinyi AU - Shpenev, Alex AU - Thulin, Erik PY - 2021/5/3 TI - Norms and Social Network?Centric Behavior Change Intervention (Nam Nalavazhvu) for Improved Toilet Usage in Peri-Urban Communities of Tamil Nadu: Protocol for a Cluster-Randomized Controlled Trial JO - JMIR Res Protoc SP - e24407 VL - 10 IS - 5 KW - sanitation KW - behavior change KW - social norms KW - toilet N2 - Background: Inconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings. Objective: The objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India. Methods: Following formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for ?our well-being?). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people?s sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals. Results: We enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context. Conclusions: Findings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage. Trial Registration: ClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824 International Registered Report Identifier (IRRID): DERR1-10.2196/24407 UR - https://www.researchprotocols.org/2021/5/e24407 UR - http://dx.doi.org/10.2196/24407 UR - http://www.ncbi.nlm.nih.gov/pubmed/33938805 ID - info:doi/10.2196/24407 ER - TY - JOUR AU - Mönninghoff, Annette AU - Kramer, Niklas Jan AU - Hess, Jan Alexander AU - Ismailova, Kamila AU - Teepe, W. Gisbert AU - Tudor Car, Lorainne AU - Müller-Riemenschneider, Falk AU - Kowatsch, Tobias PY - 2021/4/30 TI - Long-term Effectiveness of mHealth Physical Activity Interventions: Systematic Review and Meta-analysis of Randomized Controlled Trials JO - J Med Internet Res SP - e26699 VL - 23 IS - 4 KW - mHealth KW - physical activity KW - systematic review KW - meta-analysis KW - mobile phone N2 - Background: Mobile health (mHealth) interventions can increase physical activity (PA); however, their long-term impact is not well understood. Objective: The primary aim of this study is to understand the immediate and long-term effects of mHealth interventions on PA. The secondary aim is to explore potential effect moderators. Methods: We performed this study according to the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched PubMed, the Cochrane Library, SCOPUS, and PsycINFO in July 2020. Eligible studies included randomized controlled trials of mHealth interventions targeting PA as a primary outcome in adults. Eligible outcome measures were walking, moderate-to-vigorous physical activity (MVPA), total physical activity (TPA), and energy expenditure. Where reported, we extracted data for 3 time points (ie, end of intervention, follow-up ?6 months, and follow-up >6 months). To explore effect moderators, we performed subgroup analyses by population, intervention design, and control group type. Results were summarized using random effects meta-analysis. Risk of bias was assessed using the Cochrane Collaboration tool. Results: Of the 2828 identified studies, 117 were included. These studies reported on 21,118 participants with a mean age of 52.03 (SD 14.14) years, of whom 58.99% (n=12,459) were female. mHealth interventions significantly increased PA across all the 4 outcome measures at the end of intervention (walking standardized mean difference [SMD] 0.46, 95% CI 0.36-0.55; P<.001; MVPA SMD 0.28, 95% CI 0.21-0.35; P<.001; TPA SMD 0.34, 95% CI 0.20-0.47; P<.001; energy expenditure SMD 0.44, 95% CI 0.13-0.75; P=.01). Only 33 studies reported short-term follow-up measurements, and 8 studies reported long-term follow-up measurements in addition to end-of-intervention results. In the short term, effects were sustained for walking (SMD 0.26, 95% CI 0.09-0.42; P=.002), MVPA (SMD 0.20, 95% CI 0.05-0.35; P=.008), and TPA (SMD 0.53, 95% CI 0.13-0.93; P=.009). In the long term, effects were also sustained for walking (SMD 0.25, 95% CI 0.10-0.39; P=.001) and MVPA (SMD 0.19, 95% CI 0.11-0.27; P<.001). We found the study population to be an effect moderator, with higher effect scores in sick and at-risk populations. PA was increased both in scalable and nonscalable mHealth intervention designs and regardless of the control group type. The risk of bias was rated high in 80.3% (94/117) of the studies. Heterogeneity was significant, resulting in low to very low quality of evidence. Conclusions: mHealth interventions can foster small to moderate increases in PA. The effects are maintained long term; however, the effect size decreases over time. The results encourage using mHealth interventions in at-risk and sick populations and support the use of scalable mHealth intervention designs to affordably reach large populations. However, given the low evidence quality, further methodologically rigorous studies are warranted to evaluate the long-term effects. UR - https://www.jmir.org/2021/4/e26699 UR - http://dx.doi.org/10.2196/26699 UR - http://www.ncbi.nlm.nih.gov/pubmed/33811021 ID - info:doi/10.2196/26699 ER - TY - JOUR AU - Alavi, Nazanin AU - Stephenson, Callum AU - Rivera, Margo PY - 2021/4/30 TI - Effectiveness of Delivering Dialectical Behavioral Therapy Techniques by Email in Patients With Borderline Personality Disorder: Nonrandomized Controlled Trial JO - JMIR Ment Health SP - e27308 VL - 8 IS - 4 KW - borderline personality disorder KW - treatment KW - psychotherapy KW - dialectical behavioral therapy KW - barriers to treatment KW - mental health KW - online KW - internet KW - electronic N2 - Background: Borderline personality disorder is a debilitating and prevalent mental health disorder, with often inaccessible treatment options. Electronically delivered dialectical behavioral therapy could be an efficacious and more accessible intervention. Objective: We aimed to evaluate the efficacy of electronic delivery of dialectical behavioral therapy in the treatment of individuals with symptoms of borderline personality disorder. Methods: Study participants diagnosed with borderline personality disorder were offered either an email-based or in-person group format dialectical behavioral therapy skill-building program. During each session, participants were provided with both the material and feedback regarding their previous week?s homework. Electronically delivered dialectical behavioral therapy protocol and content were designed to mirror in-person content. Participants were assessed using the Self-Assessment Questionnaire (SAQ) and Difficulties in Emotion Regulation Scale (DERS). Results: There were significant increases in SAQ scores from pre- to posttreatment in the electronic delivery group (F1,92=69.32, P<.001) and in-person group (F1,92=60.97, P<.001). There were no significant differences observed between the groups at pre- and posttreatment for SAQ scores (F1,92=.05, P=.83). There were significant decreases in DERS scores observed between pre- and posttreatment in the electronic delivery group (F1,91=30.15, P<.001) and the in-person group (F1,91=58.18, P<.001). There were no significant differences observed between the groups for DERS scores pre- and posttreatment (F1,91=.24, P=.63). There was no significant difference in treatment efficacy observed between the 2 treatment arms (P<.001). Conclusions: Despite the proven efficacy of in-person dialectical behavioral therapy in the treatment of borderline personality disorder, there are barriers to receiving this treatment. With the prevalence of internet access continuing to rise globally, delivering dialectical behavioral therapy with email may provide a more accessible alternative to treatment for individuals with borderline personality disorder without sacrificing the quality of care. Trial Registration: ClinicalTrials.gov NCT04493580; https://clinicaltrials.gov/ct2/show/NCT04493580 UR - https://mental.jmir.org/2021/4/e27308 UR - http://dx.doi.org/10.2196/27308 UR - http://www.ncbi.nlm.nih.gov/pubmed/33835936 ID - info:doi/10.2196/27308 ER - TY - JOUR AU - Nagawa, S. Catherine AU - Faro, M. Jamie AU - Menon, J. Anitha AU - Ito Fukunaga, Mayuko AU - Williams, H. Jessica AU - Mourao, Dalton AU - Emidio, M. Oluwabunmi AU - Davis, Maryann AU - Pbert, Lori AU - Cutrona, L. Sarah AU - Houston, K. Thomas AU - Sadasivam, S. Rajani PY - 2021/4/30 TI - Written Advice Given by African American Smokers to Their Peers: Qualitative Study of Motivational Messages JO - JMIR Form Res SP - e21481 VL - 5 IS - 4 KW - tobacco disparities KW - peer-to-peer KW - communication KW - smoking KW - cessation KW - thematic analysis KW - intervention KW - African American N2 - Background: Although African Americans have the lowest rates of smoking onset and progression to daily smoking, they are less likely to achieve long-term cessation. Interventions tailored to promote use of cessation resources in African American individuals who smoke are needed. In our past work, we demonstrated the effectiveness of a technology-assisted peer-written message intervention for increasing smoking cessation in non-Hispanic White smokers. In this formative study, we have adapted this intervention to be specific for African American smokers. Objective: We aimed to report on the qualitative analysis of messages written by African American current and former smokers for their peers in response to hypothetical scenarios of smokers facing cessation challenges. Methods: We recruited African American adult current and former smokers (n=41) via ResearchMatch between April 2017 and November 2017. We asked participants to write motivational messages for their peers in response to smoking-related hypothetical scenarios. We also collected data on sociodemographic factors and smoking characteristics. Thematic analysis was conducted to identify cessation strategies suggested by the study participants. Results: Among the study participants, 60% (25/41) were female. Additionally, more than half (23/41, 56%) were thinking about quitting, 29% (12/41) had set a quit date, and 27% (11/41) had used electronic cigarettes in the past 30 days. Themes derived from the qualitative analysis of peer-written messages were (1) behavioral strategies, (2) seeking help, (3) improvements in quality of life, (4) attitudes and expectations, and (5) mindfulness/religious or spiritual practices. Under the behavioral strategies theme, distraction strategies were the most frequently suggested strategies (referenced 84 times in the 318 messages), followed by use of evidence-based treatments/cessation strategies. Within the seeking help theme, subthemes included seeking help or support from family/friends or close social networks (referenced 56 times) and health care professionals (referenced 22 times). The most frequent subthemes that emerged from improvements in the quality of life theme included improving one?s health (referenced 22 times) and quality of life (referenced 21 times). Subthemes that emerged from the attitude and expectations theme included practicing positive self-talk (referenced 27 times), autonomy/independence from the smoking habit (referenced six times), and financial cost of smoking (referenced five times). The two subthemes that emerged from the mindfulness/religious or spiritual practices theme were use of self-awareness techniques (referenced 36 times) and religious or spiritual practices to cope (referenced 13 times). Conclusions: Our approach to adapt a prior peer-message intervention to African American smokers yielded a set of evidence-based messages that may be suitable for smokers at all phases of motivation to quit (ready to quit or not ready to quit). In future research, we plan to assess the impact of texting these messages to African American smokers in a smoking cessation trial. UR - https://formative.jmir.org/2021/4/e21481 UR - http://dx.doi.org/10.2196/21481 UR - http://www.ncbi.nlm.nih.gov/pubmed/33929332 ID - info:doi/10.2196/21481 ER - TY - JOUR AU - McCall, C. Hugh AU - Hadjistavropoulos, D. Heather AU - Sundström, Francis Christopher Richard PY - 2021/4/29 TI - Exploring the Role of Persuasive Design in Unguided Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Adults: Systematic Review, Meta-analysis, and Meta-regression JO - J Med Internet Res SP - e26939 VL - 23 IS - 4 KW - ICBT KW - internet KW - depression KW - anxiety KW - persuasive design KW - eHealth N2 - Background: Internet-delivered cognitive behavioral therapy (ICBT) is an effective treatment that can overcome barriers to mental health care. Various research groups have suggested that unguided ICBT (ie, ICBT without therapist support) and other eHealth interventions can be designed to enhance user engagement and thus outcomes. The persuasive systems design framework captures most design recommendations for eHealth interventions, but there is little empirical evidence that persuasive design is related to clinical outcomes in unguided ICBT. Objective: This study aims to provide an updated meta-analysis of randomized controlled trials of unguided ICBT for depression and anxiety, describe the frequency with which various persuasive design principles are used in such interventions, and use meta-regression to explore whether a greater number of persuasive design elements predicts efficacy in unguided ICBT for depression and anxiety. Methods: We conducted a systematic review of 5 databases to identify randomized controlled trials of unguided ICBT for depression and anxiety. We conducted separate random effects meta-analyses and separate meta-regressions for depression and anxiety interventions. Each meta-regression included 2 steps. The first step included, as a predictor, whether each intervention was transdiagnostic. For the meta-regression of ICBT for depression, the first step also included the type of control condition. The number of persuasive design principles identified for each intervention was added as a predictor in the second step to reveal the additional variance in effect sizes explained by persuasive design. Results: Of the 4471 articles we identified in our search, 46 (1.03%) were eligible for inclusion in our analyses. Our meta-analyses showed effect sizes (Hedges g) ranging from 0.22 to 0.31 for depression interventions, depending on the measures taken to account for bias in the results. We found a mean effect size of 0.45 (95% CI 0.33-0.56) for anxiety interventions, with no evidence that the results were inflated by bias. Included interventions were identified as using between 1 and 13 persuasive design principles, with an average of 4.95 (SD 2.85). The meta-regressions showed that a greater number of persuasive design principles predicted greater efficacy in ICBT for depression (R2 change=0.27; B=0.04; P=.02) but not anxiety (R2 change=0.05; B=0.03; P=.17). Conclusions: These findings show wide variability in the use of persuasive design in unguided ICBT for depression and anxiety and provide preliminary support for the proposition that more persuasively designed interventions are more efficacious, at least in the treatment of depression. Further research is needed to clarify the role of persuasive design in ICBT. UR - https://www.jmir.org/2021/4/e26939 UR - http://dx.doi.org/10.2196/26939 UR - http://www.ncbi.nlm.nih.gov/pubmed/33913811 ID - info:doi/10.2196/26939 ER - TY - JOUR AU - Albright, Glenn AU - Khalid, Nikita AU - Shockley, Kristen AU - Robinson, Kelsey AU - Hughes, Kevin AU - Pace-Danley, Bethany PY - 2021/4/29 TI - Innovative Virtual Role Play Simulations for Managing Substance Use Conversations: Pilot Study Results and Relevance During and After COVID-19 JO - JMIR Form Res SP - e27164 VL - 5 IS - 4 KW - simulations KW - behavior change KW - motivational interviewing KW - virtual humans KW - role play KW - substance use KW - prevention KW - alcohol KW - public awareness KW - innovation KW - interview KW - COVID-19 KW - pilot study KW - simulation KW - communication KW - problem solving N2 - Background: Substance use places a substantial burden on our communities, both economically and socially. In light of COVID-19, it is predicted that as many as 75,000 more people will die from alcohol and other substance use and suicide as a result of isolation, new mental health concerns, and various other stressors related to the pandemic. Public awareness campaigns that aim to destigmatize substance use and help individuals have meaningful conversations with friends, coworkers, or family members to address substance use concerns are a timely and cost-effective means of augmenting existing behavioral health efforts related to substance use. These types of interventions can supplement the work being done by existing public health initiatives. Objective: This pilot study examines the impact of the One Degree: Shift the Influence role play simulation, designed to teach family, friends, and coworkers to effectively manage problem-solving conversations with individuals that they are concerned about regarding substance use. Methods: Participants recruited for this mixed methods study completed a presurvey, the simulation, and a postsurvey, and were sent a 6-week follow-up survey. The simulation involves practicing a role play conversation with a virtual human coded with emotions, a memory, and a personality. A virtual coach provides feedback in using evidence-based communication strategies such as motivational interviewing. Results: A matched sample analysis of variance revealed significant increases at follow-up in composite attitudinal constructs of preparedness (P<.001) and self-efficacy (P=.01), including starting a conversation with someone regarding substance use, avoiding upsetting someone while bringing up concerns, focusing on observable facts, and problem solving. Qualitative data provided further evidence of the simulation?s positive impact on the ability to have meaningful conversations about substance use. Conclusions: This study provides preliminary evidence that conversation-based simulations like One Degree: Shift the Influence that use role play practice can teach individuals to use evidence-based communication strategies and can cost-effectively reach geographically dispersed populations to support public health initiatives for primary prevention. UR - https://formative.jmir.org/2021/4/e27164 UR - http://dx.doi.org/10.2196/27164 UR - http://www.ncbi.nlm.nih.gov/pubmed/33848972 ID - info:doi/10.2196/27164 ER - TY - JOUR AU - Litrownik, Daniel AU - Gilliam, A. Elizabeth AU - Wayne, M. Peter AU - Richardson, R. Caroline AU - Kadri, Reema AU - Rist, M. Pamela AU - Moy, L. Marilyn AU - Yeh, Y. Gloria PY - 2021/4/29 TI - Development of a Novel Intervention (Mindful Steps) to Promote Long-Term Walking Behavior in Chronic Cardiopulmonary Disease: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e27826 VL - 10 IS - 4 KW - mind?body exercise KW - internet-mediated intervention KW - behavior change KW - physical activity KW - COPD KW - heart failure N2 - Background: Despite current rehabilitation programs, long-term engagement in physical activity remains a significant challenge for patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF). Novel strategies to promote physical activity in these populations are greatly needed. Emerging literature on the benefits of both mind?body interventions and web-based interventions provide the rationale for the development of the Mindful Steps intervention for increasing walking behavior. Objective: This study aims to develop a novel multimodal mind?body exercise intervention through adaptation of an existing web-based physical activity intervention and incorporation of mind?body exercise, and to pilot test the delivery of the new intervention, Mindful Steps, in a randomized controlled feasibility trial in older adults with COPD and/or HF. Methods: In phase 1, guided by a theoretical conceptual model and review of the literature on facilitators and barriers of physical activity in COPD and HF, we convened an expert panel of researchers, mind?body practitioners, and clinicians to inform development of the novel, multimodal intervention. In phase 2, we are conducting a pilot randomized controlled feasibility trial of the Mindful Steps intervention that includes in-person mind?body exercise classes, an educational website, online mind?body videos, and a pedometer with step-count feedback and goals to increase walking behavior in patients with COPD and/or HF. Outcomes include feasibility measures as well as patient-centered measures. Results: The study is currently ongoing. Phase 1 intervention development was completed in March 2019, and phase 2 data collection began in April 2019. Conclusions: Through the integration of components from a web-based physical activity intervention and mind?body exercise, we created a novel, multimodal program to impact long-term physical activity engagement for individuals with COPD and HF. This developmental work and pilot study will provide valuable information needed to design a future clinical trial assessing efficacy of this multimodal approach. Trial Registration: ClinicalTrials.gov NCT03003780; https://clinicaltrials.gov/ct2/show/NCT03003780 International Registered Report Identifier (IRRID): DERR1-10.2196/27826 UR - https://www.researchprotocols.org/2021/4/e27826 UR - http://dx.doi.org/10.2196/27826 UR - http://www.ncbi.nlm.nih.gov/pubmed/33913819 ID - info:doi/10.2196/27826 ER - TY - JOUR AU - McKeon, Grace AU - Steel, Zachary AU - Wells, Ruth AU - Newby, Jill AU - Hadzi-Pavlovic, Dusan AU - Vancampfort, Davy AU - Rosenbaum, Simon PY - 2021/4/22 TI - A Mental Health?Informed Physical Activity Intervention for First Responders and Their Partners Delivered Using Facebook: Mixed Methods Pilot Study JO - JMIR Form Res SP - e23432 VL - 5 IS - 4 KW - physical activity KW - PTSD KW - social media KW - first responders KW - mental health KW - families KW - online KW - exercise N2 - Background: First responders (eg, police, firefighters, and paramedics) are at high risk of experiencing poor mental health. Physical activity interventions can help reduce symptoms and improve mental health in this group. More research is needed to evaluate accessible, low-cost methods of delivering programs. Social media may be a potential platform for delivering group-based physical activity interventions. Objective: This study aims to examine the feasibility and acceptability of delivering a mental health?informed physical activity program for first responders and their self-nominated support partners. This study also aims to assess the feasibility of applying a novel multiple time series design and to explore the impact of the intervention on mental health symptoms, sleep quality, quality of life, and physical activity levels. Methods: We co-designed a 10-week web-based physical activity program delivered via a private Facebook group. We provided education and motivation around different topics weekly (eg, goal setting, overcoming barriers to exercise, and reducing sedentary behavior) and provided participants with a Fitbit. A multiple time series design was applied to assess psychological distress levels, with participants acting as their own control before the intervention. Results: In total, 24 participants (12 first responders and 12 nominated support partners) were recruited, and 21 (88%) completed the postassessment questionnaires. High acceptability was observed in the qualitative interviews. Exploratory analyses revealed significant reductions in psychological distress during the intervention. Preintervention and postintervention analysis showed significant improvements in quality of life (P=.001; Cohen d=0.60); total depression, anxiety, and stress scores (P=.047; Cohen d=0.35); and minutes of walking (P=.04; Cohen d=0.55). Changes in perceived social support from family (P=.07; Cohen d=0.37), friends (P=.10; Cohen d=0.38), and sleep quality (P=.28; Cohen d=0.19) were not significant. Conclusions: The results provide preliminary support for the use of social media and a multiple time series design to deliver mental health?informed physical activity interventions for first responders and their support partners. Therefore, an adequately powered trial is required. Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN): 12618001267246; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001267246. UR - https://formative.jmir.org/2021/4/e23432 UR - http://dx.doi.org/10.2196/23432 UR - http://www.ncbi.nlm.nih.gov/pubmed/33885376 ID - info:doi/10.2196/23432 ER - TY - JOUR AU - Musgrave, M. Loretta AU - Baum, Alison AU - Perera, Nilushka AU - Homer, SE Caroline AU - Gordon, Adrienne PY - 2021/4/15 TI - Baby Buddy App for Breastfeeding and Behavior Change: Retrospective Study of the App Using the Behavior Change Wheel JO - JMIR Mhealth Uhealth SP - e25668 VL - 9 IS - 4 KW - breastfeeding KW - app KW - digital health KW - smartphone app KW - behavior change wheel KW - digital behavior change intervention N2 - Background: Breastfeeding plays a major role in the health of mothers and babies and has the potential to positively shape an individual?s life both in the short and long term. In the United Kingdom (UK), although 81% of women initiate breastfeeding, only 1% of women breastfeed exclusively to 6 months as recommended by the World Health Organization. In the UK, women who are socially disadvantaged and younger are less likely to breastfeed at 6 to 8 weeks postpartum. One strategy that aims to improve these statistics is the Baby Buddy app, which has been designed and implemented by the UK charity Best Beginnings to be a universal intervention to help reduce health inequalities, including those in breastfeeding. Objective: This study aimed to retrospectively examine the development of Baby Buddy by applying the Behavior Change Wheel (BCW) framework to understand how it might increase breastfeeding self-efficacy, knowledge, and confidence. Methods: Retrospective application of the BCW was completed after the app was developed and embedded into maternity services. A three-stage process evaluation used triangulation methods and formalized tools to gain an understanding of the potential mechanisms and behaviors used in apps that are needed to improve breastfeeding rates in the UK. First, we generated a behavioral analysis by mapping breastfeeding barriers and enablers onto the Capability, Opportunity, and Motivation-Behavior (COM-B) system using documents provided by Best Beginnings. Second, we identified the intervention functions and policy categories used. Third, we linked these with the behavior change techniques identified in the app breastfeeding content using the Behavior Change Techniques Taxonomy (BCTTv1). Results: Baby Buddy is a well-designed platform that could be used to change breastfeeding behaviors. Findings from stage one showed that Best Beginnings had defined breastfeeding as a key behavior requiring support and demonstrated a thorough understanding of the context in which breastfeeding occurs, the barriers and enablers of breastfeeding, and the target actions needed to support breastfeeding. In stage two, Best Beginnings had used intervention and policy functions to address the barriers and enablers of breastfeeding. In stage three, Baby Buddy had been assessed for acceptability, practicability, effectiveness, affordability, safety, and equity. Several behavior change techniques that could assist women with decision making around breastfeeding (eg, information about health consequences and credible sources) and possibly affect attitudes and self-efficacy were identified. Of the 39 videos in the app, 19 (49%) addressed physical capabilities related to breastfeeding and demonstrated positive breastfeeding behaviors. Conclusions: Applying a theoretical framework retrospectively to a mobile app is possible and results in useful information to understand potential health benefits and to inform future development. Future research should assess which components and behavioral techniques in the app are most effective in changing behavior and supporting breastfeeding. UR - https://mhealth.jmir.org/2021/4/e25668 UR - http://dx.doi.org/10.2196/25668 UR - http://www.ncbi.nlm.nih.gov/pubmed/33856351 ID - info:doi/10.2196/25668 ER - TY - JOUR AU - Langlet, Sundström Billy AU - Odegi, Dorothy AU - Zandian, Modjtaba AU - Nolstam, Jenny AU - Södersten, Per AU - Bergh, Cecilia PY - 2021/4/13 TI - Virtual Reality App for Treating Eating Behavior in Eating Disorders: Development and Usability Study JO - JMIR Serious Games SP - e24998 VL - 9 IS - 2 KW - feeding and eating disorders KW - anorexia nervosa KW - bulimia nervosa KW - binge eating disorder KW - immersive virtual reality KW - eating disorders KW - virtual reality N2 - Background: Anorexia nervosa is one of the more severe eating disorders, which is characterized by reduced food intake, leading to emaciation and psychological maladjustment. Treatment outcomes are often discouraging, with most interventions displaying a recovery rate below 50%, a dropout rate from 20% to 50%, and a high risk of relapse. Patients with anorexia nervosa often display anxiety and aversive behaviors toward food. Virtual reality has been successful in treating vertigo, anxiety disorder, and posttraumatic stress syndrome, and could potentially be used as an aid in treating eating disorders. Objective: The aim of this study was to evaluate the feasibility and usability of an immersive virtual reality technology administered through an app for use by patients with eating disorders. Methods: Twenty-six participants, including 19 eating disorder clinic personnel and 5 information technology personnel, were recruited through emails and personal invitations. Participants handled virtual food and utensils on an app using immersive virtual reality technology comprising a headset and two hand controllers. In the app, the participants learned about the available actions through a tutorial and they were introduced to a food challenge. The challenge consisted of a meal type (meatballs, potatoes, sauce, and lingonberries) that is typically difficult for patients with anorexia nervosa to eat in real life. Participants were instructed, via visual feedback from the app, to eat at a healthy rate, which is also a challenge for patients. Participants rated the feasibility and usability of the app by responding to the mHealth Evidence Reporting and Assessment checklist, the 10-item System Usability Scale, and the 20-point heuristic evaluation questionnaire. A cognitive walkthrough was performed using video recordings of participant interactions in the virtual environment. Results: The mean age of participants was 37.9 (SD 9.7) years. Half of the participants had previous experience with virtual reality. Answers to the mHealth Evidence Reporting and Assessment checklist suggested that implementation of the app would face minor infrastructural, technological, interoperability, financial, and adoption problems. There was some disagreement on intervention delivery, specifically regarding frequency of use; however, most of the participants agreed that the app should be used at least once per week. The app received a mean score of 73.4 (range 55-90), earning an overall ?good? rating. The mean score of single items of the heuristic evaluation questionnaire was 3.6 out of 5. The lowest score (2.6) was given to the ?accuracy? item. During the cognitive walkthrough, 32% of the participants displayed difficulty in understanding what to do at the initial selection screen. However, after passing the selection screen, all participants understood how to progress through the tasks. Conclusions: Participants found the app to be usable and eating disorder personnel were positive regarding its fit with current treatment methods. Along with the food item challenges in the current app, participants considered that the app requires improvement to offer environmental and social (eg, crowded room vs eating alone) challenges. UR - https://games.jmir.org/2021/2/e24998 UR - http://dx.doi.org/10.2196/24998 UR - http://www.ncbi.nlm.nih.gov/pubmed/33847593 ID - info:doi/10.2196/24998 ER - TY - JOUR AU - Porter, J. Kathleen AU - Moon, E. Katherine AU - LeBaron, T. Virginia AU - Zoellner, M. Jamie PY - 2021/4/12 TI - A Novel Behavioral Intervention for Rural Appalachian Cancer Survivors (weSurvive): Participatory Development and Proof-of-Concept Testing JO - JMIR Cancer SP - e26010 VL - 7 IS - 2 KW - cancer survivors KW - quality of life KW - behavior change KW - rural KW - feasibility KW - Appalachia N2 - Background: Addressing the modifiable health behaviors of cancer survivors is important in rural communities that are disproportionately impacted by cancer (eg, those in Central Appalachia). However, such efforts are limited, and existing interventions may not meet the needs of rural communities. Objective: This study describes the development and proof-of-concept testing of weSurvive, a behavioral intervention for rural Appalachian cancer survivors. Methods: The Obesity-Related Behavioral Intervention Trials (ORBIT) model, a systematic model for designing behavioral interventions, informed the study design. An advisory team (n=10) of community stakeholders and researchers engaged in a participatory process to identify desirable features for interventions targeting rural cancer survivors. The resulting multimodal, 13-week weSurvive intervention was delivered to 12 participants across the two cohorts. Intervention components included in-person group classes and group and individualized telehealth calls. Indicators reflecting five feasibility domains (acceptability, demand, practicality, implementation, and limited efficacy) were measured using concurrent mixed methods. Pre-post changes and effect sizes were assessed for limited efficacy data. Descriptive statistics and content analysis were used to summarize data for other domains. Results: Participants reported high program satisfaction (acceptability). Indicators of demand included enrollment of cancer survivors with various cancer types and attrition (1/12, 8%), recruitment (12/41, 30%), and attendance (median 62%) rates. Dietary (7/12, 59%) and physical activity (PA; 10/12, 83%) behaviors were the most frequently chosen behavioral targets. However, the findings indicate that participants did not fully engage in action planning activities, including setting specific goals. Implementation indicators showed 100% researcher fidelity to delivery and retention protocols, whereas practicality indicators highlighted participation barriers. Pre-post changes in limited efficacy outcomes regarding cancer-specific beliefs and knowledge and behavior-specific self-efficacy, intentions, and behaviors were in desired directions and demonstrated small and moderate effect sizes. Regarding dietary and PA behaviors, effect sizes for fruit and vegetable intake, snacks, dietary fat, and minutes of moderate-to-vigorous activity were small (Cohen d=0.00 to 0.32), whereas the effect sizes for change in PA were small to medium (Cohen d=0.22 to 0.45). Conclusions: weSurvive has the potential to be a feasible intervention for rural Appalachian cancer survivors. It will be refined and further tested based on the study findings, which also provide recommendations for other behavioral interventions targeting rural cancer survivors. Recommendations included adding additional recruitment and engagement strategies to increase demand and practicality as well as increasing accountability and motivation for participant involvement in self-monitoring activities through the use of technology (eg, text messaging). Furthermore, this study highlights the importance of using a systematic model (eg, the ORBIT framework) and small-scale proof-of-concept studies when adapting or developing behavioral interventions, as doing so identifies the intervention?s potential for feasibility and areas that need improvement before time- and resource-intensive efficacy trials. This could support a more efficient translation into practice. UR - https://cancer.jmir.org/2021/2/e26010 UR - http://dx.doi.org/10.2196/26010 UR - http://www.ncbi.nlm.nih.gov/pubmed/33843597 ID - info:doi/10.2196/26010 ER - TY - JOUR AU - Mamede, André AU - Noordzij, Gera AU - Jongerling, Joran AU - Snijders, Merlijn AU - Schop-Etman, Astrid AU - Denktas, Semiha PY - 2021/4/12 TI - Combining Web-Based Gamification and Physical Nudges With an App (MoveMore) to Promote Walking Breaks and Reduce Sedentary Behavior of Office Workers: Field Study JO - J Med Internet Res SP - e19875 VL - 23 IS - 4 KW - internet KW - eHealth KW - mHealth KW - mobile phone KW - lifestyle KW - obesity KW - social network KW - multilevel analysis KW - physical exercise N2 - Background: Sedentary behavior (SB) and lack of physical activity (PA) have been associated with poorer health outcomes and are increasingly prevalent in individuals working in sedentary occupations such as office jobs. Gamification and nudges have attracted attention as promising strategies to promote changes in health behavior. However, most effectiveness studies thus far lacked active controls, and few studies have tested interventions combining these strategies. Objective: This study investigates the effectiveness of combining a gamified digital app with physical nudges to increase PA and reduce SB in Dutch office workers. Methods: Employees in the municipality of Rotterdam (N=298) from two office locations were randomized at the location level to either a 10-week intervention, combining a 5-week gamification phase encompassing a gamified digital app with social support features and a 5-week physical nudges phase, or to an active control (ie, basic digital app with self-monitoring and goal setting). The primary outcome was the daily step count, objectively measured via accelerometers. Secondary outcomes were self-reported PA and SB measured at baseline and at 5, 10, and 14 weeks. Mixed effects models were used to analyze the effects of the intervention on the outcome measures. Results: A total of 78.5% (234/298) of participants completed the study and provided accelerometer data, whereas 36.9% (110/298) participants completed the self-report measures at 14 weeks. In the gamification phase, step count data were missing for 13.5% (473/3492) of observations in the control and 11.4% (445/3888) in the intervention condition; however, these percentages increased to 39.6% (1154/2910) and 59.6% (1932/3492) at follow-up, respectively. During the gamification phase, intervention participants increased their number of daily steps by 634 (95% CI 154.2-1113.8; P=.01) more than participants in the control group, after controlling for relevant factors. Improvements were not sustained during the physical nudges phase (P=.76) or follow-up (P=.88). Conclusions: A digital intervention with gamification and social support features significantly increased the step count of office workers compared with an active control. Physical nudges in the workplace were insufficient to promote the maintenance of behavioral changes achieved in the gamification phase. Future research should explore the long-term effectiveness of similar gamified digital interventions. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN) 49129401; https://www.isrctn.com/ISRCTN14881571 UR - https://www.jmir.org/2021/4/e19875 UR - http://dx.doi.org/10.2196/19875 UR - http://www.ncbi.nlm.nih.gov/pubmed/33843593 ID - info:doi/10.2196/19875 ER - TY - JOUR AU - Thornton, Louise AU - Gardner, Anne Lauren AU - Osman, Bridie AU - Green, Olivia AU - Champion, Elizabeth Katrina AU - Bryant, Zachary AU - Teesson, Maree AU - Kay-Lambkin, Frances AU - Chapman, Cath AU - PY - 2021/4/12 TI - A Multiple Health Behavior Change, Self-Monitoring Mobile App for Adolescents: Development and Usability Study of the Health4Life App JO - JMIR Form Res SP - e25513 VL - 5 IS - 4 KW - mHealth KW - mobile phone KW - chronic disease KW - adolescents KW - health promotion N2 - Background: The link between chronic diseases and the Big 6 lifestyle risk behaviors (ie, poor diet, physical inactivity, smoking, alcohol use, sedentary recreational screen time, and poor sleep) is well established. It is critical to target these lifestyle risk behaviors, as they often co-occur and emerge in adolescence. Smartphones have become an integral part of everyday life, and many adolescents already use mobile apps to monitor their lifestyle behaviors and improve their health. Smartphones may be a valuable platform for engaging adolescents with interventions to prevent key chronic disease risk behaviors. Objective: The aim of this paper is to describe the development, usability, and acceptability of the Health4Life app, a self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. Methods: The development of the Health4Life app was an iterative process conducted in collaboration with adolescents and experts. The development process consisted of three stages: scoping the literature; end user consultations, which included a web-based survey (N=815; mean age 13.89, SD 0.89 years) and a focus group (N=12) among adolescents; and app development and beta testing. Following this development work, 232 adolescents were asked to rate the usability and acceptability of the app. Results: The process resulted in a self-monitoring smartphone app that allows adolescent users to track and set goals for the Big 6 health behaviors, using in-app rewards and notifications to enhance engagement. The overall adolescent feedback was positive in terms of user-friendly design, content, relevance, and helpfulness. Commonly identified areas for improvement were to increase interactive features and display recorded health behaviors differently to improve interpretability. Conclusions: The Health4Life app is a co-designed, self-monitoring smartphone app for adolescents that concurrently targets the Big 6 lifestyle behaviors. Adolescents rated the app as highly acceptable and usable. The app has the potential to efficiently and effectively modify important risk factors for chronic disease among young people and is currently being evaluated in a world-first trial of 6640 secondary school students in 71 schools across Australia. UR - https://formative.jmir.org/2021/4/e25513 UR - http://dx.doi.org/10.2196/25513 UR - http://www.ncbi.nlm.nih.gov/pubmed/33843590 ID - info:doi/10.2196/25513 ER - TY - JOUR AU - Jonathan, K. Geneva AU - Dopke, A. Cynthia AU - Michaels, Tania AU - Bank, Andrew AU - Martin, R. Clair AU - Adhikari, Krina AU - Krakauer, L. Rachel AU - Ryan, Chloe AU - McBride, Alyssa AU - Babington, Pamela AU - Frauenhofer, Ella AU - Silver, Jamilah AU - Capra, Courtney AU - Simon, Melanie AU - Begale, Mark AU - Mohr, C. David AU - Goulding, H. Evan PY - 2021/4/12 TI - A Smartphone-Based Self-management Intervention for Bipolar Disorder (LiveWell): User-Centered Development Approach JO - JMIR Ment Health SP - e20424 VL - 8 IS - 4 KW - behavioral intervention technology KW - mHealth KW - bipolar disorder KW - depression KW - illness management KW - smartphone KW - behavior change KW - early warning signs KW - self-management KW - qualitative N2 - Background: Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. Objective: This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions. Methods: Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback. Results: The core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support. Conclusions: User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development. UR - https://mental.jmir.org/2021/4/e20424 UR - http://dx.doi.org/10.2196/20424 UR - http://www.ncbi.nlm.nih.gov/pubmed/33843607 ID - info:doi/10.2196/20424 ER - TY - JOUR AU - Fehribach, Rhiannon Jamie AU - Toffolo, Jolien Marieke Bianca AU - Cornelisz, Ilja AU - van Klaveren, Chris AU - van Straten, Annemieke AU - van Gelder, Jean-Louis AU - Donker, Tara PY - 2021/4/12 TI - Virtual Reality Self-help Treatment for Aviophobia: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e22008 VL - 10 IS - 4 KW - aviophobia KW - specific phobia KW - virtual reality KW - cognitive behavioral therapy KW - exposure therapy N2 - Background: Aviophobia (the fear of flying) can greatly impact the daily life functioning of people with the condition. Traditional exposure-based treatment is hampered by the limited availability of airplane practice situations, which is a result of economical and practical concerns. Easily accessible and low-cost virtual reality exposure therapy may address these challenges. Objective: The purpose of our study is to investigate the effectiveness of ZeroPhobia: Aviophobia (a self-help mobile app?based treatment) in reducing flight anxiety symptoms and depressive and anxiety symptoms. We will also investigate the effects of usage intensity, the sense of immersion, inherent absorption ability, and perceived user-friendliness on the treatment effect. Methods: Participants (N=114) who are aged 18-64 years and experience at least mild symptoms of aviophobia will be recruited from the general Dutch population and randomized into a treatment group or waitlist control group. By using their own phones and rudimentary mobile virtual reality headsets, participants will receive six modules of psychoeducation and cognitive behavioral therapy, which will include six levels of virtual reality exposure therapy over a period of 6 weeks. Assessments will be conducted at baseline, posttest (ie, after 6 weeks), and 3- and 12-month follow-ups. The primary outcome measure of our study is the Flight Anxiety Situations Questionnaire. The secondary outcome measures include anxiety and depression measures and additional covariates (including usage intensity, the degree of immersion, etc). We will test treatment effectiveness by conducting an intention-to-treat analysis and estimating average treatment effects on the treated. The mechanisms of treatment effect will also be explored. Results: The study was funded on September 25, 2018. Ethical approval was received on October 11, 2019. Recruitment closed on May 7, 2020. Conclusions: Our study will further the scientific understanding and clinical implications of technology?s current ability to aid in providing effective, accessible treatment for the fear of flying. Trial Registration: Netherlands Trial Registry NL70238.029.19; https://www.trialregister.nl/trial/8257. International Registered Report Identifier (IRRID): DERR1-10.2196/22008 UR - https://www.researchprotocols.org/2021/4/e22008 UR - http://dx.doi.org/10.2196/22008 UR - http://www.ncbi.nlm.nih.gov/pubmed/33843605 ID - info:doi/10.2196/22008 ER - TY - JOUR AU - Xu, Ran AU - Cavallo, David PY - 2021/4/9 TI - Social Network Analysis of the Effects of a Social Media?Based Weight Loss Intervention Targeting Adults of Low Socioeconomic Status: Single-Arm Intervention Trial JO - J Med Internet Res SP - e24690 VL - 23 IS - 4 KW - weight loss intervention KW - social media intervention KW - electronic health KW - social network analysis N2 - Background: Obesity is a known risk factor for cardiovascular disease risk factors, including hypertension and type II diabetes. Although numerous weight loss interventions have demonstrated efficacy, there is considerably less evidence about the theoretical mechanisms through which they work. Delivering lifestyle behavior change interventions via social media provides unique opportunities for understanding mechanisms of intervention effects. Server data collected directly from web-based platforms can provide detailed, real-time behavioral information over the course of intervention programs that can be used to understand how interventions work. Objective: The objective of this study was to demonstrate how social network analysis can facilitate our understanding of the mechanisms underlying a social media?based weight loss intervention. Methods: We performed secondary analysis by using data from a pilot study that delivered a dietary and physical activity intervention to a group of participants via Facebook. We mapped out participants? interaction networks over the 12-week intervention period and linked participants? network characteristics (eg, in-degree, out-degree, network constraint) to participants? changes in theoretical mediators (ie, dietary knowledge, perceived social support, self-efficacy) and weight loss by using regression analysis. We also performed mediation analyses to explore how the effects of social network measures on weight loss could be mediated by the aforementioned theoretical mediators. Results: In this analysis, 47 participants from 2 waves completed the study and were included. We found that increases in the number of posts, comments, and reactions significantly predicted weight loss (?=?.94, P=.04); receiving comments positively predicted changes in self-efficacy (?=7.81, P=.009), and the degree to which one?s network neighbors are tightly connected with each other weakly predicted changes in perceived social support (?=7.70, P=.08). In addition, change in self-efficacy mediated the relationship between receiving comments and weight loss (?=?.89, P=.02). Conclusions: Our analyses using data from this pilot study linked participants? network characteristics with changes in several important study outcomes of interest such as self-efficacy, social support, and weight. Our results point to the potential of using social network analysis to understand the social processes and mechanisms through which web-based behavioral interventions affect participants? psychological and behavioral outcomes. Future studies are warranted to validate our results and to further explore the relationship between network dynamics and study outcomes in similar and larger trials. UR - https://www.jmir.org/2021/4/e24690 UR - http://dx.doi.org/10.2196/24690 UR - http://www.ncbi.nlm.nih.gov/pubmed/33835033 ID - info:doi/10.2196/24690 ER - TY - JOUR AU - Zhang, Chao AU - Lakens, Daniël AU - IJsselsteijn, A. Wijnand PY - 2021/4/9 TI - Theory Integration for Lifestyle Behavior Change in the Digital Age: An Adaptive Decision-Making Framework JO - J Med Internet Res SP - e17127 VL - 23 IS - 4 KW - behavior change KW - health behavior KW - digital health intervention KW - decision-making KW - learning KW - self-control KW - habits KW - theoretical framework UR - https://www.jmir.org/2021/4/e17127 UR - http://dx.doi.org/10.2196/17127 UR - http://www.ncbi.nlm.nih.gov/pubmed/33835036 ID - info:doi/10.2196/17127 ER - TY - JOUR AU - Biliunaite, Ieva AU - Kazlauskas, Evaldas AU - Sanderman, Robbert AU - Truskauskaite-Kuneviciene, Inga AU - Dumarkaite, Austeja AU - Andersson, Gerhard PY - 2021/4/7 TI - Internet-Based Cognitive Behavioral Therapy for Informal Caregivers: Randomized Controlled Pilot Trial JO - J Med Internet Res SP - e21466 VL - 23 IS - 4 KW - caregiver burden KW - informal caregivers KW - internet intervention KW - cognitive behavioral therapy KW - eHealth KW - mHealth N2 - Background: Caregiving for a family member can result in reduced well-being for the caregiver. Internet-delivered cognitive behavioral therapy (ICBT) may be one way to support this population. This is especially the case for caregivers in countries with limited resources, but high demand for psychological services. Objective: In this study we evaluated the effects of a therapist-guided 8-week-long ICBT intervention for informal caregivers. Methods: In total, 63 participants were recruited online and randomized either to the intervention or to the wait-list control group. The main study outcome was the Caregiver Burden Inventory (CBI). Secondary outcomes included measures of caregiver depression, anxiety, stress, and quality of life. Results: Moderate between-group effect sizes were observed for the CBI measure, in favor of the intervention group, with a Cohen d=?0.70 for the intention-to-treat analysis. Analyses of the subscales of the CBI showed significant reductions on the subscales of Development and Physical Health. Moderate reductions were found for depression and anxiety scores as indicated by the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scores. Large between-group effects were observed for reduction in stress and increase in quality of life as indicated by the Perceived Stress Scale-14 (PSS-14), The Brunnsviken Brief Quality of Life Scale (BBQ), and The World Health Organization-Five Well-Being Index (WHO-5). In addition, participants experienced little to no difficulty in using the program and were mostly satisfied with the intervention?s platform and the choice of content. Conclusions: This is the first internet intervention study for informal caregivers in Lithuania. The results suggest that therapist-guided ICBT can be effective in reducing caregiver burden, anxiety, depression, stress, and improving quality of life. Trial Registration: ClinicalTrials.gov NCT04052724; https://clinicaltrials.gov/ct2/show/NCT04052724 UR - https://www.jmir.org/2021/4/e21466 UR - http://dx.doi.org/10.2196/21466 UR - http://www.ncbi.nlm.nih.gov/pubmed/33825687 ID - info:doi/10.2196/21466 ER - TY - JOUR AU - Hayman, Melanie AU - Alfrey, Kristie-Lee AU - Cannon, Summer AU - Alley, Stephanie AU - Rebar, L. Amanda AU - Williams, Susan AU - Short, E. Camille AU - Altazan, Abby AU - Comardelle, Natalie AU - Currie, Sinead AU - Denton, Caitlin AU - Harrison, L. Cheryce AU - Lamerton, Tayla AU - Mena, P. Gabriela AU - Moran, Lisa AU - Mottola, Michelle AU - Nagpal, S. Taniya AU - Vincze, Lisa AU - Schoeppe, Stephanie PY - 2021/4/7 TI - Quality, Features, and Presence of Behavior Change Techniques in Mobile Apps Designed to Improve Physical Activity in Pregnant Women: Systematic Search and Content Analysis JO - JMIR Mhealth Uhealth SP - e23649 VL - 9 IS - 4 KW - pregnancy KW - exercise KW - physical activity KW - mobile health (mHealth) KW - applications KW - MARS KW - behavior change techniques KW - mobile phone N2 - Background: Physical activity during pregnancy is associated with several health benefits for the mother and child. However, very few women participate in regular physical activity during pregnancy. eHealth platforms (internet and mobile apps) have become an important information source for pregnant women. Although the use of pregnancy-related apps has significantly increased among pregnant women, very little is known about their theoretical underpinnings, including their utilization of behavior change techniques (BCTs). This is despite research suggesting that inclusion of BCTs in eHealth interventions are important for promoting healthy behaviors, including physical activity. Objective: The aim of this study was to conduct a systematic search and content analysis of app quality, features, and the presence of BCTs in apps designed to promote physical activity among pregnant women. Methods: A systematic search in the Australian App Store and Google Play store using search terms relating to exercise and pregnancy was performed. App quality and features were assessed using the 19-item Mobile App Rating Scale (MARS), and a taxonomy of BCTs was used to determine the presence of BCTs (26 items). BCTs previously demonstrating efficacy in behavior changes during pregnancy were also identified from a literature review. Spearman correlations were used to investigate the relationships between app quality, app features, and number of BCTs identified. Results: Nineteen exercise apps were deemed eligible for this review and they were accessed via Google Play (n=13) or App Store (n=6). The MARS overall quality scores indicated moderate app quality (mean 3.5 [SD 0.52]). Functionality was the highest scoring MARS domain (mean 4.2 [SD 0.5]), followed by aesthetics (mean 3.7 [SD 0.6]) and information quality (mean 3.16 [SD 0.42]). Subjective app quality (mean 2.54 [SD 0.64]) and likelihood for behavioral impact (mean 2.5 [SD 0.6]) were the lowest scoring MARS domains. All 19 apps were found to incorporate at least two BCTs (mean 4.74, SD 2.51; range 2-10). However, only 11 apps included BCTs that previously demonstrated efficacy for behavior change during pregnancy, the most common being provide opportunities for social comparison (n=8) and prompt self-monitoring of behavior (n=7). There was a significant positive correlation between the number of BCTs with engagement and aesthetics scores, but the number of BCTs was not significantly correlated with functionality, information quality, total MARS quality, or subjective quality. Conclusions: Our findings showed that apps designed to promote physical activity among pregnant women were functional and aesthetically pleasing, with overall moderate quality. However, the incorporation of BCTs was low, with limited prevalence of BCTs previously demonstrating efficacy in behavior change during pregnancy. Future app development should identify and adopt factors that enhance and encourage user engagement, including the use of BCTs, especially those that have demonstrated efficacy for promoting physical activity behavior change among pregnant women. UR - https://mhealth.jmir.org/2021/4/e23649 UR - http://dx.doi.org/10.2196/23649 UR - http://www.ncbi.nlm.nih.gov/pubmed/33825693 ID - info:doi/10.2196/23649 ER - TY - JOUR AU - Epstein, S. Daniel AU - Zemski, Adam AU - Enticott, Joanne AU - Barton, Christopher PY - 2021/3/31 TI - Tabletop Board Game Elements and Gamification Interventions for Health Behavior Change: Realist Review and Proposal of a Game Design Framework JO - JMIR Serious Games SP - e23302 VL - 9 IS - 1 KW - behavior change KW - games KW - serious games KW - board games KW - behavior interventions KW - health interventions KW - health games KW - game design KW - tabletop games N2 - Background: Games, when used as interventional tools, can influence behavior change by incentivizing, reinforcing, educating, providing feedback loops, prompting, persuading, or providing meaning, fun, and community. However, not all game elements will appeal to all consumers equally, and different elements might work for different people and in different contexts. Objective: The aim of this study was to conduct a realist review of tabletop games targeting behavior change and to propose a framework for designing effective behavior change games. Methods: A realist review was conducted to inform program theory in the development of tabletop games for health behavior change. The context, mechanisms used to change behavior, and outcomes of included studies were reviewed through a realist lens. Results: Thirty-one papers met the eligibility criteria and were included in the review. Several design methods were identified that enhanced the efficacy of the games to change behavior. These included design by local teams, pilot testing, clearly defined targets of behavior change, conscious attention to all aspects of game design, including game mechanics, dynamics, aesthetics, and the elicitation of emotions. Delivery with other mediums, leveraging behavioral insights, prior training for delivery, and repeated play were also important. Some design elements that were found to reduce efficacy included limited replayability or lack of fun for immersive engagement. Conclusions: Game designers need to consider all aspects of the context and the mechanisms to achieve the desired behavior change outcomes. Careful design thinking should include consideration of the game mechanics, dynamics, aesthetics, emotions, and contexts of the game and the players. People who know the players and the contexts well should design the games or have significant input. Testing in real-world settings is likely to lead to better outcomes. Careful selection and purposeful design of the behavior change mechanisms at play is essential. Fun and enjoyment of the player should be considered, as without engagement, there will be no desired intervention effect. UR - https://games.jmir.org/2021/1/e23302 UR - http://dx.doi.org/10.2196/23302 UR - http://www.ncbi.nlm.nih.gov/pubmed/33787502 ID - info:doi/10.2196/23302 ER - TY - JOUR AU - Witlox, Maartje AU - Garnefski, Nadia AU - Kraaij, Vivian AU - de Waal, M. Margot W. AU - Smit, Filip AU - Bohlmeijer, Ernst AU - Spinhoven, Philip PY - 2021/3/26 TI - Blended Acceptance and Commitment Therapy Versus Face-to-face Cognitive Behavioral Therapy for Older Adults With Anxiety Symptoms in Primary Care: Pragmatic Single-blind Cluster Randomized Trial JO - J Med Internet Res SP - e24366 VL - 23 IS - 3 KW - acceptance and commitment therapy KW - anxiety KW - older adults KW - internet interventions KW - cognitive behavioral therapy N2 - Background: Anxiety symptoms in older adults are prevalent and disabling but often go untreated. Most trials on psychological interventions for anxiety in later life have examined the effectiveness of face-to-face cognitive behavioral therapy (CBT). To bridge the current treatment gap, other treatment approaches and delivery formats should also be evaluated. Objective: This study is the first to examine the effectiveness of a brief blended acceptance and commitment therapy (ACT) intervention for older adults with anxiety symptoms, compared with a face-to-face CBT intervention. Methods: Adults aged between 55-75 years (n=314) with mild to moderately severe anxiety symptoms were recruited from general practices and cluster randomized to either blended ACT or face-to-face CBT. Assessments were performed at baseline (T0), posttreatment (T1), and at 6- and 12-month follow-ups (T2 and T3, respectively). The primary outcome was anxiety symptom severity (Generalized Anxiety Disorder-7). Secondary outcomes were positive mental health, depression symptom severity, functional impairment, presence of Diagnostic and Statistical Manual of Mental Disorders V anxiety disorders, and treatment satisfaction. Results: Conditions did not differ significantly regarding changes in anxiety symptom severity during the study period (T0-T1: B=.18, P=.73; T1-T2: B=?.63, P=.26; T1-T3: B=?.33, P=.59). Large reductions in anxiety symptom severity (Cohen d?0.96) were found in both conditions post treatment, and these were maintained at the 12-month follow-up. The rates of clinically significant changes in anxiety symptoms were also not different for the blended ACT group and CBT group (?21=0.2, P=.68). Regarding secondary outcomes, long-term effects on positive mental health were significantly stronger in the blended ACT group (B=.27, P=.03, Cohen d=0.29), and treatment satisfaction was significantly higher for blended ACT than CBT (B=3.19, P<.001, Cohen d=0.78). No other differences between the conditions were observed in the secondary outcomes. Conclusions: The results show that blended ACT is a valuable treatment alternative to CBT for anxiety in later life. Trial Registration: Netherlands Trial Register TRIAL NL6131 (NTR6270); https://www.trialregister.nl/trial/6131 UR - https://www.jmir.org/2021/3/e24366 UR - http://dx.doi.org/10.2196/24366 UR - http://www.ncbi.nlm.nih.gov/pubmed/33769293 ID - info:doi/10.2196/24366 ER - TY - JOUR AU - Chatterjee, Ayan AU - Gerdes, Martin AU - Prinz, Andreas AU - Martinez, Santiago PY - 2021/3/24 TI - Human Coaching Methodologies for Automatic Electronic Coaching (eCoaching) as Behavioral Interventions With Information and Communication Technology: Systematic Review JO - J Med Internet Res SP - e23533 VL - 23 IS - 3 KW - coaching KW - electronic coaching KW - human behavior KW - healthy lifestyle KW - persuasive technology N2 - Background: We systematically reviewed the literature on human coaching to identify different coaching processes as behavioral interventions and methods within those processes. We then reviewed how those identified coaching processes and the used methods can be utilized to improve an electronic coaching (eCoaching) process for the promotion of a healthy lifestyle with the support of information and communication technology (ICT). Objective: This study aimed to identify coaching and eCoaching processes as behavioral interventions and the methods behind these processes. Here, we mainly looked at processes (and corresponding models that describe coaching as certain processes) and the methods that were used within the different processes. Several methods will be part of multiple processes. Certain processes (or the corresponding models) will be applicable for both human coaching and eCoaching. Methods: We performed a systematic literature review to search the scientific databases EBSCOhost, Scopus, ACM, Nature, SpringerLink, IEEE Xplore, MDPI, Google Scholar, and PubMed for publications that included personal coaching (from 2000 to 2019) and persuasive eCoaching as behavioral interventions for a healthy lifestyle (from 2014 to 2019). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework was used for the evidence-based systematic review and meta-analysis. Results: The systematic search resulted in 79 publications, including 72 papers and seven books. Of these, 53 were related to behavioral interventions by eCoaching and the remaining 26 were related to human coaching. The most utilized persuasive eCoaching methods were personalization (n=19), interaction and cocreation (n=17), technology adoption for behavior change (n= 17), goal setting and evaluation (n=16), persuasion (n=15), automation (n=14), and lifestyle change (n=14). The most relevant methods for human coaching were behavior (n=23), methodology (n=10), psychology (n=9), and mentoring (n=6). Here, ?n? signifies the total number of articles where the respective method was identified. In this study, we focused on different coaching methods to understand the psychology, behavioral science, coaching philosophy, and essential coaching processes for effective coaching. We have discussed how we can integrate the obtained knowledge into the eCoaching process for healthy lifestyle management using ICT. We identified that knowledge, coaching skills, observation, interaction, ethics, trust, efficacy study, coaching experience, pragmatism, intervention, goal setting, and evaluation of coaching processes are relevant for eCoaching. Conclusions: This systematic literature review selected processes, associated methods, strengths, and limitations for behavioral interventions from established coaching models. The identified methods of coaching point toward integrating human psychology in eCoaching to develop effective intervention plans for healthy lifestyle management and overcome the existing limitations of human coaching. UR - https://www.jmir.org/2021/3/e23533 UR - http://dx.doi.org/10.2196/23533 UR - http://www.ncbi.nlm.nih.gov/pubmed/33759793 ID - info:doi/10.2196/23533 ER - TY - JOUR AU - Li, H. Sophie AU - Graham, M. Bronwyn AU - Werner-Seidler, Aliza PY - 2021/3/23 TI - Gender Differences in Adolescent Sleep Disturbance and Treatment Response to Smartphone App?Delivered Cognitive Behavioral Therapy for Insomnia: Exploratory Study JO - JMIR Form Res SP - e22498 VL - 5 IS - 3 KW - insomnia KW - gender differences KW - adolescents KW - sleep disturbance KW - sleep quality KW - sleep KW - gender KW - digital interventions N2 - Background: Insomnia and sleep disturbance are pervasive and debilitating conditions affecting up to 40% of adolescents. Women and girls are at greater risk of insomnia, yet differences in treatment responsiveness between genders have not been adequately investigated. Additionally, while women report greater symptom severity and burden of illness than men, this discrepancy requires further examination in adolescents. Objective: The purpose of this study was to examine gender differences in sleep symptom profiles and treatment response in adolescents. Methods: Digital cognitive behavioral therapy for insomnia (CBT-I) treatment responsiveness, as indexed by changes in Insomnia Severity Index (ISI) and Global Pittsburgh Sleep Quality Index (PSQI) scores, was compared in boys and girls (aged 12-16 years; N=49) who participated in a pilot evaluation of the Sleep Ninja smartphone app. Gender differences in self-reported baseline insomnia symptom severity (ISI), sleep quality (PSQI), and sleep characteristics derived from sleep diaries were also examined. Results: Compared with boys, we found that girls reported greater symptom severity (P=.04) and nighttime wakefulness (P=.01 and P=.04) and reduced sleep duration (P=.02) and efficiency (P=.03), but not poorer sleep quality (P=.07), more nighttime awakenings (P=.16), or longer time to get to sleep (P=.21). However, gender differences in symptom severity and sleep duration were accounted for by boys being marginally younger in age. Treatment response to CBT-I was equivalent between boys and girls when comparing reductions in symptom severity (P=.32); there was a trend showing gender differences in improvements in sleep quality, but this was not statistically significant (P=.07). Conclusions: These results demonstrate the presence of gender differences in insomnia symptoms and severity in adolescents and suggest further research is required to understand gender differences in insomnia symptom profiles to inform the development of gender-specific digital interventions delivered to adolescents. UR - https://formative.jmir.org/2021/3/e22498 UR - http://dx.doi.org/10.2196/22498 UR - http://www.ncbi.nlm.nih.gov/pubmed/33755029 ID - info:doi/10.2196/22498 ER - TY - JOUR AU - Marcotte-Beaumier, Gabrielle AU - Bouchard, Stéphane AU - Gosselin, Patrick AU - Langlois, Frédéric AU - Belleville, Geneviève AU - Marchand, André AU - Dugas, J. Michel PY - 2021/3/15 TI - The Role of Intolerance of Uncertainty and Working Alliance in the Outcome of Cognitive Behavioral Therapy for Generalized Anxiety Disorder Delivered by Videoconference: Mediation Analysis JO - JMIR Ment Health SP - e24541 VL - 8 IS - 3 KW - working alliance KW - videoconference KW - cognitive behavioral therapy KW - intolerance of uncertainty KW - generalized anxiety disorder KW - treatment KW - outcome KW - therapy KW - anxiety KW - uncertainty KW - telehealth N2 - Background: Previous meta-analyses have shown a significant relationship between working alliance and treatment outcome in general. Some studies have examined the relationship between working alliance and treatment outcome during telepsychotherapy, but to the best of our knowledge, no study has examined the mediating role of individual components of the working alliance. Objective: As part of a clinical trial of cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) delivered by videoconference (VC), the aim of this study is to examine the mediating role of intolerance of uncertainty on the relationship between the components of the working alliance and treatment outcome. Methods: A sample of 46 adults with primary GAD received 15 sessions of CBT for GAD delivered over VC. Participants completed the measure of working alliance immediately after the fifth therapy session. The degree of change in intolerance of uncertainty (a key psychological process) was assessed from pre- to posttreatment. Treatment outcome was assessed via changes in GAD symptoms from pretreatment to the 6-month follow-up. Results: The results revealed that the therapeutic bond did not predict treatment outcome (r=?0.23; P=.12). However, agreement on therapeutic goals and tasks did predict treatment outcome (r=?0.42; P=.004 and r=?0.37; P=.01, respectively). In addition, the relationship between consensus on therapeutic tasks and treatment outcome was completely mediated by changes in intolerance of uncertainty (unstandardized ?=?0.03; r2=0.12), whereas consensus relative to treatment goals had a direct impact on treatment outcome. Conclusions: These results provide a better understanding of the differential role of the components of the working alliance in telepsychotherapy as a facilitative factor for changes in key cognitive processes, leading to therapeutic change. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 12662027; http://www.isrctn.com/ISRCTN12662027. UR - https://mental.jmir.org/2021/3/e24541 UR - http://dx.doi.org/10.2196/24541 UR - http://www.ncbi.nlm.nih.gov/pubmed/33720024 ID - info:doi/10.2196/24541 ER - TY - JOUR AU - Baumel, Amit AU - Muench, J. Frederick PY - 2021/3/12 TI - Effort-Optimized Intervention Model: Framework for Building and Analyzing Digital Interventions That Require Minimal Effort for Health-Related Gains JO - J Med Internet Res SP - e24905 VL - 23 IS - 3 KW - behavior change KW - digital health KW - mental health KW - addiction KW - intervention KW - behavioral health KW - effort KW - salience KW - persuasive design UR - https://www.jmir.org/2021/3/e24905 UR - http://dx.doi.org/10.2196/24905 UR - http://www.ncbi.nlm.nih.gov/pubmed/33709943 ID - info:doi/10.2196/24905 ER - TY - JOUR AU - Ritvo, Paul AU - Knyahnytska, Yuliya AU - Pirbaglou, Meysam AU - Wang, Wei AU - Tomlinson, George AU - Zhao, Haoyu AU - Linklater, Renee AU - Bai, Shari AU - Kirk, Megan AU - Katz, Joel AU - Harber, Lillian AU - Daskalakis, Zafiris PY - 2021/3/10 TI - Online Mindfulness-Based Cognitive Behavioral Therapy Intervention for Youth With Major Depressive Disorders: Randomized Controlled Trial JO - J Med Internet Res SP - e24380 VL - 23 IS - 3 KW - intervention study KW - telemedicine KW - electronic CBT KW - clinical trial KW - depression KW - cognitive behavioral therapy KW - CBT KW - online therapy KW - online intervention KW - youth KW - young adult N2 - Background: Approximately 70% of mental health disorders appear prior to 25 years of age and can become chronic when ineffectively treated. Individuals between 18 and 25 years old are significantly more likely to experience mental health disorders, substance dependencies, and suicidality. Treatment progress, capitalizing on the tendencies of youth to communicate online, can strategically address depressive disorders. Objective: We performed a randomized controlled trial (RCT) that compared online mindfulness-based cognitive behavioral therapy (CBT-M) combined with standard psychiatric care to standard psychiatric care alone in youth (18-30 years old) diagnosed with major depressive disorder. Methods: Forty-five participants were randomly assigned to CBT-M and standard care (n=22) or to standard psychiatric care alone (n=23). All participants were provided standard psychiatric care (ie, 1 session per month), while participants in the experimental group received an additional intervention consisting of the CBT-M online software program. Interaction with online workbooks was combined with navigation coaching delivered by phone and secure text messaging. Results: In a two-level linear mixed-effects model intention-to-treat analysis, significant between-group differences were found for the Beck Depression Inventory-II score (difference ?8.54, P=.01), Quick Inventory of Depressive Symptoms score (difference ?4.94, P=.001), Beck Anxiety Inventory score (difference ?11.29, P<.001), and Brief Pain Inventory score (difference ?1.99, P=.03), while marginal differences were found for the Five Facet Mindfulness Questionnaire?Nonjudging subscale (difference ?2.68, P=.05). Conclusions: These results confirm that youth depression can be effectively treated with online CBT-M that can be delivered with less geographic restriction. Trial Registration: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052 UR - https://www.jmir.org/2021/3/e24380 UR - http://dx.doi.org/10.2196/24380 UR - http://www.ncbi.nlm.nih.gov/pubmed/33688840 ID - info:doi/10.2196/24380 ER - TY - JOUR AU - Ponnada, Aditya AU - Thapa-Chhetry, Binod AU - Manjourides, Justin AU - Intille, Stephen PY - 2021/3/10 TI - Measuring Criterion Validity of Microinteraction Ecological Momentary Assessment (Micro-EMA): Exploratory Pilot Study With Physical Activity Measurement JO - JMIR Mhealth Uhealth SP - e23391 VL - 9 IS - 3 KW - ecological momentary assessment (EMA) KW - experience sampling KW - physical activity KW - smartwatch KW - microinteractions KW - criterion validity KW - activity monitor KW - ?EMA N2 - Background: Ecological momentary assessment (EMA) is an in situ method of gathering self-report on behaviors using mobile devices. In typical phone-based EMAs, participants are prompted repeatedly with multiple-choice questions, often causing participation burden. Alternatively, microinteraction EMA (micro-EMA or ?EMA) is a type of EMA where all the self-report prompts are single-question surveys that can be answered using a 1-tap glanceable microinteraction conveniently on a smartwatch. Prior work suggests that ?EMA may permit a substantially higher prompting rate than EMA, yielding higher response rates and lower participation burden. This is achieved by ensuring ?EMA prompt questions are quick and cognitively simple to answer. However, the validity of participant responses from ?EMA self-report has not yet been formally assessed. Objective: In this pilot study, we explored the criterion validity of ?EMA self-report on a smartwatch, using physical activity (PA) assessment as an example behavior of interest. Methods: A total of 17 participants answered 72 ?EMA prompts each day for 1 week using a custom-built ?EMA smartwatch app. At each prompt, they self-reported whether they were doing sedentary, light/standing, moderate/walking, or vigorous activities by tapping on the smartwatch screen. Responses were compared with a research-grade activity monitor worn on the dominant ankle simultaneously (and continuously) measuring PA. Results: Participants had an 87.01% (5226/6006) ?EMA completion rate and a 74.00% (5226/7062) compliance rate taking an average of only 5.4 (SD 1.5) seconds to answer a prompt. When comparing ?EMA responses with the activity monitor, we observed significantly higher (P<.001) momentary PA levels on the activity monitor when participants self-reported engaging in moderate+vigorous activities compared with sedentary or light/standing activities. The same comparison did not yield any significant differences in momentary PA levels as recorded by the activity monitor when the ?EMA responses were randomly generated (ie, simulating careless taps on the smartwatch). Conclusions: For PA measurement, high-frequency ?EMA self-report could be used to capture information that appears consistent with that of a research-grade continuous sensor for sedentary, light, and moderate+vigorous activity, suggesting criterion validity. The preliminary results show that participants were not carelessly answering ?EMA prompts by randomly tapping on the smartwatch but were reporting their true behavior at that moment. However, more research is needed to examine the criterion validity of ?EMA when measuring vigorous activities. UR - https://mhealth.jmir.org/2021/3/e23391 UR - http://dx.doi.org/10.2196/23391 UR - http://www.ncbi.nlm.nih.gov/pubmed/33688843 ID - info:doi/10.2196/23391 ER - TY - JOUR AU - Robinson, Anna AU - Slight, D. Robert AU - Husband, K. Andrew AU - Slight, P. Sarah PY - 2021/3/8 TI - Designing the Optimal Digital Health Intervention for Patients? Use Before and After Elective Orthopedic Surgery: Qualitative Study JO - J Med Internet Res SP - e25885 VL - 23 IS - 3 KW - digital technology KW - orthopedic surgery KW - behavior change KW - perioperative care KW - prehabilitation KW - qualitative research KW - mHealth KW - eHealth KW - mobile phone N2 - Background: Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term. Objective: The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery. Methods: Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call?based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority. Results: A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention?s ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery. Conclusions: Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings. UR - https://www.jmir.org/2021/3/e25885 UR - http://dx.doi.org/10.2196/25885 UR - http://www.ncbi.nlm.nih.gov/pubmed/33683208 ID - info:doi/10.2196/25885 ER - TY - JOUR AU - Särnholm, Josefin AU - Skúladóttir, Helga AU - Rück, Christian AU - Klavebäck, Sofia AU - Ólafsdóttir, Eva AU - Pedersen, S. Susanne AU - Braunschweig, Frieder AU - Ljótsson, Brjánn PY - 2021/3/2 TI - Internet-Delivered Exposure-Based Therapy for Symptom Preoccupation in Atrial Fibrillation: Uncontrolled Pilot Trial JO - JMIR Cardio SP - e24524 VL - 5 IS - 1 KW - atrial fibrillation KW - arrhythmia KW - cognitive behavior therapy KW - quality of life KW - anxiety N2 - Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. AF is associated with a poor quality of life (QoL) and, in many patients, current medical treatments are inadequate in alleviating AF symptoms (eg, palpitations). Patients often present with symptom preoccupation in terms of symptom fear, avoidance, and control behaviors. Internet-delivered cognitive behavior therapy is effective for treating other somatic disorders but has never been evaluated in patients with AF. Objective: The aim of this study is to evaluate the efficacy and feasibility of AF-specific internet-delivered cognitive behavior therapy. Methods: We conducted an uncontrolled pilot study in which 19 patients with symptomatic paroxysmal AF underwent internet-delivered cognitive behavior therapy. Participants completed self-assessments at pretreatment, posttreatment, and at a 6-month follow-up along with handheld electrocardiogram measurements with symptom registration. The treatment lasted 10 weeks and included exposure to physical sensations, reduction in avoidance behavior, and behavioral activation. Results: We observed large within-group improvements in the primary outcome, AF-specific QoL (Cohen d=0.80; P<.001), and in symptom preoccupation (Cohen d=1.24; P<.001) at posttreatment; the results were maintained at the 6-month follow-up. Treatment satisfaction and adherence rates were also high. We observed an increased AF burden, measured by electrocardiogram, at the 6-month follow-up, but a significant decrease was observed in the overestimation of AF symptoms at posttreatment and 6-month follow-up. Exploratory mediation analysis showed that a reduction in symptom preoccupation mediated the effects of internet-delivered cognitive behavior therapy on AF-specific QoL. Conclusions: This study presents preliminary evidence for the potential efficacy and feasibility of a novel approach in treating patients with symptomatic AF with internet-delivered cognitive behavior therapy. Trial Registration: ClinicalTrials.gov NCT02694276; https://clinicaltrials.gov/ct2/show/NCT02694276 UR - https://cardio.jmir.org/2021/1/e24524 UR - http://dx.doi.org/10.2196/24524 UR - http://www.ncbi.nlm.nih.gov/pubmed/33650972 ID - info:doi/10.2196/24524 ER - TY - JOUR AU - Alawadhi, Balqees AU - Fallaize, Rosalind AU - Franco, Zenun Rodrigo AU - Hwang, Faustina AU - Lovegrove, Julie PY - 2021/3/2 TI - Web-Based Dietary Intake Estimation to Assess the Reproducibility and Relative Validity of the EatWellQ8 Food Frequency Questionnaire: Validation Study JO - JMIR Form Res SP - e13591 VL - 5 IS - 3 KW - web-based KW - Kuwait KW - weighed food record KW - app KW - food frequency questionnaire KW - validation KW - dietary assessment N2 - Background: The web-based EatWellQ8 food frequency questionnaire (FFQ) was developed as a dietary assessment tool for healthy adults in Kuwait. Validation against reliable instruments and assessment of its reproducibility are required to ensure the accuracy of the EatWellQ8 FFQ in computing nutrient intake. Objective: This study aims to assess the reproducibility and relative validity of the EatWellQ8 146-item FFQ, which included images of food portion sizes based on The Composition of Foods by McCance and Widdowson and food composition tables from Kuwait and the Kingdom of Bahrain, against a paper-based FFQ (PFFQ) and a 4-day weighed food record (WFR). Methods: Reproducibility of the EatWellQ8 FFQ was assessed using a test-retest methodology. Participants were required to complete the FFQ at 2 time points, 4 weeks apart. To assess the relative validity of the EatWellQ8 FFQ, a subset of the participants were asked to complete a PFFQ or a 4-day WFR 1 week after the administration of the EatWellQ8 FFQ. The level of agreement between nutrient and food group intakes was estimated by repeated EatWellQ8 FFQ administration. The EatWellQ8 FFQ, PFFQ, and 4-day WFR were also evaluated using the Bland-Altman methodology and classified into quartiles of daily intake. Crude unadjusted correlation coefficients were also calculated for nutrients and food groups. Results: A total of 99 Kuwaiti participants (64/99, 65% female and 35/99, 35% male) completed the study?53 participated in the reproducibility study and the 4-day WFR validity study (mean age 37.1 years, SD 9.9) and 46 participated in the PFFQ validity study (mean age 36.2 years, SD 8.3). Crude unadjusted correlations for repeated EatWellQ8 FFQs ranged from 0.37 to 0.93 (mean r=0.67, SD 0.14; 95% CI 0.11-0.95) for nutrients and food groups (P=.01). Mean cross-classification into exact agreement plus adjacent was 88% for nutrient intakes and 86% for food groups, and Bland-Altman plots showed good agreement for energy-adjusted macronutrient intakes. The association between the EatWellQ8 FFQ and PFFQ varied, with crude unadjusted correlations ranging from 0.42 to 0.73 (mean r=0.46, SD 0.12; 95% CI ?0.02 to 0.84; P=.046). Mean cross-classification into exact agreement plus adjacent was 84% for nutrient intake and 74% for food groups. Bland-Altman plots showed moderate agreement for both energy and energy-controlled nutrient intakes. Crude unadjusted correlations for the EatWellQ8 FFQ and the 4-day WFR ranged from 0.40 to 0.88 (mean r=0.58, SD 0.13; 95% CI 0.01-0.58; P=.01). Mean cross-classification into exact agreement plus adjacent was 85% for nutrient intake and 83% for food groups. Bland-Altman plots showed moderate agreement for energy-adjusted macronutrient intakes. Conclusions: The results indicate that the web-based EatWellQ8 FFQ is reproducible for assessing nutrient and food group intake and has moderate agreement compared with a PFFQ and a 4-day WFR for measuring energy and nutrient intakes. UR - https://formative.jmir.org/2021/3/e13591 UR - http://dx.doi.org/10.2196/13591 UR - http://www.ncbi.nlm.nih.gov/pubmed/33650974 ID - info:doi/10.2196/13591 ER - TY - JOUR AU - Hollander, B. Justin AU - Folta, C. Sara AU - Graves, Michelle Erin AU - Allen, D. Jennifer AU - Situ, Minyu PY - 2021/3/1 TI - A Fitness App for Monitoring Walking Behavior and Perception (Runkeeper): Mixed Methods Pilot Study JO - JMIR Form Res SP - e22571 VL - 5 IS - 3 KW - physical activity KW - smartphone KW - mobile app KW - sense of belongingness KW - community cohesion N2 - Background: Physical activity has a strong positive impact on both physical and mental health, and public health interventions often encourage walking as a means to promote physical activity. Social connectivity, such as that among spouses, families, friends, and colleagues, highly influences physical activity. Although technology-based interventions have some influence on human behavior, they have not been fully implemented and evaluated for their influence on walking through social connectivity. Objective: We aimed to pilot-test the organization of neighborhood walking clubs and use of a mobile app (Runkeeper) to encourage social connectedness and neighborhood cohesion, as well as to increase physical activity. Methods: We used a convenience sampling method to recruit 46 adults from an urban location in Greater Boston, Massachusetts. We assigned participants to teams based on their geographic location and neighborhood and required them to use the app (Runkeeper). Participants completed 2 self-administered web-based surveys before and after the intervention period. The surveys included standard measures to evaluate physical activity, social connectedness, perceived social support, and neighborhood cohesion (Buckner Neighborhood Cohesion Scale) before and after the intervention. Following the intervention, we randomly selected 14 participants to participate in postintervention, in-depth phone interviews to gain an understanding of their experiences. Results: This study was approved by the institutional review board in June 2018 and funded in January 2018. Recruitment started in May 2019 and lasted for 2 months. Data were collected from July 2019 to January 2020. In this study, Runkeeper was of limited feasibility as an app for measuring physical activity or promoting social connectedness. Data from the app recorded sparse and uneven walking behaviors among the participants. Qualitative interviews revealed that users experienced difficulties in using the settings and features of the app. In the questionnaire, there was no change between pre-post assessments in walking minutes (b=?.79; 95% CI ?4.0 to 2.4; P=.63) or miles (b=?.07; 95% CI ?0.15 to 0.01; P=.09). We observed a pre-post increase in social connectedness and a decrease in neighborhood cohesion. Both quantitative and qualitative results indicated that the psychosocial aspects of walking motivated the participants and helped them relieve stress. Interview results showed that participants felt a greater virtual connection in their assigned groups and enhanced connections with friends and family members. Conclusions: Our study found that Runkeeper created a virtual connection among walking group members and its data sharing and ranking motivated walking. Participants felt that walking improved their mental health, helped to relieve stress, and made them feel more connected with friends or family members. In future studies, it will be important to use an app that integrates with a wearable physical activity device. There is also a need to develop and test intervention components that might be more effective in fostering neighborhood cohesion. UR - https://formative.jmir.org/2021/3/e22571 UR - http://dx.doi.org/10.2196/22571 UR - http://www.ncbi.nlm.nih.gov/pubmed/33646132 ID - info:doi/10.2196/22571 ER - TY - JOUR AU - Duan, Yanping AU - Shang, Borui AU - Liang, Wei AU - Du, Gaohui AU - Yang, Min AU - Rhodes, E. Ryan PY - 2021/2/22 TI - Effects of eHealth-Based Multiple Health Behavior Change Interventions on Physical Activity, Healthy Diet, and Weight in People With Noncommunicable Diseases: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e23786 VL - 23 IS - 2 KW - systematic review KW - meta-analysis KW - noncommunicable disease KW - multiple health behavior change KW - weight-related KW - physical activity KW - healthy diet KW - eHealth N2 - Background: Noncommunicable diseases (NCDs) are associated with the burden of premature deaths and huge medical costs globally. There is an increasing number of studies combining a multiple health behavior change (MHBC) intervention paradigm with eHealth approaches to jointly promote weight-related health behaviors among people with NCD; yet, a comprehensive summary of these studies is lacking. Objective: This review aims to meta-analyze the effectiveness and systematically summarize the characteristics of the relevant intervention studies for improving the outcomes of physical activity, healthy diet, and weight among people with NCD. Methods: Following PRISMA guidelines, 4 electronic databases (PsycINFO, PubMed, Scopus, SPORTDiscus) were systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. Article selection, quality assessment, and data extraction were independently performed by 2 authors. The standardized mean difference (SMD) was calculated to evaluate the effectiveness of interventions for 3 intervention outcomes (physical activity, healthy diet, and weight), and subsequent subgroup analyses were performed for gender, age, intervention duration, channel, and theory. Calculations were conducted, and figures were produced in SPSS 22 and Review Manager 5.3. Results: Of the 664 original hits generated by the systematic searches, 15 eligible studies with moderate to high quality were included. No potential publication bias was detected using statistical analyses. Studies varied in intervention channel, intensity, and content. The meta-analysis revealed that the eHealth MHBC interventions significantly promoted physical activity (SMD 0.85, 95% CI 0.23 to 1.47, P=.008) and healthy diet (SMD 0.78, 95% CI 0.13 to 1.43, P=.02), but did not contribute to a healthy weight status (SMD ?0.13, 95% CI= ?0.47 to 0.20, P=.43) among people with NCDs, compared to the control conditions. Results from subgroup analysis indicated that theory-based interventions achieved greater effect than nontheory-based interventions in promoting physical activity, and interventions with traditional approaches (SMS, telephone) were more effective than those with modern internet-based approaches in promoting healthy diet. Conclusions: The results of this review indicates that eHealth MHBC interventions achieve preliminary success in promoting physical activity and healthy diet behaviors among people with NCD. Future studies could improve the intervention design to achieve better intervention effectiveness. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42019118629; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=118629 UR - https://www.jmir.org/2021/2/e23786 UR - http://dx.doi.org/10.2196/23786 UR - http://www.ncbi.nlm.nih.gov/pubmed/33616534 ID - info:doi/10.2196/23786 ER - TY - JOUR AU - Mclaughlin, Matthew AU - Delaney, Tessa AU - Hall, Alix AU - Byaruhanga, Judith AU - Mackie, Paul AU - Grady, Alice AU - Reilly, Kathryn AU - Campbell, Elizabeth AU - Sutherland, Rachel AU - Wiggers, John AU - Wolfenden, Luke PY - 2021/2/19 TI - Associations Between Digital Health Intervention Engagement, Physical Activity, and Sedentary Behavior: Systematic Review and Meta-analysis JO - J Med Internet Res SP - e23180 VL - 23 IS - 2 KW - engagement KW - adherence KW - digital health intervention KW - digital behavior change intervention KW - physical activity KW - sedentary behavior KW - mobile phone N2 - Background: The effectiveness of digital health interventions is commonly assumed to be related to the level of user engagement with the digital health intervention, including measures of both digital health intervention use and users? subjective experience. However, little is known about the relationships between the measures of digital health intervention engagement and physical activity or sedentary behavior. Objective: This study aims to describe the direction and strength of the association between engagement with digital health interventions and physical activity or sedentary behavior in adults and explore whether the direction of association of digital health intervention engagement with physical activity or sedentary behavior varies with the type of engagement with the digital health intervention (ie, subjective experience, activities completed, time, and logins). Methods: Four databases were searched from inception to December 2019. Grey literature and reference lists of key systematic reviews and journals were also searched. Studies were eligible for inclusion if they examined a quantitative association between a measure of engagement with a digital health intervention targeting physical activity and a measure of physical activity or sedentary behavior in adults (aged ?18 years). Studies that purposely sampled or recruited individuals on the basis of pre-existing health-related conditions were excluded. In addition, studies were excluded if the individual engaging with the digital health intervention was not the target of the physical activity intervention, the study had a non?digital health intervention component, or the digital health interventions targeted multiple health behaviors. A random effects meta-analysis and direction of association vote counting (for studies not included in meta-analysis) were used to address objective 1. Objective 2 used vote counting on the direction of the association. Results: Overall, 10,653 unique citations were identified and 375 full texts were reviewed. Of these, 19 studies (26 associations) were included in the review, with no studies reporting a measure of sedentary behavior. A meta-analysis of 11 studies indicated a small statistically significant positive association between digital health engagement (based on all usage measures) and physical activity (0.08, 95% CI 0.01-0.14, SD 0.11). Heterogeneity was high, with 77% of the variation in the point estimates explained by the between-study heterogeneity. Vote counting indicated that the relationship between physical activity and digital health intervention engagement was consistently positive for three measures: subjective experience measures (2 of 3 associations), activities completed (5 of 8 associations), and logins (6 of 10 associations). However, the direction of associations between physical activity and time-based measures of usage (time spent using the intervention) were mixed (2 of 5 associations supported the hypothesis, 2 were inconclusive, and 1 rejected the hypothesis). Conclusions: The findings indicate a weak but consistent positive association between engagement with a physical activity digital health intervention and physical activity outcomes. No studies have targeted sedentary behavior outcomes. The findings were consistent across most constructs of engagement; however, the associations were weak. UR - http://www.jmir.org/2021/2/e23180/ UR - http://dx.doi.org/10.2196/23180 UR - http://www.ncbi.nlm.nih.gov/pubmed/33605897 ID - info:doi/10.2196/23180 ER - TY - JOUR AU - Kaur, Nimran AU - Gupta, Madhu AU - Malhi, Prahbhjot AU - Grover, Sandeep PY - 2021/2/11 TI - A Multicomponent Intervention to Reduce Screen Time Among Children Aged 2-5 Years in Chandigarh, North India: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e24106 VL - 10 IS - 2 KW - multimedia KW - digital-media KW - preschooler KW - sedentary behaviors KW - toddler KW - sedentary KW - screen KW - children KW - youth N2 - Background: Excessive digital screen exposure (?1 hour per day) is associated with limited growth and development in children. Objective: This study aims to develop and assess a multicomponent intervention program's effectiveness in reducing excessive screen time among children aged 2-5 years. Methods: A theory-based multicomponent intervention known as Program to Lower Unwanted Media Screens (PLUMS) at the household level has been developed. It is based on the social cognitive theory for children and self-determination theory for caregivers. After pretesting, a randomized control trial will be conducted to assess this intervention's effectiveness among healthy children aged 2-5 (±3 months) years and their primary caregivers who have at least one digital media gadget at home in zone three of Chandigarh (population of 2,730,035). A sample size of 428 children is estimated per arm. PLUMS includes disseminating specific information, education, communication in the form of videos and posters to the primary caregivers, and conducting motivational interviewing as and when needed. Children will be provided suggestions for playful activities as alternatives to digital media gadgets. The primary outcome is the mean change in the duration of screen time, and secondary outcomes are sleep duration and patterns, emotional-behavioral problems, and level of physical activity of the children. Per-protocol and intention-to-treat analyses will be conducted using SPSS for Macintosh, Version 25.0. Results: The intervention package will be disseminated once a week for 8 weeks to the participants via the caregivers' preferred means of communication. The endline assessment will be done immediately postintervention and after the 6 months of follow-up. The Institute's ethics committee, Postgraduate Institute of Medical Education and Research, Chandigarh, India, has approved this study (INT/IEC/2019/000711). The Indian Council of Medical Research, New Delhi (3/1/3/Next-100/JRF-2015/HRD), and PGIMER, Chandigarh (71/2-Edu-16/92, Dated 08/01/2018) funded this study. Conclusions: PLUMS might be effective in reducing excessive screen time among children aged 2-5 years in a North Indian Union Territory. Trial Registration: Clinical Trial Registry India CTRI/2017/09/009761; https://tinyurl.com/53q6dpjs International Registered Report Identifier (IRRID): DERR1-10.2196/24106 UR - http://www.researchprotocols.org/2021/2/e24106/ UR - http://dx.doi.org/10.2196/24106 UR - http://www.ncbi.nlm.nih.gov/pubmed/33570499 ID - info:doi/10.2196/24106 ER - TY - JOUR AU - Hrynyschyn, Robert AU - Dockweiler, Christoph PY - 2021/2/10 TI - Effectiveness of Smartphone-Based Cognitive Behavioral Therapy Among Patients With Major Depression: Systematic Review of Health Implications JO - JMIR Mhealth Uhealth SP - e24703 VL - 9 IS - 2 KW - mobile health KW - depression KW - cognitive behavioral therapy KW - systematic review KW - mobile phone N2 - Background: Depression is often associated with rapid changes in mood and quality of life that persist for a period of 2 weeks. Despite medical innovations, there are problems in the provision of care. Long waiting times for treatment and high recurrence rates of depression cause enormous costs for health care systems. At the same time, comprehensive limitations in physical, psychological, and social dimensions are observed for patients with depression, which significantly reduce their quality of life. In addition to patient-specific limitations, undersupply and inappropriate health care have been determined. For this reason, new forms of care are discussed. Smartphone-based therapy is considered to have great potential due to its reach and easy accessibility. Low socioeconomic groups, which are always difficult to reach for public health interventions, can now be accessed due to the high dispersion of smartphones. There is still little information about the impact and mechanisms of smartphone-based therapy on depression. In a systematic literature review, the health implications of smartphone-based therapy were presented in comparison with standard care. Objective: The objective of this review was to identify and summarize the existing evidence regarding smartphone-based cognitive behavioral therapy for patients with depression and to present the health implications of smartphone-based cognitive behavioral therapy of considered endpoints. Methods: A systematic literature review was conducted to identify relevant studies by means of inclusion and exclusion criteria. For this purpose, the PubMed and Psyndex databases were systematically searched using a search syntax. The endpoints of depressive symptoms, depression-related anxiety, self-efficacy or self-esteem, and quality of life were analyzed. Identified studies were evaluated for study quality and risk of bias. After applying the inclusion and exclusion criteria, 8 studies were identified. Results: The studies examined in this review reported contradictory results regarding the investigated endpoints. In addition, due to clinical and methodological heterogeneity, it was difficult to derive evident results. All included studies reported effects on depressive symptoms. The other investigated endpoints were only reported by isolated studies. Only 50% (4/8) of the studies reported effects on depression-related anxiety, self-efficacy or self-esteem, and quality of life. Conclusions: No clear implications of smartphone-based cognitive behavioral therapy could be established. Evidence for the treatment of depression using smartphone-based cognitive behavioral therapy is limited. Additional research projects are needed to demonstrate the effects of smartphone-based cognitive behavioral therapy in the context of evidence-based medicine and to enable its translation into standard care. Participatory technology development might help to address current problems in mobile health intervention studies. UR - http://mhealth.jmir.org/2021/2/e24703/ UR - http://dx.doi.org/10.2196/24703 UR - http://www.ncbi.nlm.nih.gov/pubmed/33565989 ID - info:doi/10.2196/24703 ER - TY - JOUR AU - Humphreys, Gabrielle AU - Evans, Rebecca AU - Makin, Harriet AU - Cooke, Richard AU - Jones, Andrew PY - 2021/2/9 TI - Identification of Behavior Change Techniques From Successful Web-Based Interventions Targeting Alcohol Consumption, Binge Eating, and Gambling: Systematic Review JO - J Med Internet Res SP - e22694 VL - 23 IS - 2 KW - systematic review KW - web-based intervention KW - behavior and behavior mechanism KW - behavior change technique KW - alcohol consumption KW - binge eating KW - gambling N2 - Background: Web-based interventions are thought to overcome barriers to treatment, such as accessibility and geographical location, which can undermine the effectiveness of traditional face-to-face interventions. Owing to these features, researchers are increasingly testing the efficacy of web-based interventions as ways to reduce alcohol misuse, binge eating, and gambling. However, many web-based interventions have poorly defined mechanisms of action; therefore, it is often uncertain how they propose to bring about behavior change. Objective: This systematic review aims to identify effective behavior change techniques (BCTs) present in web-based interventions aimed at reducing alcohol consumption, binge eating, or gambling. Methods: This systematic review covered research conducted in the last 20 years. Inclusion criteria for interventions were web-based administration; targeting alcohol use, binge eating, and/or gambling; and reporting on baseline and postintervention measures of behavior. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. We coded intervention effectiveness, study quality, and BCTs present in the interventions. Results: Following removal of 4152 ineligible articles, 45 were included in the review: 32 (71%) targeted alcohol misuse, 6 (13%) targeted binge eating, and 7 (16%) targeted gambling. In total, 5 frequency counts were performed to identify the most commonly used BCTs: all studies, effective interventions, high-quality studies at 2 thresholds, and both high quality and effective studies. The results obtained from this were integrated to identify 7 BCTs. These 7 BCTs were problem solving, feedback on behavior, self-monitoring of behavior, self-monitoring of outcomes, instruction on how to perform a behavior, information about social and health consequences, and social comparison. A total of 4 BCTs were found in all frequency counts: feedback on behavior, self-monitoring of behavior, instruction on how to perform a behavior, and social comparison. Self-monitoring of outcomes of behavior was found in 3 of the 5 frequency counts, problem solving was found in 2 frequency counts, and information about social and health consequences was found in 1 frequency count. Conclusions: This systematic review identified 7 of the most frequently used BCTs used in web-based interventions focused on alcohol misuse, binge eating, and gambling. These results can inform the development of evidence-based eHealth interventions that have the potential to lead to effective, positive behavior changes in all 3 areas. UR - http://www.jmir.org/2021/2/e22694/ UR - http://dx.doi.org/10.2196/22694 UR - http://www.ncbi.nlm.nih.gov/pubmed/33560243 ID - info:doi/10.2196/22694 ER - TY - JOUR AU - Hoenink, C. Jody AU - Mackenbach, D. Joreintje AU - van der Laan, Nynke Laura AU - Lakerveld, Jeroen AU - Waterlander, Wilma AU - Beulens, J. Joline W. PY - 2021/2/9 TI - Recruitment of Participants for a 3D Virtual Supermarket: Cross-sectional Observational Study JO - JMIR Form Res SP - e19234 VL - 5 IS - 2 KW - online study KW - nudges KW - pricing KW - recruitment strategies N2 - Background: Virtual supermarkets offer a practical and affordable setting to test the efficacy of different pricing and nudging strategies before they are implemented in the real world. Despite the advantages of using virtual supermarkets for this purpose, conducting studies in online settings is challenging with regard to recruitment and retention of sufficient and suitable participants. Objective: To describe cost, time, and retention with regard to participants recruited using various strategies and potential sociodemographic differences between participants recruited via different strategies. Methods: This cross-sectional study used data from a randomized controlled trial in which 455 Dutch adults with low and high educational levels were invited to shop 5 times in a 3D virtual supermarket. Participants were recruited via social media and flyers. A log that tracked the costs of and time spent on the different recruitment strategies was kept by the study team. Outcome measures included the cost of recruitment strategies, the time investment by researchers, and recruitment and attrition rates of participants in the study. Results: The median age of study completers was 31.0 (IQR 25.0) and 157 out of 346 study completers (45.4%) were highly educated. Out of the 455 included participants, 235 (51.6%) were recruited via social media campaigns, 131 (28.8%) via home-delivered flyers, 38 (8.4%) via flyers directly distributed by the study team, and 46 (10.1%) via word-of-mouth. Of all paid recruitment strategies, social media campaigns were the cheapest and least time-consuming, whereas the distribution of flyers by the study team was the most expensive and time-consuming recruitment strategy. Age, sex, overweight status, employment situation, and number of adults within the household varied by recruitment strategy. Conclusions: Using different recruitment strategies resulted in the efficient recruitment of a representative study sample and retention of participants was relatively high. While ?word-of-mouth? was the most cost- and time-effective recruitment strategy, using only one type of recruitment strategy could result in a demographically skewed study population. UR - http://formative.jmir.org/2021/2/e19234/ UR - http://dx.doi.org/10.2196/19234 UR - http://www.ncbi.nlm.nih.gov/pubmed/33560230 ID - info:doi/10.2196/19234 ER - TY - JOUR AU - Cole, Anne Casey AU - Powers, Shannon AU - Tomko, L. Rachel AU - Froeliger, Brett AU - Valafar, Homayoun PY - 2021/2/5 TI - Quantification of Smoking Characteristics Using Smartwatch Technology: Pilot Feasibility Study of New Technology JO - JMIR Form Res SP - e20464 VL - 5 IS - 2 KW - smartwatch KW - CReSS KW - smoking topography KW - ASPIRE KW - automated KW - wearable technology KW - wearable computing KW - smoking N2 - Background: While there have been many technological advances in studying the neurobiological and clinical basis of tobacco use disorder and nicotine addiction, there have been relatively minor advances in technologies for monitoring, characterizing, and intervening to prevent smoking in real time. Better understanding of real-time smoking behavior can be helpful in numerous applications without the burden and recall bias associated with self-report. Objective: The goal of this study was to test the validity of using a smartwatch to advance the study of temporal patterns and characteristics of smoking in a controlled laboratory setting prior to its implementation in situ. Specifically, the aim was to compare smoking characteristics recorded by Automated Smoking PerceptIon and REcording (ASPIRE) on a smartwatch with the pocket Clinical Research Support System (CReSS) topography device, using video observation as the gold standard. Methods: Adult smokers (N=27) engaged in a video-recorded laboratory smoking task using the pocket CReSS while also wearing a Polar M600 smartwatch. In-house software, ASPIRE, was used to record accelerometer data to identify the duration of puffs and interpuff intervals (IPIs). The recorded sessions from CReSS and ASPIRE were manually annotated to assess smoking topography. Agreement between CReSS-recorded and ASPIRE-recorded smoking behavior was compared. Results: ASPIRE produced more consistent number of puffs and IPI durations relative to CReSS, when comparing both methods to visual puff count. In addition, CReSS recordings reported many implausible measurements in the order of milliseconds. After filtering implausible data recorded from CReSS, ASPIRE and CReSS produced consistent results for puff duration (R2=.79) and IPIs (R2=.73). Conclusions: Agreement between ASPIRE and other indicators of smoking characteristics was high, suggesting that the use of ASPIRE is a viable method of passively characterizing smoking behavior. Moreover, ASPIRE was more accurate than CReSS for measuring puffs and IPIs. Results from this study provide the foundation for future utilization of ASPIRE to passively and accurately monitor and quantify smoking behavior in situ. UR - https://formative.jmir.org/2021/2/e20464 UR - http://dx.doi.org/10.2196/20464 UR - http://www.ncbi.nlm.nih.gov/pubmed/33544083 ID - info:doi/10.2196/20464 ER - TY - JOUR AU - Easton, Katherine AU - Kellett, Stephen AU - Cooper, Martin AU - Millings, Abigail AU - Varela, Jo AU - Parry, Glenys PY - 2021/2/1 TI - Blending Cognitive Analytic Therapy With a Digital Support Tool: Mixed Methods Study Involving a User-Centered Design of a Prototype App JO - JMIR Ment Health SP - e20213 VL - 8 IS - 2 KW - cognitive analytic therapy KW - digital app KW - relational awareness KW - user-centered design KW - acceptability KW - user testing N2 - Background: Patients can struggle to make good use of psychotherapy owing to deficits in awareness, and digital technologies that support awareness are at a premium. Currently, when patients participate in cognitive analytic therapy (CAT), the technology supporting relational awareness work involves completion of paper-based worksheets as between-session tasks. Objective: We aimed to design, with therapists and patients, a prototype digital mobile app. This was to help patients better engage in the ?recognition? phase of the CAT treatment model by providing an unobtrusive means for practicing relational awareness with dynamic feedback on progress. Methods: A national online survey was conducted with CAT therapists (n=50) to determine readiness for adoption of a mobile app in clinical practice and to identify core content, functionality, and potential barriers to adoption. A prototype mobile app based on data and existing paper-based worksheets was built. Initial face-to-face user testing of the prototype system was completed with three therapists and three CAT expatients. Results: Among the therapists surveyed, 72% (36/50) reported not currently using any digital tools during CAT. However, the potential value of a mobile app to support patient awareness was widely endorsed. Areas of therapist concern were data security, data governance, and equality of access. These concerns were mirrored during subsequent user testing by CAT therapists. Expatients generated additional user specifications on the design, functionality, and usability of the app. Results from both streams were integrated to produce five key changes for the reiteration of the app. Conclusions: The user-centered design process has enabled a prototype CAT-App to be developed to enhance the relational awareness work of CAT. This means that patients can now practice relational awareness in a much more unobtrusive manner and with ongoing dynamic feedback of progress. Testing the acceptability and feasibility of this technological innovation in clinical practice is the next stage in the research process, which has since been conducted and has been submitted. The important challenges of data protection and governance must be navigated in order to ensure implementation and adoption if the CAT-App is found to be acceptable and clinically effective. UR - https://mental.jmir.org/2021/2/e20213 UR - http://dx.doi.org/10.2196/20213 UR - http://www.ncbi.nlm.nih.gov/pubmed/33522979 ID - info:doi/10.2196/20213 ER - TY - JOUR AU - Schachner, Theresa AU - Gross, Christoph AU - Hasl, Andrea AU - v Wangenheim, Florian AU - Kowatsch, Tobias PY - 2021/1/29 TI - Deliberative and Paternalistic Interaction Styles for Conversational Agents in Digital Health: Procedure and Validation Through a Web-Based Experiment JO - J Med Internet Res SP - e22919 VL - 23 IS - 1 KW - conversational agents KW - chatbots KW - human-computer interaction KW - physician-patient relationship KW - interaction styles, deliberative interaction KW - paternalistic interaction KW - digital health KW - chronic conditions KW - COPD N2 - Background: Recent years have witnessed a constant increase in the number of people with chronic conditions requiring ongoing medical support in their everyday lives. However, global health systems are not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. Moreover, different aspects of CAs have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the interaction between patients and physicians. Patient-physician interaction is recognized as a critical success factor for patient satisfaction, treatment adherence, and subsequent treatment outcomes. However, so far, it remains effectively unknown how different interaction styles can be implemented into CA interactions and whether these styles are recognizable by users. Objective: The objective of this study was to develop an approach to reproducibly induce 2 specific interaction styles into CA-patient dialogs and subsequently test and validate them in a chronic health care context. Methods: On the basis of the Roter Interaction Analysis System and iterative evaluations by scientific experts and medical health care professionals, we identified 10 communication components that characterize the 2 developed interaction styles: deliberative and paternalistic interaction styles. These communication components were used to develop 2 CA variations, each representing one of the 2 interaction styles. We assessed them in a web-based between-subject experiment. The participants were asked to put themselves in the position of a patient with chronic obstructive pulmonary disease. These participants were randomly assigned to interact with one of the 2 CAs and subsequently asked to identify the respective interaction style. Chi-square test was used to assess the correct identification of the CA-patient interaction style. Results: A total of 88 individuals (42/88, 48% female; mean age 31.5 years, SD 10.1 years) fulfilled the inclusion criteria and participated in the web-based experiment. The participants in both the paternalistic and deliberative conditions correctly identified the underlying interaction styles of the CAs in more than 80% of the assessments (X21,88=38.2; P<.001; phi coefficient r?=0.68). The validation of the procedure was hence successful. Conclusions: We developed an approach that is tailored for a medical context to induce a paternalistic and deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the procedure in a web-based experiment involving 88 participants. Future research should implement and test this approach among actual patients with chronic diseases and compare the results in different medical conditions. This approach can further be used as a starting point to develop dynamic CAs that adapt their interaction styles to their users. UR - http://www.jmir.org/2021/1/e22919/ UR - http://dx.doi.org/10.2196/22919 UR - http://www.ncbi.nlm.nih.gov/pubmed/33512328 ID - info:doi/10.2196/22919 ER - TY - JOUR AU - Gans, M. Kim AU - Dulin, Akilah AU - Palomo, Vanessa AU - Benitez, Tanya AU - Dunsiger, Shira AU - Dionne, Laura AU - Champion, Gregory AU - Edgar, Rachelle AU - Marcus, Bess PY - 2021/1/29 TI - A Tailored Web- and Text-Based Intervention to Increase Physical Activity for Latino Men: Protocol for a Randomized Controlled Feasibility Trial JO - JMIR Res Protoc SP - e23690 VL - 10 IS - 1 KW - physical activity KW - Latino KW - Hispanic KW - men KW - eHealth KW - expert system KW - internet KW - text messaging KW - mobile phone KW - social media N2 - Background: Latino men in the United States report low physical activity (PA) levels and related health conditions (eg, diabetes and obesity). Engaging in regular PA can reduce the risk of chronic diseases and yield many health benefits; however, there is a paucity of interventions developed exclusively for Latino men. Objective: To address the need for culturally relevant PA interventions, this study aims to develop and evaluate Hombres Saludables, a 6-month theory-based, tailored web- and text message-based PA intervention in Spanish for Latino men. This protocol paper describes the study design, intervention, and evaluation methods for Hombres Saludables. Methods: Latino men aged 18-65 years were randomized to either the individually tailored PA internet intervention arm or the nutrition and wellness internet control arm. The PA intervention included 2 check-in phone calls; automated SMS text messages; a pedometer; a 6-month gym membership; access to a private Facebook group; and an interactive website with PA tracking, goal setting, and individually tailored PA content. The primary outcomes were feasibility, acceptability, and efficacy (minutes per week of total moderate-to-vigorous PA assessed via the ActiGraph GT3X+ accelerometer worn at the waist and 7-day physical activity recall at baseline and 6 months). Secondary outcomes examined potential moderators (eg, demographics, acculturation, and environmental variables) and mediators (eg, self-efficacy and cognitive and behavioral processes of change) of treatment effects at 6 months post randomization. Results: This study was funded in September 2016. Initial institutional review board approval was received in February 2017, and focus groups and intervention development were conducted from April 2017 to January 2018. Recruitment for the clinical trial was carried out from February 2018 to July 2019. Baseline data collection was carried out from February 2018 to October 2019, with a total of 43 participants randomized. Follow-up data were collected through April 2020. Data cleaning and analysis are ongoing. Conclusions: We developed and tested protocols for a highly accessible, culturally and linguistically relevant, theory-driven PA intervention for Latino men. Hombres Saludables used an innovative, interactive, web- and text message?based intervention for improving PA among Latino men, an underserved population at risk of low PA and related chronic disease. If the intervention demonstrates feasibility, acceptability, and preliminary efficacy, we will refine and evaluate it in a larger randomized control trial. Trial Registration: Clinicaltrials.gov: NCT03196570; https://clinicaltrials.gov/ct2/show/NCT03196570 International Registered Report Identifier (IRRID): DERR1-10.2196/23690 UR - http://www.researchprotocols.org/2021/1/e23690/ UR - http://dx.doi.org/10.2196/23690 UR - http://www.ncbi.nlm.nih.gov/pubmed/33512327 ID - info:doi/10.2196/23690 ER - TY - JOUR AU - Lord, E. Sarah AU - Campbell, C. Aimee N. AU - Brunette, F. Mary AU - Cubillos, Leonardo AU - Bartels, M. Sophia AU - Torrey, C. William AU - Olson, L. Ardis AU - Chapman, H. Steven AU - Batsis, A. John AU - Polsky, Daniel AU - Nunes, V. Edward AU - Seavey, M. Katherine AU - Marsch, A. Lisa PY - 2021/1/28 TI - Workshop on Implementation Science and Digital Therapeutics for Behavioral Health JO - JMIR Ment Health SP - e17662 VL - 8 IS - 1 KW - mHealth KW - mobile health KW - digital health KW - telemedicine KW - eHealth KW - behavioral sciences KW - substance-related disorders KW - mental health KW - implementation science UR - https://mental.jmir.org/2021/1/e17662 UR - http://dx.doi.org/10.2196/17662 UR - http://www.ncbi.nlm.nih.gov/pubmed/33507151 ID - info:doi/10.2196/17662 ER - TY - JOUR AU - Wang, Yunlong AU - König, M. Laura AU - Reiterer, Harald PY - 2021/1/27 TI - A Smartphone App to Support Sedentary Behavior Change by Visualizing Personal Mobility Patterns and Action Planning (SedVis): Development and Pilot Study JO - JMIR Form Res SP - e15369 VL - 5 IS - 1 KW - sedentary behavior KW - data visualization KW - mobile app KW - action planning KW - human mobility patterns KW - mobile phone N2 - Background: Prolonged sedentary behavior is related to a number of risk factors for chronic diseases. Given the high prevalence of sedentary behavior in daily life, simple yet practical solutions for behavior change are needed to avoid detrimental health effects. Objective: The mobile app SedVis was developed based on the health action process approach. The app provides personal mobility pattern visualization (for both physical activity and sedentary behavior) and action planning for sedentary behavior change. The primary aim of the study is to investigate the effect of mobility pattern visualization on users? action planning for changing their sedentary behavior. The secondary aim is to evaluate user engagement with the visualization and user experience of the app. Methods: A 3-week user study was conducted with 16 participants who had the motivation to reduce their sedentary behavior. Participants were allocated to either an active control group (n=8) or an intervention group (n=8). In the 1-week baseline period, none of the participants had access to the functions in the app. In the following 2-week intervention period, only the intervention group was given access to the visualizations, whereas both groups were asked to make action plans every day and reduce their sedentary behavior. Participants? sedentary behavior was estimated based on the sensor data of their smartphones, and their action plans and interaction with the app were also recorded by the app. Participants? intention to change their sedentary behavior and user experience of the app were assessed using questionnaires. Results: The data were analyzed using both traditional null hypothesis significance testing (NHST) and Bayesian statistics. The results suggested that the visualizations in SedVis had no effect on the participants? action planning according to both the NHST and Bayesian statistics. The intervention involving visualizations and action planning in SedVis had a positive effect on reducing participants? sedentary hours, with weak evidence according to Bayesian statistics (Bayes factor, BF+0=1.92; median 0.52; 95% CI 0.04-1.25), whereas no change in sedentary time was more likely in the active control condition (BF+0=0.28; median 0.18; 95% CI 0.01-0.64). Furthermore, Bayesian analysis weakly suggested that the more frequently the users checked the app, the more likely they were to reduce their sedentary behavior (BF?0=1.49; r=?0.50). Conclusions: Using a smartphone app to collect data on users? mobility patterns and provide real-time feedback using visualizations may be a promising method to induce changes in sedentary behavior and may be more effective than action planning alone. Replications with larger samples are needed to confirm these findings. UR - http://formative.jmir.org/2021/1/e15369/ UR - http://dx.doi.org/10.2196/15369 UR - http://www.ncbi.nlm.nih.gov/pubmed/33502322 ID - info:doi/10.2196/15369 ER - TY - JOUR AU - Orlando, Stefano AU - Palla, Ilaria AU - Ciccacci, Fausto AU - Triulzi, Isotta AU - Thole, Darlington AU - Sangaré, Mamary Hawa AU - Marazzi, Cristina Maria AU - Nielsen-Saines, Karin AU - Turchetti, Giuseppe AU - Palombi, Leonardo PY - 2021/1/25 TI - Improving Treatment Adherence and Retention of HIV-Positive Women Through Behavioral Change Interventions Aimed at Their Male Partners: Protocol for a Prospective, Controlled Before-and-After Study JO - JMIR Res Protoc SP - e19384 VL - 10 IS - 1 KW - retention in care KW - therapeutic adherence and compliance KW - men's role KW - acquired immunodeficiency syndrome KW - AIDS KW - HIV KW - behavior KW - intervention study KW - health education KW - community health education KW - Malawi KW - mother-to-child transmission KW - health-related behavior KW - social ecology N2 - Background: According to the World Health Organization, in 2018, 37.9 million people were living with HIV globally. More than two-thirds were residing in sub-Saharan Africa, where the HIV prevalence in the adult population (aged 15-49 years) was 3.9%. This population included 1.3 million pregnant women, of whom 82% had received antiretroviral therapy (ART) for the prevention of HIV mother-to-child transmission. In these countries, one challenge is an insufficient level of treatment adherence, particularly in HIV-positive pregnant women. Among the causes, the lack of involvement from a male partner is a significant contributor to the problem. This issue has strongly emerged in Malawi, one of the countries with the highest HIV prevalence in the world: 9.2% of its adult population were living with HIV in 2018. Objective: This study aims to assess 3 interventions that are aimed at improving ART adherence and retention among HIV-positive women through engagement with their male partners in 4 Malawian health care centers. Methods: The prospective, controlled before-and-after study is conducted in 3 phases (total duration: 24 months): preintervention, intervention, and postintervention analyses. The number of selected clusters (clinical centers) is limited to 4: one for each intervention, plus a cluster where no intervention is performed (control arm). The interventions are as follows: opening the facility on one Saturday per month only for men, defined as a special day; testing peer-to-peer counseling among men, male champions; and providing a noneconomic incentive to all women who are accompanied by their partners to the facility, nudge. The primary outcome of the study is to evaluate the differences in retention in care and adherence to therapeutic protocols among women; the intermediate outcome is the assessment of differences in male involvement. The level of male involvement in the health of their partners (intermediate outcome) will be evaluated through a dedicated questionnaire administered at baseline and in the postintervention phase. Data will be collected at the clinical centers and stored in 2 electronic databases managed using 2 different types of software. Results: The analysis of data collected in the 4 centers during the preintervention phase is ongoing, as enrollment ended on March 31, 2020. The total number of patients enrolled was 452 (Namandanje: 133; Kapeni: 78; Kapire: 75; and Balaka: 166). Meanwhile, several meetings have been conducted to organize the intervention phase. Conclusions: The study will identify the best intervention that enhances the involvement of male partners in women?s health, using an approach that considers a broad spectrum of behaviors. An important aspect is the use of educational tools focused on messages, thereby initiating a reflective discussion of stereotypes and false beliefs related to the idea of masculinity present in the Malawian culture. International Registered Report Identifier (IRRID): DERR1-10.2196/19384 UR - http://www.researchprotocols.org/2021/1/e19384/ UR - http://dx.doi.org/10.2196/19384 UR - http://www.ncbi.nlm.nih.gov/pubmed/33492232 ID - info:doi/10.2196/19384 ER - TY - JOUR AU - Darville, Gabrielle AU - Burns, Jade AU - Chavanduka, Tanaka AU - Anderson-Lewis, Charkarra PY - 2021/1/22 TI - Utilizing Theories and Evaluation in Digital Gaming Interventions to Increase Human Papillomavirus Vaccination Among Young Males: Qualitative Study JO - JMIR Serious Games SP - e21303 VL - 9 IS - 1 KW - digital games KW - behavior change KW - theory KW - evaluation KW - game design KW - health care providers N2 - Background: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV attributes to most cancers including anal, oral, cervical, and penile. Despite infection rates in the United States, recommendations and communication campaigns have traditionally focused on females. Because of this, males lack knowledge about reasons for vaccination, the benefits of being vaccinated, and their HPV risk, overall. Gaming as a health education strategy can be beneficial as mechanism that can promote behavior change for this key demographic because of the popularity of gaming. Objective: We sought to explore the relationship between gamification and HPV vaccine uptake. Methods: Interviews were conducted with experts (n=22) in the fields of cancer prevention, sexual and reproductive health, public health, game design, technology, and health communication on how a game should be developed to increase HPV vaccination rates among males. Results: Overwhelmingly, theoretical models such as the health belief model were identified with key constructs such as self-efficacy and risk perception. Experts also suggested using intervention mapping and logic models as planning tools for health promotion interventions utilizing a digital game as a medium. In game and out of game measures were discussed as assessments for quality and impact by our expert panel. Conclusions: This study shows that interventions should focus on whether greater utilization of serious games, and the incorporation of theory and standardized methods, can encourage young men to get vaccinated and to complete the series of HPV vaccinations. UR - http://games.jmir.org/2021/1/e21303/ UR - http://dx.doi.org/10.2196/21303 UR - http://www.ncbi.nlm.nih.gov/pubmed/33480856 ID - info:doi/10.2196/21303 ER - TY - JOUR AU - Shams, Farhud AU - Wong, H. James S. AU - Nikoo, Mohammadali AU - Outadi, Ava AU - Moazen-Zadeh, Ehsan AU - Kamel, M. Mostafa AU - Song, Jae Michael AU - Jang, L. Kerry AU - Krausz, Michael Reinhard PY - 2021/1/21 TI - Understanding eHealth Cognitive Behavioral Therapy Targeting Substance Use: Realist Review JO - J Med Internet Res SP - e20557 VL - 23 IS - 1 KW - eHealth CBT KW - substance use KW - realist review KW - eHealth mechanisms KW - opioid crisis N2 - Background: There is a growing body of evidence regarding eHealth interventions that target substance use disorders. Development and funding decisions in this area have been challenging, due to a lack of understanding of what parts of an intervention work in which context. Objective: We conducted a realist review of the literature on electronic cognitive behavioral therapy (eCBT) programs for substance use with the goal of answering the following realist question: ?How do different eCBT interventions for substance use interact with different contexts to produce certain outcomes?? Methods: A literature search of published and gray literature on eHealth programs targeting substance use was conducted. After data extraction, in order to conduct a feasible realist review in a timely manner, the scope had to be refined further and, ultimately, only included literature focusing on eCBT programs targeting substance use. We synthesized the available evidence from the literature into Context-Mechanism-Outcome configurations (CMOcs) in order to better understand when and how programs work. Results: A total of 54 papers reporting on 24 programs were reviewed. Our final results identified eight CMOcs from five unique programs that met criteria for relevance and rigor. Conclusions: Five strategies that may be applied to future eCBT programs for substance use are discussed; these strategies may contribute to a better understanding of mechanisms and, ultimately, may help design more effective solutions in the future. Future research on eCBT programs should try to understand the mechanisms of program strategies and how they lead to outcomes in different contexts. UR - http://www.jmir.org/2021/1/e20557/ UR - http://dx.doi.org/10.2196/20557 UR - http://www.ncbi.nlm.nih.gov/pubmed/33475520 ID - info:doi/10.2196/20557 ER - TY - JOUR AU - Elbers, Stefan AU - van Gessel, Christa AU - Renes, Jan Reint AU - van der Lugt, Remko AU - Wittink, Harriët AU - Hermsen, Sander PY - 2021/1/20 TI - Innovation in Pain Rehabilitation Using Co-Design Methods During the Development of a Relapse Prevention Intervention: Case Study JO - J Med Internet Res SP - e18462 VL - 23 IS - 1 KW - co-design KW - participatory design KW - chronic pain KW - intervention development KW - rehabilitation KW - behavior change KW - relapse KW - prevention N2 - Background: Many intervention development projects fail to bridge the gap from basic research to clinical practice. Instead of theory-based approaches to intervention development, co-design prioritizes the end users? perspective as well as continuous collaboration between stakeholders, designers, and researchers throughout the project. This alternative approach to the development of interventions is expected to promote the adaptation to existing treatment activities and to be responsive to the requirements of end users. Objective: The first objective was to provide an overview of all activities that were employed during the course of a research project to develop a relapse prevention intervention for interdisciplinary pain treatment programs. The second objective was to examine how co-design may contribute to stakeholder involvement, generation of relevant insights and ideas, and incorporation of stakeholder input into the intervention design. Methods: We performed an embedded single case study and used the double diamond model to describe the process of intervention development. Using all available data sources, we also performed deductive content analysis to reflect on this process. Results: By critically reviewing the value and function of a co-design project with respect to idea generation, stakeholder involvement, and incorporation of stakeholder input into the intervention design, we demonstrated how co-design shaped the transition from ideas, via concepts, to a prototype for a relapse prevention intervention. Conclusions: Structural use of co-design throughout the project resulted in many different participating stakeholders and stimulating design activities. As a consequence, the majority of the components of the final prototype can be traced back to the information that stakeholders provided during the project. Although this illustrates how co-design facilitates the integration of contextual information into the intervention design, further experimental testing is required to evaluate to what extent this approach ultimately leads to improved usability as well as patient outcomes in the context of clinical practice. UR - http://www.jmir.org/2021/1/e18462/ UR - http://dx.doi.org/10.2196/18462 UR - http://www.ncbi.nlm.nih.gov/pubmed/33470937 ID - info:doi/10.2196/18462 ER - TY - JOUR AU - Hwang, Hyunchan AU - Bae, Sujin AU - Hong, Sun Ji AU - Han, Hyun Doug PY - 2021/1/19 TI - Comparing Effectiveness Between a Mobile App Program and Traditional Cognitive Behavior Therapy in Obsessive-Compulsive Disorder: Evaluation Study JO - JMIR Ment Health SP - e23778 VL - 8 IS - 1 KW - obsessive-compulsive disorder KW - exposure and response prevention KW - cognitive behavior therapy KW - cortico-striato-thalamo-cortical tract KW - functional connectivity KW - prevention KW - cognitive KW - mental illness KW - behavior therapy N2 - Background: This study proposes a digital program for the treatment of mental illness that could increase motivation and improve learning outcomes for patients. Several studies have already applied this method by using an exposure and response prevention?inspired serious game to treat patients with obsessive-compulsive disorder (OCD). Objective: We hypothesized that a mobile cognitive behavior therapy (CBT) program would be as effective in treating OCD as traditional offline CBT. In addition, the treatment efficacy in response to mobile CBT for OCD might be associated with increased brain activity within the cortico-striato-thalamo-cortical (CSTC) tract. Methods: The digital CBT treatment program for OCD, OCfree, consists of 6 education sessions, 10 quests, and 7 casual games. Information was gathered from 27 patients with OCD (15 offline CBT and 12 OCfree CBT). During the 6-week intervention period, changes in clinical symptoms and brain function activity were analyzed. Results: There was no significant difference in the change in OCD symptoms and depressive symptoms between the two groups. However, the OCfree group showed greater improvement in anxiety symptoms compared to the offline CBT group. Both offline CBT and OCfree CBT increased the functional connectivity within the CSTC tract in all patients with OCD. However, CBT using OCfree showed greater changes in brain connectivity within the thalamus and insula, compared to offline CBT. Conclusions: OCfree, an OCD treatment app program, was effective in the treatment of drug-naïve patients with OCD. The treatment effects of OCfree are associated with increased brain connectivity within the CSTC tract. Multisensory stimulation by education, quests, and games in OCfree increases the activity within the thalamus and insula in patients with OCD. UR - http://mental.jmir.org/2021/1/e23778/ UR - http://dx.doi.org/10.2196/23778 UR - http://www.ncbi.nlm.nih.gov/pubmed/33464208 ID - info:doi/10.2196/23778 ER - TY - JOUR AU - Niu, Zhaomeng AU - Willoughby, Fitts Jessica AU - Coups, J. Elliot AU - Stapleton, L. Jerod PY - 2021/1/13 TI - Effects of Website Interactivity on Skin Cancer?Related Intentions and User Experience: Factorial Randomized Experiment JO - J Med Internet Res SP - e18299 VL - 23 IS - 1 KW - behavioral intention KW - computer-mediated communication KW - skin cancer KW - interactivity KW - user experience N2 - Background: Digital media technologies provide users with the ability to interact with content and to receive information based on their preferences and engagement. Objective: We used skin cancer and sun protection as a health topic to explore how modality interactivity, interface tools that afford users greater activity, resulting in greater depth and breadth of mentally representing and experiencing mediated content, and message interactivity, the extent to which the system allows users to exchange messages back and forth on health websites, influenced users? attitudes, knowledge, behavioral intentions, and experience. Methods: We employed a 2×2 (modality interactivity: high vs low; message interactivity: high vs low) between-subject online experiment for which 4 websites were created. Participants (n=293) were recruited using Amazon Mechanical Turk and randomly assigned into to 1 of 4 conditions. After browsing the website, participants completed an online survey regarding their experience and cognitive perceptions. General linear models and path analysis were used to analyze the data. Results: Both modality interactivity (P=.001) and message interactivity (P<.001) had an impact on intention to use sun protection. Attitudes toward health websites and perceived knowledge mediated the effects of modality interactivity and message interactivity on sun protection use intention, individually. Participants in the high modality interactivity and high message interactivity condition felt more satisfied (P=.02). Participants in the low message interactivity condition had more interest in the experience with health websites than participants in the high message interactivity condition (P=.044). Conclusions: Findings suggested that modality interactivity influenced intention to use sun protection directly as well as via attitudes toward the websites. Message interactivity impacted intention to use sunscreen directly and also through perceived knowledge. Implications for designing health websites and health intervention content are discussed. UR - http://www.jmir.org/2021/1/e18299/ UR - http://dx.doi.org/10.2196/18299 UR - http://www.ncbi.nlm.nih.gov/pubmed/33439131 ID - info:doi/10.2196/18299 ER - TY - JOUR AU - Vinci, Christine AU - Brandon, O. Karen AU - Kleinjan, Marloes AU - Hernandez, M. Laura AU - Sawyer, E. Leslie AU - Haneke, Jody AU - Sutton, K. Steven AU - Brandon, H. Thomas PY - 2020/12/31 TI - Augmented Reality for Smoking Cessation: Development and Usability Study JO - JMIR Mhealth Uhealth SP - e21643 VL - 8 IS - 12 KW - augmented reality KW - smoking cessation KW - cue exposure therapy KW - cue reactivity KW - behavior change KW - smoking KW - smartphone app KW - mobile phone N2 - Background: The recent widespread availability of augmented reality via smartphone offers an opportunity to translate cue exposure therapy for smoking cessation from the laboratory to the real world. Despite significant reductions in the smoking rates in the last decade, approximately 13.7% of the adults in the United States continue to smoke. Smoking-related cue exposure has demonstrated promise as an adjuvant therapy in the laboratory, but practical limitations have prevented its success in the real world. Augmented reality technology presents an innovative approach to overcome these limitations. Objective: The aim of this study was to develop a smartphone app that presents smoking-related augmented reality images for cue exposure. Smokers provided feedback on the images and reported on the perceived urge to smoke, qualities of reality/coexistence, and general feedback about quality and functioning. The feedback was used to refine the augmented reality images within the app. Methods: In collaboration with an augmented reality design company, we developed 6 smoking-related images (cigarette, lighter, ashtray, lit cigarette in ashtray, etc) and 6 neutral images similar in size or complexity for comparison (pen, eraser, notebook, soda bottle with droplets, etc). Ten smokers completed a survey of demographic characteristics, smoking history and behavior, dependence on nicotine, motivation to quit smoking, and familiarity with augmented reality technology. Then, participants viewed each augmented reality image and provided ratings on 10-point Likert scales for urge to smoke and reality/coexistence of the image into the scene. Participants were also queried with open-ended questions regarding the features of the images. Results: Of the 10 participants, 5 (50%) had experienced augmented reality prior to the laboratory visit, but only 4 of those 5 participants used augmented reality at least weekly. Although the sample was small (N=10), smokers reported significantly higher urge to smoke after viewing the smoking-related augmented reality images (median 4.58, SD 3.49) versus the neutral images (median 1.42, SD 3.01) (Z=?2.14, P=.03; d=0.70). The average reality and coexistence ratings of the images did not differ between smoking-related and neutral images (all P>.29). Augmented reality images were found on average to be realistic (mean [SD] score 6.49 [3.11]) and have good environmental coexistence (mean [SD] score 6.93 [3.04]) and user coexistence (mean [SD] score 6.38 [3.27]) on the 10-point scale. Participant interviews revealed some areas of excellence (eg, details of the lit cigarette) and areas for improvement (eg, stability of images, lighting). Conclusions: All images were generally perceived as being realistic and well-integrated into the environment. However, the smoking augmented reality images produced higher urge to smoke than the neutral augmented reality images. In total, our findings support the potential utility of augmented reality for cue exposure therapy. Future directions and next steps are discussed. UR - http://mhealth.jmir.org/2020/12/e21643/ UR - http://dx.doi.org/10.2196/21643 UR - http://www.ncbi.nlm.nih.gov/pubmed/33382377 ID - info:doi/10.2196/21643 ER - TY - JOUR AU - Chan, M. June AU - Van Blarigan, L. Erin AU - Langlais, S. Crystal AU - Zhao, Shoujun AU - Ramsdill, W. Justin AU - Daniel, Kimi AU - Macaire, Greta AU - Wang, Elizabeth AU - Paich, Kellie AU - Kessler, R. Elizabeth AU - Beer, M. Tomasz AU - Lyons, S. Karen AU - Broering, M. Jeanette AU - Carroll, R. Peter AU - Kenfield, A. Stacey AU - Winters-Stone, M. Kerri PY - 2020/12/31 TI - Feasibility and Acceptability of a Remotely Delivered, Web-Based Behavioral Intervention for Men With Prostate Cancer: Four-Arm Randomized Controlled Pilot Trial JO - J Med Internet Res SP - e19238 VL - 22 IS - 12 KW - diet KW - physical activity KW - exercise KW - lifestyle KW - cancer KW - survivorship KW - text messages KW - internet N2 - Background: Diet and exercise may be associated with quality of life and survival in men with prostate cancer. Objective: This study aimed to determine the feasibility and acceptability of a remotely delivered web-based behavioral intervention among men with prostate cancer. Methods: We conducted a multi-site 4-arm pilot randomized controlled trial of a 3-month intervention (TrueNTH Community of Wellness). Eligibility included self-reported prostate cancer diagnosis, having a personal device that connected to the internet, age ?18 years, and ability to read English and receive text messages and emails. Men receiving chemotherapy or radiation, or those who reported contraindications to exercise, could participate with physician clearance. Participants were randomized (1:1:1:1) to additive intervention levels: website; website and personalized diet and exercise prescription; website, personalized prescription, Fitbit, and text messages; and website, personalized prescription, Fitbit, text messages, and 2 30-minute phone calls?one with an exercise trainer and one with a registered dietician. Primary outcomes were feasibility (accrual and attrition) and acceptability (survey data and website use). We described self-reported diet and exercise behavior at the time of enrollment, 3 months, and 6 months as secondary outcomes. Results: In total, 202 men consented and were randomized between August 2017 and September 2018 (level 1: 49, level 2: 51, level 3: 50, level 4: 52). A total of 160 men completed the onboarding process and were exposed to their randomly assigned intervention (38, 38, 42, and 42 in levels 1, 2, 3, and 4, respectively). The follow-up rate was 82.7% (167/202) at 3 months and 77.2% (156/202) at 6 months. Participants had a median age of 70 years and were primarily White and college educated. Website visit frequency over the 3-month intervention period increased across levels (median: 2, 9, 11, and 16 visits for levels 1, 2, 3, and 4, respectively). Most were satisfied or very satisfied with the intervention (20/39, 51%; 27/42, 64%; 23/44, 52%; and 27/42, 64% for levels 1, 2, 3, and 4, respectively). The percentage of men who reported being very satisfied was highest among level 4 participants (10/42, 24% vs 4/39, 10%; 5/42, 12%; and 5/44, 11% for levels 1, 2, and 3, respectively). Dissatisfaction was highest in level 1 (5/39, 13% vs 1/42, 2%; 3/44, 7%; and 2/42, 5% for levels 2, 3, and 4, respectively). We observed small improvements in diet and physical activity at 3 months among men in level 4 versus those in level 1. Conclusions: A web-based, remotely delivered, tailored behavioral intervention for men with prostate cancer is feasible. Future studies are warranted to increase the effect of the intervention on patient behavior while maintaining sustainability and scalability as well as to design and implement interventions for more diverse populations. Trial Registration: ClinicalTrials.gov NCT03406013; http://clinicaltrials.gov/ct2/show/NCT03406013 UR - http://www.jmir.org/2020/12/e19238/ UR - http://dx.doi.org/10.2196/19238 UR - http://www.ncbi.nlm.nih.gov/pubmed/33382378 ID - info:doi/10.2196/19238 ER - TY - JOUR AU - Kellett, Stephen AU - Easton, Katherine AU - Cooper, Martin AU - Millings, Abigail AU - Simmonds-Buckley, Melanie AU - Parry, Glenys PY - 2020/12/18 TI - Evaluation of a Mobile App to Enhance Relational Awareness and Change During Cognitive Analytic Therapy: Mixed Methods Case Series JO - JMIR Ment Health SP - e19888 VL - 7 IS - 12 KW - cognitive analytic therapy KW - case series KW - effectiveness KW - outcome KW - eHealth KW - app KW - awareness KW - mHealth KW - innovation KW - therapy N2 - Background: There has been a lack of technological innovation regarding improving the delivery of integrative psychotherapies. This project sought to evaluate an app designed to replace previous paper-based methods supporting relational awareness and change during cognitive analytic therapy (CAT). Objective: We aimed to assess patients? and therapists? experience of using the technology (ie, the ?CAT-App?) and to evaluate the relationship between app usage and clinical outcome. Methods: The design was a mixed methods case series. Patients completed the Clinical Outcomes in Routine Evaluation-Outcome Measure pre- and post-CAT. Mood data plus the frequency and effectiveness of relational awareness and change were collected via the app. Therapists and patients were interviewed about their experiences using the app. Results: Ten patients (treated by 3 therapists) were enrolled; seven completed treatment and 4 had a reliable improvement in their mental health. App usage and mood change did not differ according to clinical outcome, but there was a statistically significant difference in app usage between completers and dropouts. The qualitative themes described by the therapists were (1) the challenge of incorporating the technology into their clinical practice and (2) the barriers and benefits of the technology. Clients? themes were (1) data protection, (2) motivation and engagement, and (3) restrictions versus flexibility. Conclusions: The CAT-App is capable of supporting relational awareness and change and is an upgrade on older, paper-based formats. Further clinical evaluation is required. UR - http://mental.jmir.org/2020/12/e19888/ UR - http://dx.doi.org/10.2196/19888 UR - http://www.ncbi.nlm.nih.gov/pubmed/33337342 ID - info:doi/10.2196/19888 ER - TY - JOUR AU - Alavi, Nazanin AU - Yang, Megan AU - Stephenson, Callum AU - Nikjoo, Niloofar AU - Malakouti, Niloufar AU - Layzell, Gina AU - Jagayat, Jasleen AU - Shirazi, Amirhossein AU - Groll, Dianne AU - Omrani, Mohsen AU - O'Riordan, Anne AU - Khalid-Khan, Sarosh AU - Freire, Rafael AU - Brietzke, Elisa AU - Gomes, Alves Fabiano AU - Milev, Roumen AU - Soares, N. Claudio PY - 2020/12/18 TI - Using the Online Psychotherapy Tool to Address Mental Health Problems in the Context of the COVID-19 Pandemic: Protocol for an Electronically Delivered Cognitive Behavioral Therapy Program JO - JMIR Res Protoc SP - e24913 VL - 9 IS - 12 KW - mental health KW - COVID-19 KW - depression KW - anxiety KW - psychotherapy KW - cognitive behavioural therapy KW - online KW - internet KW - electronic KW - mental health care N2 - Background: The considerable rise of mental health challenges during the COVID-19 pandemic has had detrimental effects on the public health sector and economy. To meet the overwhelming and growing demand for mental health care, innovative approaches must be employed to significantly expand mental health care delivery capacity. Although it is not feasible to increase the number of mental health care providers or hours they work in the short term, improving their time efficiency may be a viable solution. Virtually and digitally delivering psychotherapy, which has been shown to be efficient and clinically effective, might be a good method for addressing this growing demand. Objective: This research protocol aims to evaluate the feasibility and efficacy of using an online, digital, asynchronous care model to treat mental health issues that are started or aggravated by stressors associated with the COVID-19 pandemic. Methods: This nonrandomized controlled trial intervention will be delivered through the Online Psychotherapy Tool, a secure, cloud-based, digital mental health platform. Participants will be offered a 9-week electronically delivered cognitive behavioral therapy program that is tailored to address mental health problems in the context of the COVID-19 pandemic. This program will involve weekly self-guided educational material that provides an overview of behavioral skills and weekly homework. Participants (N=80) will receive personalized feedback from and weekly interaction with a therapist throughout the course of the program. The efficacy of the program will be evaluated using clinically validated symptomology questionnaires, which are to be completed by participants at baseline, week 5, and posttreatment. Inclusion criteria includes the capacity to consent; a primary diagnosis of generalized anxiety disorder or major depressive disorder, with symptoms that started or worsened during the COVID-19 pandemic; the ability to speak and read English; and consistent and reliable access to the internet. Exclusion criteria includes active psychosis, acute mania, severe alcohol or substance use disorder, and active suicidal or homicidal ideation. Results: This study received funding in May 2020. Ethics approval was received in June 2020. The recruitment of participants began in June 2020. Participant recruitment is being conducted via social media, web-based communities, and physician referrals. To date, 58 participants have been recruited (intervention group: n=35; control group: n=23). Data collection is expected to conclude by the end of 2020. Analyses (ie, linear regression analysis for continuous outcomes and binomial regression analysis for categorical outcomes) are expected to be completed by February 2021. Conclusions: If proven feasible, this care delivery method could increase care capacity by up to fourfold. The findings from this study can potentially influence clinical practices and policies and increase accessibility to care during the COVID-19 pandemic, without sacrificing the quality of care. Trial Registration: ClinicalTrials.gov NCT04476667; https://clinicaltrials.gov/ct2/show/NCT04476667 International Registered Report Identifier (IRRID): DERR1-10.2196/24913 UR - http://www.researchprotocols.org/2020/12/e24913/ UR - http://dx.doi.org/10.2196/24913 UR - http://www.ncbi.nlm.nih.gov/pubmed/33290245 ID - info:doi/10.2196/24913 ER - TY - JOUR AU - Bindoff, Ivan AU - Ling, R. Tristan AU - Gee, Peter AU - Geelan, Benjamin AU - Ferguson, G. Stuart AU - Peterson, M. Gregory PY - 2020/12/14 TI - Effects of a Mobile App Called Quittr, Which Utilizes Premium Currency and Games Features, on Improving Engagement With Smoking Cessation Intervention: Pilot Randomized Controlled Trial JO - JMIR Serious Games SP - e23734 VL - 8 IS - 4 KW - smoking KW - cessation KW - Quittr KW - engagement KW - retention KW - churn KW - cigarette KW - mHealth KW - game N2 - Background: Numerous mobile health (mHealth) apps have been developed to support smokers attempting to quit smoking. Although these apps have been reported to be successful, only modest improvements in the quit rate have been measured. It has been proposed that efforts to improve user engagement and retention may improve the quit rate further. Owing to the high cost of smoking-related disease, it is considered worthwhile to pursue even small improvements. Objective: The aim of this study was to test a novel smartphone app that leverages premium currency strategies developed by the mobile games industry in an attempt to improve engagement and retention with a smoking cessation intervention. Methods: We designed and developed a smoking cessation app called ?Quittr? in line with previously developed smoking cessation mHealth apps. In addition to this established framework, we added a stand-alone fully featured city-building clicker-style game called ?Tappy Town,? and a premium virtual currency called ?QuitCoins.? The user earns QuitCoins for using the app in a way that contributes positively toward their quit attempt, and they can redeem these coins in Tappy Town for bonuses. To establish whether these features improved engagement and retention, we ran a 5-month randomized controlled trial where the intervention group had the full app with the extra games features, while the control group had the standard app only. Recruitment was performed via web-based advertising. Participants (N=175) had no direct contact with the researchers or other support staff. Results: No significant differences in terms of engagement, retention, or smoking outcomes were found between the control and intervention groups. However, survey data indicated that the majority of the participants valued Tappy Town (10/17, 59%) and the QuitCoins rewards system (13/17, 77%). Usage data also suggested that Tappy Town was widely played and was generally appealing to users (mean total time spent in app, control group: 797 seconds vs intervention group: 3502 seconds, P<.001). Analysis of the results suggests that users in the intervention group may have been negatively affected by the aspects of the chosen design, and some theories were explored to explain this unexpected outcome. Conclusions: Although the novel features of the Quittr app failed to improve the key outcomes measured in this study, there were enough positive indications to warrant further exploration of the concept. Additional research will be required to identify and correct any design flaws that may have adversely affected our participants before a follow-up study can be completed. Trial Registration: Australian and New Zealand Clinical Trials Register ACTRN12617000491369; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372661&isReview=true UR - http://games.jmir.org/2020/4/e23734/ UR - http://dx.doi.org/10.2196/23734 UR - http://www.ncbi.nlm.nih.gov/pubmed/33315016 ID - info:doi/10.2196/23734 ER - TY - JOUR AU - Newton, Amanda AU - Bagnell, Alexa AU - Rosychuk, Rhonda AU - Duguay, Janelle AU - Wozney, Lori AU - Huguet, Anna AU - Henderson, Joanna AU - Curran, Janet PY - 2020/12/8 TI - A Mobile Phone?Based App for Use During Cognitive Behavioral Therapy for Adolescents With Anxiety (MindClimb): User-Centered Design and Usability Study JO - JMIR Mhealth Uhealth SP - e18439 VL - 8 IS - 12 KW - anxiety disorders KW - mobile apps KW - adolescents KW - usability testing KW - development KW - design KW - anxiety N2 - Background: Mobile device?based tools to help adolescents practice skills outside of cognitive behavioral therapy (CBT) sessions for treating an anxiety disorder may lead to greater treatment gains. Objective: This study aimed to develop, design, and test the acceptability, learnability, heuristics, and usability of MindClimb, a smartphone-based app for adolescents with anxiety to use between CBT sessions to plan and complete exposure activities using skills (cognitive, relaxation, exposure practice, and reward) learned in treatment. Methods: This 3-phase study took place from August 2015 to December 2018. In phase 1, the app was designed and developed in consultation with young people and CBT therapists to identify desired functions and content. Feedback was subjected to thematic analysis using a general inductive approach. In phase 2, we conducted 2 high-fidelity testing sessions using the think-aloud approach (acceptability, learnability, usability) and 10-item System Usability Scale with 10 adolescents receiving CBT. The high-fidelity MindClimb app was evaluated by 5 app developers based on Nielsen?s usability heuristics and 5-point severity ranking scale. In phase 3, a total of 8 adolescents and 3 therapists assessed the usability of MindClimb during CBT sessions by recording the frequency of skills practice, use of MindClimb features, satisfaction with the app, and barriers and facilitators to app use during treatment. Results: Feedback from phase 1 consultations indicated that the app should (1) be responsive to user needs and preferences, (2) be easy to use and navigate, (3) have relevant content to the practice of CBT for anxiety, and (4) be aesthetically appealing. Using this feedback as a guide, a fully functional app prototype for usability testing and heuristic evaluation was developed. In phase 2, think-aloud and usability data resulted in minor revisions to the app, including refinement of exposure activities. The average system usability score was 77 in both testing cycles, indicating acceptable usability. The heuristic evaluation by app developers identified only minor errors (eg, loading speed of app content, with a score of 1 on the severity ranking scale). In phase 3, adolescents considered app features for completing exposure (6.2/10) and relaxation (6.4/10) modestly helpful. Both adolescents (average score 11.3/15, SD 1.6) and therapists (average score 10.0/12, 2.6 SD) reported being satisfied with the app. Conclusions: The user-centered approach to developing and testing MindClimb resulted in a mobile health app that can be used by adolescents during CBT for anxiety. Evaluation of the use of this app in a clinical practice setting demonstrated that adolescents and therapists generally felt it was helpful for CBT practice outside of therapy sessions. Implementation studies with larger youth samples are necessary to evaluate how to optimize the use of technology in clinical care and examine the impact of the app plus CBT on clinical care processes and patient outcomes. UR - https://mhealth.jmir.org/2020/12/e18439 UR - http://dx.doi.org/10.2196/18439 UR - http://www.ncbi.nlm.nih.gov/pubmed/33289671 ID - info:doi/10.2196/18439 ER - TY - JOUR AU - Granholm, Eric AU - Holden, Jason AU - Dwyer, Kristen AU - Mikhael, Tanya AU - Link, Peter AU - Depp, Colin PY - 2020/12/1 TI - Mobile-Assisted Cognitive Behavioral Therapy for Negative Symptoms: Open Single-Arm Trial With Schizophrenia Patients JO - JMIR Ment Health SP - e24406 VL - 7 IS - 12 KW - motivation KW - persistent negative symptoms KW - dysfunctional attitudes KW - mHealth KW - blended intervention KW - mobile phone N2 - Background: Negative symptoms are an important unmet treatment need for schizophrenia. This study is a preliminary, open, single-arm trial of a novel hybrid intervention called mobile-assisted cognitive behavioral therapy for negative symptoms (mCBTn). Objective: The primary aim was to test whether mCBTn was feasible and could reduce severity of the target mechanism, defeatist performance attitudes, which are associated with experiential negative symptoms and poor functioning in schizophrenia. Methods: Participants with schizophrenia or schizoaffective disorder (N=31) who met prospective criteria for persistent negative symptoms were enrolled. The blended intervention combines weekly in-person group therapy with a smartphone app called CBT2go. The app extended therapy group skills, including recovery goal setting, thought challenging, scheduling of pleasurable activities and social interactions, and pleasure-savoring interventions to modify defeatist attitudes and improve experiential negative symptoms. Results: Retention was excellent (87% at 18 weeks), and severity of defeatist attitudes and experiential negative symptoms declined significantly in the mCBTn intervention with large effect sizes. Conclusions: The findings suggest that mCBTn is a feasible and potentially effective treatment for experiential negative symptoms, if confirmed in a larger randomized controlled trial. The findings also provide support for the defeatist attitude model of experiential negative symptoms and suggest that blended technology-supported interventions such as mCBTn can strengthen and shorten intensive psychosocial interventions for schizophrenia. Trial Registration: ClinicalTrials.gov NCT03179696; https://clinicaltrials.gov/ct2/show/NCT03179696 UR - https://mental.jmir.org/2020/12/e24406 UR - http://dx.doi.org/10.2196/24406 UR - http://www.ncbi.nlm.nih.gov/pubmed/33258792 ID - info:doi/10.2196/24406 ER - TY - JOUR AU - Asbjørnsen, Aune Rikke AU - Wentzel, Jobke AU - Smedsrød, Lien Mirjam AU - Hjelmesæth, Jøran AU - Clark, M. Matthew AU - Solberg Nes, Lise AU - Van Gemert-Pijnen, C. Julia E. W. PY - 2020/11/30 TI - Identifying Persuasive Design Principles and Behavior Change Techniques Supporting End User Values and Needs in eHealth Interventions for Long-Term Weight Loss Maintenance: Qualitative Study JO - J Med Internet Res SP - e22598 VL - 22 IS - 11 KW - eHealth KW - weight loss maintenance KW - behavior change KW - design thinking KW - digital health interventions KW - persuasive technology KW - human-centered design N2 - Background: An increasing number of eHealth interventions aim to support healthy behaviors that facilitate weight loss. However, there is limited evidence of the effectiveness of the interventions and little focus on weight loss maintenance. Knowledge about end user values and needs is essential to create meaningful and effective eHealth interventions, and to identify persuasive system design (PSD) principles and behavior change techniques (BCTs) that may contribute to the behavior change required for successful long-term weight loss maintenance. Objective: This study aimed to provide insight into the design of eHealth interventions supporting behavior change for long-term weight maintenance. The study sought to identify the values and needs of people with obesity aiming to maintain weight after weight loss, and to identify PSD principles, BCTs, and design requirements that potentially enable an eHealth intervention to meet end user values and needs. Methods: This study presents the concept of integrating PSD principles and BCTs into the design process of eHealth interventions to meet user values and needs. In this study, individual interviews and focus groups were conducted with people with obesity (n=23) and other key stakeholders (n=27) to explore end user values and needs related to weight loss maintenance. Design thinking methods were applied during the focus group sessions to identify design elements and to explore how eHealth solutions can support the needs to achieve sustainable weight loss maintenance. The PSD model and behavior change taxonomy by Michie were used to identify PSD principles and BCT clusters to meet end user values and needs. Results: A total of 8 key end user values were identified, reflecting user needs for weight loss maintenance support: self-management, personalized care, autonomy, feel supported, positive self-image, motivation, happiness, and health. Goals and planning, feedback and monitoring, repetition and substitution, shaping knowledge, social support, identity, and self-belief were some of the BCT clusters identified to address these concepts, together with PSD principles such as personalization, tailoring, self-monitoring, praise, and suggestions. Conclusions: The process of translating end user values and needs into design elements or features of eHealth technologies is an important part of the design process. To our knowledge, this is the first study to explore how PSD principles and BCTs can be integrated when designing eHealth self-management interventions for long-term weight loss maintenance. End users and other key stakeholders highlighted important factors to be considered in the design of eHealth interventions supporting sustained behavior change. The PSD principles and BCTs identified provide insights and suggestions about design elements and features to include for supporting weight loss maintenance. The findings indicate that a combination of BCTs and PSD principles may be needed in evidence-based eHealth interventions to stimulate motivation and adherence to support healthy behaviors and sustained weight loss maintenance. Trial Registration: ClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988 UR - http://www.jmir.org/2020/11/e22598/ UR - http://dx.doi.org/10.2196/22598 UR - http://www.ncbi.nlm.nih.gov/pubmed/33252347 ID - info:doi/10.2196/22598 ER - TY - JOUR AU - Brown, Menna AU - Hooper, Nic AU - Eslambolchilar, Parisa AU - John, Ann PY - 2020/11/30 TI - Development of a Web-Based Acceptance and Commitment Therapy Intervention to Support Lifestyle Behavior Change and Well-Being in Health Care Staff: Participatory Design Study JO - JMIR Form Res SP - e22507 VL - 4 IS - 11 KW - participatory design KW - eMental health KW - engagement KW - acceptance and commitment therapy N2 - Background: Positive emotional well-being is associated with healthier lifestyle choices and overall health function, whereas poor mental health is associated with significant economic and psychological costs. Thus, the development of effective interventions that improve emotional well-being is crucial to address the worldwide burden of disease. Objective: This study aims to develop a web-based emotional well-being intervention for use by health care staff using participatory design to consider adherence and engagement from a user perspective. Methods: A 3-staged iterative participatory design process was followed, including multiple stakeholders: researchers, computer scientists, mental health experts, and health care staff. Stage 1 used document analyses, direct observation, and welcome interviews; stage 2 used focus group discussions, rapid prototyping, and usability tasks; and stage 3 evaluated a high-fidelity prototype. Results: Different health care staff (N=38) participated during a sustained period. A structured, sequential, automated, 12-week, web-based emotional well-being intervention based on acceptance and commitment therapy was developed. Freely navigated psychoeducational resources were also included. Conclusions: The iterative and collaborative participatory design process successfully met its objectives. It generated an in-depth understanding of well-being within the workplace and identified barriers to access. The 3-staged process ensured that participants had the opportunity to explore and articulate criteria relevant to their roles over time and reflect on decisions made at each stage. UR - https://formative.jmir.org/2020/11/e22507 UR - http://dx.doi.org/10.2196/22507 UR - http://www.ncbi.nlm.nih.gov/pubmed/33252350 ID - info:doi/10.2196/22507 ER - TY - JOUR AU - Düking, Peter AU - Tafler, Marie AU - Wallmann-Sperlich, Birgit AU - Sperlich, Billy AU - Kleih, Sonja PY - 2020/11/19 TI - Behavior Change Techniques in Wrist-Worn Wearables to Promote Physical Activity: Content Analysis JO - JMIR Mhealth Uhealth SP - e20820 VL - 8 IS - 11 KW - cardiorespiratory fitness KW - innovation KW - smartwatch KW - technology KW - wearable KW - eHealth KW - mHealth N2 - Background: Decreasing levels of physical activity (PA) increase the incidences of noncommunicable diseases, obesity, and mortality. To counteract these developments, interventions aiming to increase PA are urgently needed. Mobile health (mHealth) solutions such as wearable sensors (wearables) may assist with an improvement in PA. Objective: The aim of this study is to examine which behavior change techniques (BCTs) are incorporated in currently available commercial high-end wearables that target users? PA behavior. Methods: The BCTs incorporated in 5 different high-end wearables (Apple Watch Series 3, Garmin Vívoactive 3, Fitbit Versa, Xiaomi Amazfit Stratos 2, and Polar M600) were assessed by 2 researchers using the BCT Taxonomy version 1 (BCTTv1). Effectiveness of the incorporated BCTs in promoting PA behavior was assessed by a content analysis of the existing literature. Results: The most common BCTs were goal setting (behavior), action planning, review behavior goal(s), discrepancy between current behavior and goal, feedback on behavior, self-monitoring of behavior, and biofeedback. Fitbit Versa, Garmin Vívoactive 3, Apple Watch Series 3, Polar M600, and Xiaomi Amazfit Stratos 2 incorporated 17, 16, 12, 11, and 11 BCTs, respectively, which are proven to effectively promote PA. Conclusions: Wearables employ different numbers and combinations of BCTs, which might impact their effectiveness in improving PA. To promote PA by employing wearables, we encourage researchers to develop a taxonomy specifically designed to assess BCTs incorporated in wearables. We also encourage manufacturers to customize BCTs based on the targeted populations. UR - http://mhealth.jmir.org/2020/11/e20820/ UR - http://dx.doi.org/10.2196/20820 UR - http://www.ncbi.nlm.nih.gov/pubmed/33211023 ID - info:doi/10.2196/20820 ER - TY - JOUR AU - Nicol, E. Ginger AU - Ricchio, R. Amanda AU - Metts, L. Christopher AU - Yingling, D. Michael AU - Ramsey, T. Alex AU - Schweiger, A. Julia AU - Miller, Philip J. AU - Lenze, J. Eric PY - 2020/11/13 TI - A Smartphone-Based Technique to Detect Dynamic User Preferences for Tailoring Behavioral Interventions: Observational Utility Study of Ecological Daily Needs Assessment JO - JMIR Mhealth Uhealth SP - e18609 VL - 8 IS - 11 KW - mobile health KW - telemedicine KW - needs assessment KW - healthy lifestyle KW - ecological momentary assessment KW - mobile applications KW - behavior intervention KW - behavior therapy N2 - Background: Mobile health apps are promising vehicles for delivering scalable health behavior change interventions to populations that are otherwise difficult to reach and engage, such as young adults with psychiatric conditions. To improve uptake and sustain consumer engagement, mobile health interventions need to be responsive to individuals? needs and preferences, which may change over time. We previously created an ecological daily needs assessment to capture microprocesses influencing user needs and preferences for mobile health treatment adaptation. Objective: The objective of our study was to test the utility of a needs assessment anchored within a mobile app to capture individualized, contextually relevant user needs and preferences within the framework of a weight management mobile health app. Methods: Participants with an iOS device could download the study app via the study website or links from social media. In this fully remote study, we screened, obtained informed consent from, and enrolled participants through the mobile app. The mobile health framework included daily health goal setting and self-monitoring, with up to 6 daily prompts to determine in-the-moment needs and preferences for mobile health?assisted health behavior change. Results: A total of 24 participants downloaded the app and provided e-consent (22 female; 2 male), with 23 participants responding to at least one prompt over 2 weeks. The mean length of engagement was 5.6 (SD 4.7) days, with a mean of 2.8 (1.1) responses per day. We observed individually dynamic needs and preferences, illustrating daily variability within and between individuals. Qualitative feedback indicated preferences for self-adapting features, simplified self-monitoring, and the ability to personalize app-generated message timing and content. Conclusions: The technique provided an individually dynamic and contextually relevant alternative and complement to traditional needs assessment for assessing individually dynamic user needs and preferences during treatment development or adaptation. The results of this utility study suggest the importance of personalization and learning algorithms for sustaining app engagement in young adults with psychiatric conditions. Further study in broader user populations is needed. UR - http://mhealth.jmir.org/2020/11/e18609/ UR - http://dx.doi.org/10.2196/18609 UR - http://www.ncbi.nlm.nih.gov/pubmed/33055063 ID - info:doi/10.2196/18609 ER - TY - JOUR AU - Bielinski, Luisa Laura AU - Krieger, Tobias AU - Moggi, Franz AU - Trimpop, Leonie AU - Willutzki, Ulrike AU - Nissen, Christoph AU - Berger, Thomas PY - 2020/11/12 TI - REMOTION Blended Transdiagnostic Intervention for Symptom Reduction and Improvement of Emotion Regulation in an Outpatient Psychotherapeutic Setting: Protocol for a Pilot Randomized Controlled Trial JO - JMIR Res Protoc SP - e20936 VL - 9 IS - 11 KW - blended therapy KW - internet-based intervention KW - emotion regulation KW - transdiagnostic KW - online therapy N2 - Background: Emotion regulation has been identified as an important transdiagnostic factor relevant to the treatment of mental health disorders. Many empirically validated psychotherapeutic treatments incorporate elements targeting emotion regulation. Most of these treatment approaches are conceptualized as standard face-to-face treatments not as blended treatments, which include an internet-based intervention. Objective: The aim of this study is to examine, for the first time, a new internet-based intervention?REMOTION?that will be provided transdiagnostically, as an add-on to psychotherapy, to provide a blended treatment format. Methods: A total of 70 participants will be assigned (1:1 allocation ratio) to either the intervention group (REMOTION + psychotherapy) or the treatment-as-usual group that receives psychotherapy alone. To maximize external validity, a typical outpatient treatment sample of patients diagnosed with a range of disorders such as depression, anxiety disorders, and adjustment disorder will be recruited from a university outpatient clinic. Patients with bipolar disorder, psychotic disorders, or acute suicidality will be excluded from the study. The feasibility and potential effectiveness of the intervention will be examined by assessing data at baseline, 6 weeks (post), and 12 weeks (follow-up). The primary outcome is general symptom severity, assessed with the Brief Symptom Inventory. Secondary outcomes are emotion regulation, depressive symptoms, anxiety symptoms, health related quality of life, well-being, and a variety of feasibility parameters. Quantitative data will be analyzed on an intention-to-treat basis. Results: Participant recruitment and data collection started in February 2020, and as of November 2020, are ongoing. Results for the study are expected in 2022. Conclusions: This pilot randomized controlled trial will inform future studies using transdiagnostic blended treatment. Trial Registration: ClinicalTrials.gov NCT04262726; http://clinicaltrials.gov/ct2/show/NCT04262726 International Registered Report Identifier (IRRID): DERR1-10.2196/20936 UR - http://www.researchprotocols.org/2020/11/e20936/ UR - http://dx.doi.org/10.2196/20936 UR - http://www.ncbi.nlm.nih.gov/pubmed/33180026 ID - info:doi/10.2196/20936 ER - TY - JOUR AU - Paul, Margot AU - Bullock, Kim AU - Bailenson, Jeremy PY - 2020/11/3 TI - Virtual Reality Behavioral Activation as an Intervention for Major Depressive Disorder: Case Report JO - JMIR Ment Health SP - e24331 VL - 7 IS - 11 KW - virtual reality KW - case report KW - major depressive disorder KW - behavioral activation KW - VR KW - depression KW - COVID-19 KW - behavior KW - intervention KW - feasibility KW - acceptability KW - telehealth KW - pilot study N2 - Background: Major depressive disorder (MDD) is a global problem with an increasing incidence and prevalence. There has additionally been an increase in depression due to the COVID-19 pandemic. Behavioral activation is considered an evidence-based treatment for MDD. However, there are many barriers that could hinder one?s ability to engage in behavioral activation, with COVID-19 ?shelter-in-place? and social distancing orders being current and large impediments. Virtual reality (VR) has been successfully used to help treat a variety of mental health conditions, but it has not yet been used as a method of administering behavioral activation to a clinical population. Using VR to engage in behavioral activation could eliminate barriers that pandemic precautions place and help decrease symptoms of depression that are especially exacerbated in these times. Objective: The following case report examines the feasibility, acceptability, and tolerability of VR behavioral activation for an adult with MDD during a global pandemic. This participant was part of a larger pilot study, and the case serves as a description of the VR intervention. Methods: The participant engaged in a weekly 50-minute psychotherapy Zoom session for 4 weeks, in which a modified behavioral activation protocol was administered using a VR headset to simulate activities. Data on mood ratings, homework compliance, and headset use were obtained from the headset. Acceptability, tolerability, and depression symptoms were obtained using self-report rating scales. Results: The intervention was feasible, acceptable, and tolerable, as reported by this participant. The participant?s depressive symptoms decreased by five-points on the Patient Health Questionnaire-9 over a month, with a beginning score of 10 (moderate depression) and a final score of 5 (mild depression). Conclusions: The implications of these findings for future research are discussed. Trial Registration: ClinicalTrials.gov NCT04268316; http://clinicaltrials.gov/ct2/show/NCT04268316 UR - https://mental.jmir.org/2020/11/e24331 UR - http://dx.doi.org/10.2196/24331 UR - http://www.ncbi.nlm.nih.gov/pubmed/33031046 ID - info:doi/10.2196/24331 ER - TY - JOUR AU - Baumel, Amit AU - Fleming, Theresa AU - Schueller, M. Stephen PY - 2020/10/29 TI - Digital Micro Interventions for Behavioral and Mental Health Gains: Core Components and Conceptualization of Digital Micro Intervention Care JO - J Med Internet Res SP - e20631 VL - 22 IS - 10 KW - micro intervention KW - mental health KW - mhealth KW - eHealth KW - engagement KW - intervention KW - adherence KW - behavior change KW - behavioral health UR - http://www.jmir.org/2020/10/e20631/ UR - http://dx.doi.org/10.2196/20631 UR - http://www.ncbi.nlm.nih.gov/pubmed/33118946 ID - info:doi/10.2196/20631 ER - TY - JOUR AU - Chamberlain, R. Liam AU - Hall, L. Charlotte AU - Andrén, Per AU - Davies, Bethan E. AU - Kilgariff, Joseph AU - Kouzoupi, Natalia AU - Murphy, Tara AU - Hollis, Chris PY - 2020/10/23 TI - Therapist-Supported Online Interventions for Children and Young People With Tic Disorders: Lessons Learned From a Randomized Controlled Trial and Considerations for Future Practice JO - JMIR Ment Health SP - e19600 VL - 7 IS - 10 KW - Tourette syndrome KW - tic disorders KW - internet-based cognitive behavioral therapy (iCBT) KW - remote therapy KW - therapist support UR - http://mental.jmir.org/2020/10/e19600/ UR - http://dx.doi.org/10.2196/19600 UR - http://www.ncbi.nlm.nih.gov/pubmed/33095180 ID - info:doi/10.2196/19600 ER - TY - JOUR AU - Beerlage-de Jong, Nienke AU - Kip, Hanneke AU - Kelders, Marion Saskia PY - 2020/10/23 TI - Evaluation of the Perceived Persuasiveness Questionnaire: User-Centered Card-Sort Study JO - J Med Internet Res SP - e20404 VL - 22 IS - 10 KW - eHealth KW - behavior change support systems KW - card sort KW - perceived persuasiveness KW - persuasive systems design KW - mental model KW - questionnaire evaluation N2 - Background: eHealth technologies aim to change users? health-related behavior. Persuasive design and system features can make an eHealth technology more motivating, engaging, or supportive to its users. The Persuasive Systems Design (PSD) model incorporates software features that have the possibility to increase the persuasiveness of technologies. However, the effects of specific PSD software features on the effectiveness of an intervention are still largely unknown. The Perceived Persuasiveness Questionnaire (PPQ) was developed to gain insight into the working mechanisms of persuasive technologies. Although the PPQ seems to be a suitable method for measuring subjective persuasiveness, it needs to be further evaluated to determine how suitable it is for measuring perceived persuasiveness among the public. Objective: This study aims to evaluate the face and construct validity of the PPQ, identify points of improvement, and provide suggestions for further development of the PPQ. Methods: A web-based closed-ended card-sort study was performed wherein participants grouped existing PPQ items under existing PPQ constructs. Participants were invited via a Massive Open Online Course on eHealth. A total of 398 people (average age 44.15 years, SD 15.17; 251/398, 63.1% women) completed the card sort. Face validity was evaluated by determining the item-level agreement of the original PPQ constructs. Construct validity was evaluated by determining the construct in which each item was placed most often, regardless of the original placement and how often 2 items were (regardless of the constructs) paired together and what interitem correlations were according to a cluster analysis. Results: Four PPQ constructs obtained relatively high face validity scores: perceived social support, use continuance, perceived credibility, and perceived effort. Item-level agreement on the other constructs was relatively low. Item-level agreement for almost all constructs, except perceived effort and perceived effectiveness, would increase if items would be grouped differently. Finally, a cluster analysis of the PPQ indicated that the strengths of the newly identified 9 clusters varied strongly. Unchanged strong clusters were only found for perceived credibility support, perceived social support, and use continuance. The placement of the other items was much more spread out over the other constructs, suggesting an overlap between them. Conclusions: The findings of this study provide a solid starting point toward a redesigned PPQ that is a true asset to the field of persuasiveness research. To achieve this, we advocate that the redesigned PPQ should adhere more closely to what persuasiveness is according to the PSD model and to the mental models of potential end users of technology. The revised PPQ should, for example, enquire if the user thinks anything is done to provide task support but not how this is done exactly. UR - http://www.jmir.org/2020/10/e20404/ UR - http://dx.doi.org/10.2196/20404 UR - http://www.ncbi.nlm.nih.gov/pubmed/33095173 ID - info:doi/10.2196/20404 ER - TY - JOUR AU - Bostrøm, Katrine AU - Børøsund, Elin AU - Varsi, Cecilie AU - Eide, Hilde AU - Flakk Nordang, Elise AU - Schreurs, MG Karlein AU - Waxenberg, B. Lori AU - Weiss, E. Karen AU - Morrison, J. Eleshia AU - Cvancarova Småstuen, Milada AU - Stubhaug, Audun AU - Solberg Nes, Lise PY - 2020/10/23 TI - Digital Self-Management in Support of Patients Living With Chronic Pain: Feasibility Pilot Study JO - JMIR Form Res SP - e23893 VL - 4 IS - 10 KW - chronic pain KW - feasibility KW - acceptability KW - self-management KW - eHealth KW - digital KW - cognitive-behavioral pain KW - usability KW - user centered N2 - Background: Chronic pain can be complex and taxing to live with, and treatment and support require a multicomponent approach, which may not always be offered or available. Smartphones, tablets, and personal computers are already incorporated into patients? daily lives, and therefore, they can be used to communicate, educate, and support self-management. Although some web-based self-management interventions exist, research examining the evidence and effect of digital solutions supporting self-management for patients living with chronic pain is limited, findings are inconclusive, and new innovative ideas and solutions are needed. Objective: This feasibility pilot study aimed to explore the system use, perceived usefulness, ease of use, and preliminary effects of EPIO, an app-based cognitive-behavioral pain self-management intervention program for patients living with chronic pain. Methods: The EPIO intervention was delivered in a blended-care model containing (1) one face-to-face introduction session, (2) nine cognitive behavior?based pain self-management modules, delivered in an app-based format for smartphones or tablets, and (3) one follow-up phone call at 2 to 3 weeks after the introduction session. Patients living with chronic pain (N=50) completed pre-post outcome measures at baseline and 3 months after the introduction session, with registration of system use (ie, log data) until 6 months. The use, perceived usefulness, and ease of use of the EPIO program were examined through system use data, as well as a study-specific use/usability questionnaire and the System Usability Scale (SUS). Outcome measures to test feasibility of use and estimate preliminary effects included the Brief Pain Inventory, health-related quality of life (HRQoL) scale, Hospital Anxiety and Depression Scale, Self-Regulatory Fatigue scale, Pain Catastrophizing Scale, and Chronic Pain Acceptance Questionnaire. Results: Participants (N=50) had a median age of 52 years (range 29-74 years) at inclusion and were mainly female (40/50, 80%). Thirty-one participants completed at least six of the nine modules within the 3-month study period (62% completion rate). Forty-five participants completed outcome measures at 3 months, and the EPIO program was rated as useful (ie, ?totally agree? or ?agree?; 39/45, 87%) and easy to use (42/45, 93%), and as having easily understandable exercises (44/45, 98%). The average overall system usability (SUS) score was 85.7, indicating grade A and excellent system usability. Preliminary psychosocial outcome measure estimates showed primarily nonsignificant pre-post intervention improvements at 3 months, but with significant positive effects related to some aspects of HRQoL (bodily pain, P=.02 and change, P=.049). Conclusions:  Digital self-management intervention programs may be of use and support for patients living with chronic pain. In this feasibility study, EPIO showed an acceptable program completion rate and was rated as useful and easy to use, with excellent user satisfaction. Program optimization and efficacy testing in a large-scale randomized controlled trial are warranted and in progress. Trial Registration: ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104 UR - http://formative.jmir.org/2020/10/e23893/ UR - http://dx.doi.org/10.2196/23893 UR - http://www.ncbi.nlm.nih.gov/pubmed/33094734 ID - info:doi/10.2196/23893 ER - TY - JOUR AU - Schmidt-Kraepelin, Manuel AU - Toussaint, A. Philipp AU - Thiebes, Scott AU - Hamari, Juho AU - Sunyaev, Ali PY - 2020/10/19 TI - Archetypes of Gamification: Analysis of mHealth Apps JO - JMIR Mhealth Uhealth SP - e19280 VL - 8 IS - 10 KW - mHealth KW - smartphones KW - mobile phones KW - gamification KW - quantified-self KW - exergames, persuasive technology N2 - Background: Nowadays, numerous health-related mobile apps implement gamification in an attempt to draw on the motivational potential of video games and thereby increase user engagement or foster certain health behaviors. However, research on effective gamification is still in its infancy and researchers increasingly recognize methodological shortcomings of existing studies. What we actually know about the phenomenon today stems from fragmented pieces of knowledge, and a variety of different perspectives. Existing research primarily draws on conceptual knowledge that is gained from research prototypes, and isolated from industry best practices. We still lack knowledge on how gamification has been successfully designed and implemented within the industry and whether certain gamification approaches have shown to be particularly suitable for certain health behaviors. Objective: We address this lack of knowledge concerning best practices in the design and implementation of gamification for health-related mobile apps by identifying archetypes of gamification approaches that have emerged in pertinent health-related mobile apps and analyzing to what extent those gamification approaches are influenced by the underlying desired health-related outcomes. Methods: A 3-step research approach is employed. As a first step, a database of 143 pertinent gamified health-related mobile apps from the Apple App Store and Google Play Store is set up. Second, the gamification approach of each app within the database is classified based on an established taxonomy for gamification in health-related apps. Finally, a 2-step cluster analysis is conducted in order to identify archetypes of the most dominant gamification approaches in pertinent gamified health-related mobile apps. Results: Eight archetypes of gamification emerged from the analysis of health-related mobile apps: (1) competition and collaboration, (2) pursuing self-set goals without rewards, (3) episodical compliance tracking, (4) inherent gamification for external goals, (5) internal rewards for self-set goals, (6) continuous assistance through positive reinforcement, (7) positive and negative reinforcement without rewards, and (8) progressive gamification for health professionals. The results indicate a close relationship between the identified archetypes and the actual health behavior that is being targeted. Conclusions: By unveiling salient best practices and discussing their relationship to targeted health behaviors, this study contributes to a more profound understanding of gamification in mobile health. The results can serve as a foundation for future research that advances the knowledge on how gamification may positively influence health behavior change and guide practitioners in the design and development of highly motivating and effective health-related mobile health apps. UR - https://mhealth.jmir.org/2020/10/e19280 UR - http://dx.doi.org/10.2196/19280 UR - http://www.ncbi.nlm.nih.gov/pubmed/33074155 ID - info:doi/10.2196/19280 ER - TY - JOUR AU - Wang, Di AU - Lyu, Chen Joanne AU - Zhao, Xiaoyu PY - 2020/10/14 TI - Public Opinion About E-Cigarettes on Chinese Social Media: A Combined Study of Text Mining Analysis and Correspondence Analysis JO - J Med Internet Res SP - e19804 VL - 22 IS - 10 KW - e-cigarettes KW - public opinion KW - social media KW - infodemiology KW - infoveillance KW - regulation KW - China N2 - Background: Electronic cigarettes (e-cigarettes) have become increasingly popular. China has accelerated its legislation on e-cigarettes in recent years by issuing two policies to regulate their use: the first on August 26, 2018, and the second on November 1, 2019. Social media provide an efficient platform to access information on the public opinion of e-cigarettes. Objective: To gain insight into how policies have influenced the reaction of the Chinese public to e-cigarettes, this study aims to understand what the Chinese public say about e-cigarettes and how the focus of discussion might have changed in the context of policy implementation. Methods: This study uses a combination of text mining and correspondence analysis to content analyze 1160 e-cigarette?related questions and their corresponding answers from Zhihu, China?s largest question-and-answer platform and one of the country?s most trustworthy social media sources. From January 1, 2017, to December 31, 2019, Python was used to text mine the most frequently used words and phrases in public e-cigarette discussions on Zhihu. The correspondence analysis was used to examine the similarities and differences between high-frequency words and phrases across 3 periods (ie, January 1, 2017, to August 27, 2018; August 28, 2018, to October 31, 2019; and November 1, 2019, to January 1, 2020). Results: The results of the study showed that the consistent themes across time were comparisons with traditional cigarettes, health concerns, and how to choose e-cigarette products. The issuance of government policies on e-cigarettes led to a change in the focus of public discussion. The discussion of e-cigarettes in period 1 mainly focused on the use and experience of e-cigarettes. In period 2, the public?s attention was not only on the substances related to e-cigarettes but also on the smoking cessation functions of e-cigarettes. In period 3, the public shifted their attention to the e-cigarette industry and government policy on the banning of e-cigarette sales to minors. Conclusions: Social media are an informative source, which can help policy makers and public health professionals understand the public?s concerns over and understanding of e-cigarettes. When there was little regulation, public discussion was greatly influenced by industry claims about e-cigarettes; however, once e-cigarette policies were issued, these policies, to a large extent, set the agenda for public discussion. In addition, media reporting of these policies might have greatly influenced the way e-cigarette policies were discussed. Therefore, monitoring e-cigarette discussions on social media and responding to them in a timely manner will both help improve the public?s e-cigarette literacy and facilitate the implementation of e-cigarette?related policies. UR - http://www.jmir.org/2020/10/e19804/ UR - http://dx.doi.org/10.2196/19804 UR - http://www.ncbi.nlm.nih.gov/pubmed/33052127 ID - info:doi/10.2196/19804 ER - TY - JOUR AU - Edmonds, R. Michael AU - Hadjistavropoulos, D. Heather AU - Gullickson, M. Kirsten AU - Asmundson, JN Aleiia AU - Dear, F. Blake AU - Titov, Nickolai PY - 2020/10/13 TI - Understanding Problems With Sleep, Sexual Functioning, Energy, and Appetite Among Patients Who Access Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy for Anxiety and Depression: Qualitative Exploratory Study JO - JMIR Form Res SP - e15037 VL - 4 IS - 10 KW - cognitive behavioral therapy KW - anxiety KW - depression KW - internet-based intervention KW - sleep KW - sexual health KW - motivation KW - appetite N2 - Background: Transdiagnostic internet-delivered cognitive behavioral therapy (T-ICBT) is an effective treatment for anxiety and depression, and nowadays, there is interest in exploring ways to optimize T-ICBT in routine care. T-ICBT programs are designed to address the primary cognitive-affective and behavioral symptoms of anxiety and depression (eg, low mood, worry, anhedonia, and avoidance). Treatment also has the potential to resolve other symptom concerns (eg, sleep disruption, sexual dysfunction, lack of energy, and appetite or weight changes). Having additional information regarding the extent of these concerns and how concerns change over time could prove beneficial for further development of T-ICBT in routine care. Objective: This exploratory formative study aims to better understand sleep, sexual functioning, energy, and appetite concerns among T-ICBT clients seeking treatment for depression and anxiety. A qualitative analytic approach was used to identify themes in the symptom concerns reported by patients in the areas of sleep, sexual functioning, energy, and appetite at the time of enrollment. Patient responses to related items from screening measures for anxiety and depression were also examined pre- and posttreatment. Methods: Patients in routine care who applied for a T-ICBT program for depression and anxiety over a 1-year period were included in this study. As part of the application and screening process, participants completed depression and anxiety symptom measures (ie, 9-item Patient Health Questionnaire and 7-item Generalized Anxiety Disorder scale). These same measures were administered posttreatment. Subsequently, they were asked if they were experiencing any problems with sleep, sexual activity, energy, or appetite (yes or no). If their response was yes, they were presented with an open-ended comment box that asked them to describe the problems they had experienced in those areas. Results: A total of 462 patients were admitted to T-ICBT during the study period, of which 438 endorsed having some problems with sleep, sexual activity, energy, or appetite. The analysis of open-ended responses indicated that 73.4% (339/462) of patients reported sleep problems (eg, difficulty initiating or maintaining sleep), 69.3% (320/462) of patients reported problems with energy or motivation (eg, tiredness and low motivation), 57.4% (265/462) of patients reported appetite or body weight concerns (eg, changes in appetite and weight loss or gain), and 30.1% (139/462) of patients described concerns with sexual functioning (eg, loss of interest in sex and difficulty with arousal). Item analysis of symptom measures demonstrated that T-ICBT produced improvements in sleep, energy, and appetite in 8 weeks. Sexual dysfunction and weight changes were not represented in the screening measures, so it remains unclear what effect T-ICBT has on these symptoms. Conclusions: Sleep disruption, lack of energy, appetite or weight changes, and sexual dysfunction are common concerns reported by clients enrolled in T-ICBT in routine practice and may deserve greater attention in T-ICBT program development and administration. UR - http://formative.jmir.org/2020/10/e15037/ UR - http://dx.doi.org/10.2196/15037 UR - http://www.ncbi.nlm.nih.gov/pubmed/33048054 ID - info:doi/10.2196/15037 ER - TY - JOUR AU - Schure, Mark AU - McCrory, Bernadette AU - Tuchscherer Franklin, Kathryn AU - Greist, John AU - Weissman, Striegel Ruth PY - 2020/10/2 TI - Twelve-Month Follow-Up to a Fully Automated Internet-Based Cognitive Behavior Therapy Intervention for Rural Adults With Depression Symptoms: Single-Arm Longitudinal Study JO - J Med Internet Res SP - e21336 VL - 22 IS - 10 KW - internet-based cognitive behavior therapy KW - depression KW - anxiety KW - long-term outcomes KW - iCBT KW - CBT KW - therapy KW - mental health KW - outcome N2 - Background: Internet-based cognitive behavior therapy (iCBT) interventions have the potential to help individuals with depression, regardless of time and location. Yet, limited information exists on the longer-term (>6 months) effects of iCBT and adherence to these interventions. Objective: The primary aim of this study was to evaluate the longitudinal (12 months) effectiveness of a fully automated, self-guided iCBT intervention called Thrive, designed to enhance engagement with a rural population of adults with depression symptoms. The secondary aim was to determine whether the program adherence enhanced the effectiveness of the Thrive intervention. Methods: We analyzed data from 181 adults who used the Thrive intervention. Using self-reports, participants were evaluated at baseline, 8 weeks, 6 months, and 12 months for the primary outcome of depression symptom severity using the Patient Health Questionnaire-9 (PHQ-9) scale and secondary outcome measures, namely, the Generalized Anxiety Disorder Scale-7 (GAD-7) scores, Work and Social Adjustment Scale (WSAS) scores, Conner-Davidson Resilience Scale-10 (CD-RISC-10) scores, and suicidal ideation (ninth item of the PHQ-9 scale) scores. The Thrive program adherence was measured using the numbers of program logins, page views, and lessons completed. Results: The assessment response rates for 8-week, 6-month, and 12-month outcomes were 58.6% (106/181), 50.3% (91/181), and 51.4% (93/181), respectively. By 8 weeks, significant improvements were observed for all outcome measures. These improvements were maintained at 12 months with mean reductions in severities of depression (mean ?6.5; P<.001) and anxiety symptoms (mean ?4.3; P<.001). Improvements were also observed in work and social functioning (mean ?6.9; P<.001) and resilience (mean 4.3; P<.001). Marked decreases were observed in suicidal ideation (PHQ-9 ninth item score >1) at 6 months (16.5%) and 12 months (17.2%) compared to baseline (39.8%) (P<.001). In regard to the program adherence, cumulative counts of page views and lessons completed were significantly related to lower PHQ-9, GAD-7, and WSAS scores and higher CD-RISC-10 scores (all P values <.001 with an exception of page views with WSAS for which P value was .02). Conclusions: The Thrive intervention was effective at reducing depression and anxiety symptom severity and improving functioning and resilience among a population of adults from mostly rural communities in the United States. These gains were maintained at 1 year. Program adherence, measured by the number of logins and lessons completed, indicates that users who engage more with the program benefit more from the intervention. Trial Registration: ClinicalTrials.gov NCT03244878; https://clinicaltrials.gov/ct2/show/NCT03244878 UR - https://www.jmir.org/2020/10/e21336 UR - http://dx.doi.org/10.2196/21336 UR - http://www.ncbi.nlm.nih.gov/pubmed/33006561 ID - info:doi/10.2196/21336 ER - TY - JOUR AU - Zhang, Jingwen AU - Oh, Jung Yoo AU - Lange, Patrick AU - Yu, Zhou AU - Fukuoka, Yoshimi PY - 2020/9/30 TI - Artificial Intelligence Chatbot Behavior Change Model for Designing Artificial Intelligence Chatbots to Promote Physical Activity and a Healthy Diet: Viewpoint JO - J Med Internet Res SP - e22845 VL - 22 IS - 9 KW - chatbot KW - conversational agent KW - artificial intelligence KW - physical activity KW - diet KW - intervention KW - behavior change KW - natural language processing KW - communication N2 - Background: Chatbots empowered by artificial intelligence (AI) can increasingly engage in natural conversations and build relationships with users. Applying AI chatbots to lifestyle modification programs is one of the promising areas to develop cost-effective and feasible behavior interventions to promote physical activity and a healthy diet. Objective: The purposes of this perspective paper are to present a brief literature review of chatbot use in promoting physical activity and a healthy diet, describe the AI chatbot behavior change model our research team developed based on extensive interdisciplinary research, and discuss ethical principles and considerations. Methods: We conducted a preliminary search of studies reporting chatbots for improving physical activity and/or diet in four databases in July 2020. We summarized the characteristics of the chatbot studies and reviewed recent developments in human-AI communication research and innovations in natural language processing. Based on the identified gaps and opportunities, as well as our own clinical and research experience and findings, we propose an AI chatbot behavior change model. Results: Our review found a lack of understanding around theoretical guidance and practical recommendations on designing AI chatbots for lifestyle modification programs. The proposed AI chatbot behavior change model consists of the following four components to provide such guidance: (1) designing chatbot characteristics and understanding user background; (2) building relational capacity; (3) building persuasive conversational capacity; and (4) evaluating mechanisms and outcomes. The rationale and evidence supporting the design and evaluation choices for this model are presented in this paper. Conclusions: As AI chatbots become increasingly integrated into various digital communications, our proposed theoretical framework is the first step to conceptualize the scope of utilization in health behavior change domains and to synthesize all possible dimensions of chatbot features to inform intervention design and evaluation. There is a need for more interdisciplinary work to continue developing AI techniques to improve a chatbot?s relational and persuasive capacities to change physical activity and diet behaviors with strong ethical principles. UR - https://www.jmir.org/2020/9/e22845 UR - http://dx.doi.org/10.2196/22845 UR - http://www.ncbi.nlm.nih.gov/pubmed/32996892 ID - info:doi/10.2196/22845 ER - TY - JOUR AU - Meyers, Milena AU - Margraf, Jürgen AU - Velten, Julia PY - 2020/9/29 TI - Psychological Treatment of Low Sexual Desire in Women: Protocol for a Randomized, Waitlist-Controlled Trial of Internet-Based Cognitive Behavioral and Mindfulness-Based Treatments JO - JMIR Res Protoc SP - e20326 VL - 9 IS - 9 KW - sexual desire KW - sexual dysfunction KW - women?s sexual health KW - cognitive behavioral therapy N2 - Background: Psychological therapies are effective treatments for hypoactive sexual desire dysfunction (HSDD; formerly hypoactive sexual desire disorder), a common sexual dysfunction among women. Access to evidence-based treatments, however, remains difficult. Internet-based interventions are effective for a variety of psychological disorders and may be a promising means to close the treatment gap for HSDD. Objective: This article describes the treatment protocol and study design of a randomized controlled trial, aiming to study the efficacy of cognitive behavioral and mindfulness-based interventions delivered via the internet for women with HSDD to a waitlist control group. Outcomes are sexual desire (primary) and sexual distress (secondary). Additional variables (eg, depression, mindfulness, rumination) will be assessed as potential moderators or mediators of treatment success. Methods: A cognitive behavioral and a mindfulness-based self-help intervention for HSDD will be provided online. Overall, 266 women with HSDD will be recruited and assigned either to one of the intervention groups, or to a waitlist control group (2:2:1). Outcome data will be assessed at baseline, at 12 weeks, and at 6 and 12 months after randomization. Intention-to-treat and completer analyses will be conducted. Results: We expect improvements in sexual desire and sexuality-related distress in both intervention groups compared to the waitlist control. Recruitment has begun in January 2019 and is expected to be completed in August 2021. Results will be published in 2022. Conclusions: This study aims to contribute to the improvement and dissemination of psychological treatments for women with HSDD and to clarify whether cognitive behavioral and/or mindfulness-based treatments for HSDD are feasible and effective when delivered via the internet. Trial Registration: ClinicalTrials.gov NCT03780751; https://clinicaltrials.gov/ct2/show/NCT03780751 International Registered Report Identifier (IRRID): DERR1-10.2196/20326 UR - http://www.researchprotocols.org/2020/9/e20326/ UR - http://dx.doi.org/10.2196/20326 UR - http://www.ncbi.nlm.nih.gov/pubmed/32990248 ID - info:doi/10.2196/20326 ER - TY - JOUR AU - Bennell, Kim AU - Nelligan, K. Rachel AU - Schwartz, Sarah AU - Kasza, Jessica AU - Kimp, Alexander AU - Crofts, JC Samuel AU - Hinman, S. Rana PY - 2020/9/28 TI - Behavior Change Text Messages for Home Exercise Adherence in Knee Osteoarthritis: Randomized Trial JO - J Med Internet Res SP - e21749 VL - 22 IS - 9 KW - knee osteoarthritis KW - exercise KW - patient compliance KW - mobile phone KW - randomized controlled trial N2 - Background: Exercise is a core recommended treatment for knee osteoarthritis (OA), yet adherence declines, particularly following cessation of clinician supervision. Objective: This study aims to evaluate whether a 24-week SMS intervention improves adherence to unsupervised home exercise in people with knee OA and obesity compared with no SMS. Methods: A two-group superiority randomized controlled trial was performed in a community setting. Participants were people aged 50 years with knee OA and BMI ?30 kg/m2 who had undertaken a 12-week physiotherapist-supervised exercise program as part of a preceding clinical trial. Both groups were asked to continue their home exercise program unsupervised three times per week for 24 weeks and were randomly allocated to a behavior change theory?informed, automated, semi-interactive SMS intervention addressing exercise barriers and facilitators or to control (no SMS). Primary outcomes were self-reported home exercise adherence at 24 weeks measured by the Exercise Adherence Rating Scale (EARS) Section B (0-24, higher number indicating greater adherence) and the number of days exercised in the past week (0-3). Secondary outcomes included self-rated adherence (numeric rating scale), knee pain, physical function, quality of life, global change, physical activity, self-efficacy, pain catastrophizing, and kinesiophobia. Results: A total of 110 participants (56 SMS group and 54 no SMS) were enrolled and 99 (90.0%) completed both primary outcomes (48/56, 86% SMS group and 51/54, 94% no SMS). At 24 weeks, the SMS group reported higher EARS scores (mean 16.5, SD 6.5 vs mean 13.3, SD 7.0; mean difference 3.1, 95% CI 0.8-5.5; P=.01) and more days exercised in the past week (mean 1.8, SD 1.2 vs mean 1.3, SD 1.2; mean difference 0.6, 95% CI 0.2-1.0; P=.01) than the control group. There was no evidence of between-group differences in secondary outcomes. Conclusions: An SMS program increased self-reported adherence to unsupervised home exercise in people with knee OA and obesity, although this did not translate into improved clinical outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry 12617001243303; https://tinyurl.com/y2ud7on5 International Registered Report Identifier (IRRID): RR2-10.1186/s12891-019-2801-z UR - http://www.jmir.org/2020/9/e21749/ UR - http://dx.doi.org/10.2196/21749 UR - http://www.ncbi.nlm.nih.gov/pubmed/32985994 ID - info:doi/10.2196/21749 ER - TY - JOUR AU - Christ, Carolien AU - Schouten, JE Maria AU - Blankers, Matthijs AU - van Schaik, JF Digna AU - Beekman, TF Aartjan AU - Wisman, A. Marike AU - Stikkelbroek, AJ Yvonne AU - Dekker, JM Jack PY - 2020/9/25 TI - Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e17831 VL - 22 IS - 9 KW - cognitive behavior therapy KW - internet KW - anxiety KW - depression KW - youth KW - meta-analysis N2 - Background: Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited. Objective: The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects. Methods: We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome. Results: The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI ?0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=?0.70, 95% CI ?1.51 to 0.11, P=.09), but heterogeneity was very high (I2=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies. Conclusions: cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population. Trial Registration: PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9. UR - https://www.jmir.org/2020/9/e17831 UR - http://dx.doi.org/10.2196/17831 UR - http://www.ncbi.nlm.nih.gov/pubmed/32673212 ID - info:doi/10.2196/17831 ER - TY - JOUR AU - Norman, P. Kim AU - Govindjee, Anita AU - Norman, R. Seth AU - Godoy, Michael AU - Cerrone, L. Kimberlie AU - Kieschnick, W. Dustin AU - Kassler, William PY - 2020/9/23 TI - Natural Language Processing Tools for Assessing Progress and Outcome of Two Veteran Populations: Cohort Study From a Novel Online Intervention for Posttraumatic Growth JO - JMIR Form Res SP - e17424 VL - 4 IS - 9 KW - natural language analysis KW - emotional tone KW - personality KW - values KW - PTSD KW - military sexual trauma KW - online interventions KW - internet-based cognitive behavioral therapy KW - narrative therapy KW - mindfulness N2 - Background: Over 100 million Americans lack affordable access to behavioral health care. Among these, military veterans are an especially vulnerable population. Military veterans require unique behavioral health services that can address military experiences and challenges transitioning to the civilian sector. Real-world programs to help veterans successfully transition to civilian life must build a sense of community, have the ability to scale, and be able to reach the many veterans who cannot or will not access care. Digitally based behavioral health initiatives have emerged within the past few years to improve this access to care. Our novel behavioral health intervention teaches mindfulness-based cognitive behavioral therapy and narrative therapy using peer support groups as guides, with human-facilitated asynchronous online discussions. Our study applies natural language processing (NLP) analytics to assess effectiveness of our online intervention in order to test whether NLP may provide insights and detect nuances of personal change and growth that are not currently captured by subjective symptom measures. Objective: This paper aims to study the value of NLP analytics in assessing progress and outcomes among combat veterans and military sexual assault survivors participating in novel online interventions for posttraumatic growth. Methods: IBM Watson and Linguistic Inquiry and Word Count tools were applied to the narrative writings of combat veterans and survivors of military sexual trauma who participated in novel online peer-supported group therapies for posttraumatic growth. Participants watched videos, practiced skills such as mindfulness meditation, told their stories through narrative writing, and participated in asynchronous, facilitated online discussions with peers. The writings, including online postings, by the 16 participants who completed the program were analyzed after completion of the program. Results: Our results suggest that NLP can provide valuable insights on shifts in personality traits, personal values, needs, and emotional tone in an evaluation of our novel online behavioral health interventions. Emotional tone analysis demonstrated significant decreases in fear and anxiety, sadness, and disgust, as well as increases in joy. Significant effects were found for personal values and needs, such as needing or desiring closeness and helping others, and for personality traits of openness, conscientiousness, extroversion, agreeableness, and neuroticism (ie, emotional range). Participants also demonstrated increases in authenticity and clout (confidence) of expression. NLP results were generally supported by qualitative observations and analysis, structured data, and course feedback. Conclusions: The aggregate of results in our study suggest that our behavioral health intervention was effective and that NLP can provide valuable insights on shifts in personality traits, personal values, and needs, as well as measure changes in emotional tone. NLP?s sensitivity to changes in emotional tone, values, and personality strengths suggests the efficacy of NLP as a leading indicator of treatment progress. UR - https://formative.jmir.org/2020/9/e17424 UR - http://dx.doi.org/10.2196/17424 UR - http://www.ncbi.nlm.nih.gov/pubmed/32769074 ID - info:doi/10.2196/17424 ER - TY - JOUR AU - Stawarz, Katarzyna AU - Preist, Chris AU - Tallon, Debbie AU - Wiles, Nicola AU - Kessler, David AU - Turner, Katrina AU - Shafran, Roz AU - Coyle, David PY - 2020/9/3 TI - Design Considerations for the Integrated Delivery of Cognitive Behavioral Therapy for Depression: User-Centered Design Study JO - JMIR Ment Health SP - e15972 VL - 7 IS - 9 KW - cognitive behavioral therapy KW - depression KW - mental health KW - blended therapy KW - integrated therapy KW - user-centered design KW - qualitative research N2 - Background: Adherence to computerized cognitive behavioral therapy (cCBT) programs in real-world settings can be poor, and in the absence of therapist support, effects are modest and short term. Moreover, because cCBT systems tend toward limited support and thus low-intensity treatment, they are typically most appropriate for people experiencing mild to moderate mental health difficulties. Blended therapy, that is, combining direct therapist contact with cCBT or psychoeducational materials, has been identified as one possible approach to address these limitations and widen access to individual CBT for depression. Building on the initial success of blended therapy, we explore an integrated approach that seeks to seamlessly combine face-to-face contact, electronic contact, and between-session activities. Integration also considers how the technology can support therapists? workflow and integrate with broader health care systems. The ultimate aim is to provide a structure within which therapists can deliver high-intensity treatments, while also greatly reducing face-to-face contact. Objective: The research aimed to explore patients? and therapists? views on using a system for the delivery of individual treatment for depression that integrates face-to-face therapist contact with access to online resources and with synchronous online therapy sessions that allow collaborative exercises, and to establish design requirements and thus key design considerations for integrated systems that more seamlessly combine different modes of communication. Methods: We conducted a series of four user-centered design studies. This included four design workshops and seven prototype testing sessions with 18 people who had received CBT for depression in the past, and 11 qualitative interviews and three role-play sessions with 12 CBT therapists experienced in the treatment of depression. Studies took place between July and December 2017 in Bristol, United Kingdom. Results: Workshops and prototyping sessions with people who had received CBT identified three important requirements for integrated platforms delivering CBT therapy for depression as follows: (1) features that help to overcome depression-related barriers, (2) features that support engagement, and (3) features that reinforce learning and support the development of new skills. Research with therapists highlighted the importance of the therapist and client working together, the impact of technology on therapists? workflow and workload, challenges and opportunities related to the use of online resources, and the potential of technology to support patient engagement. We use these findings to inform 12 design considerations for developing integrated therapy systems. Conclusions: To meet clients? and therapists? needs, integrated systems need to help retain the personal connection, support both therapist- and patient-led activities, and provide access to materials and the ability to monitor progress. However, developers of such systems should be mindful of their capacity to disrupt current work practices and increase therapists? workload. Future research should evaluate the impact of integrated systems on patients and therapists in a real-world context. UR - https://mental.jmir.org/2020/9/e15972 UR - http://dx.doi.org/10.2196/15972 UR - http://www.ncbi.nlm.nih.gov/pubmed/32880580 ID - info:doi/10.2196/15972 ER - TY - JOUR AU - Etzelmueller, Anne AU - Vis, Christiaan AU - Karyotaki, Eirini AU - Baumeister, Harald AU - Titov, Nickolai AU - Berking, Matthias AU - Cuijpers, Pim AU - Riper, Heleen AU - Ebert, Daniel David PY - 2020/8/31 TI - Effects of Internet-Based Cognitive Behavioral Therapy in Routine Care for Adults in Treatment for Depression and Anxiety: Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e18100 VL - 22 IS - 8 KW - internet-based interventions KW - depression KW - anxiety KW - effectiveness KW - acceptability KW - routine care N2 - Background: Although there is evidence for the efficacy of internet-based cognitive behavioral therapy (iCBT), the generalizability of results to routine care is limited. Objective: This study systematically reviews effectiveness studies of guided iCBT interventions for the treatment of depression or anxiety. Methods: The acceptability (uptake, participants? characteristics, adherence, and satisfaction), effectiveness, and negative effects (deterioration) of nonrandomized pre-post designs conducted under routine care conditions were synthesized using systematic review and meta-analytic approaches. Results: A total of 19 studies including 30 groups were included in the analysis. Despite high heterogeneity, individual effect sizes of investigated studies indicate clinically relevant changes, with effect sizes ranging from Hedges? g=0.42-1.88, with a pooled effect of 1.78 for depression and 0.94 for anxiety studies. Uptake, participants? characteristics, adherence, and satisfaction indicate a moderate to high acceptability of the interventions. The average deterioration across studies was 2.9%. Conclusions: This study provides evidence supporting the acceptability and effectiveness of guided iCBT for the treatment of depression and anxiety in routine care. Given the high heterogeneity between interventions and contexts, health care providers should select interventions that have been proven in randomized controlled clinical trials. The successful application of iCBT may be an effective way of increasing health care in multiple contexts. UR - http://www.jmir.org/2020/8/e18100/ UR - http://dx.doi.org/10.2196/18100 UR - http://www.ncbi.nlm.nih.gov/pubmed/32865497 ID - info:doi/10.2196/18100 ER - TY - JOUR AU - Venkatesan, Aarathi AU - Rahimi, Lily AU - Kaur, Manpreet AU - Mosunic, Christopher PY - 2020/8/26 TI - Digital Cognitive Behavior Therapy Intervention for Depression and Anxiety: Retrospective Study JO - JMIR Ment Health SP - e21304 VL - 7 IS - 8 KW - depression KW - anxiety KW - CBT KW - digital mental health intervention KW - digital therapeutics KW - cognitive behavioral therapy KW - therapy KW - digital health KW - intervention KW - mental health N2 - Background: Digital mental health interventions offer a scalable solution that reduces barriers to seeking care for clinical depression and anxiety. Objective: We aimed to examine the effectiveness of a 12-week therapist supported, app-based cognitive behavioral therapy program in improving symptoms of depression and anxiety within 9 months. Methods: A total of 323 participants with mild to moderately severe depression or anxiety were enrolled in a 12-week digital cognitive behavior therapy program. The analysis was restricted to participants who provided at least one follow-up assessment after baseline. As a result, 146 participants (45.2%) were included in the analysis?74 (50.7%) participants completed assessments at 3 months, 31 participants (21.2%) completed assessments at 6 months, and 21 participants (14.4%) completed assessments at 9 months. The program included structured lessons and tools (ie, exercises and practices) as well as one-on-one weekly video counseling sessions with a licensed therapist for 12 weeks and monthly check-in sessions for 1 year. The clinically validated Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder Scale (GAD-7) were used to assess depression and anxiety, respectively. Linear mixed-effects modeling was employed to examine changes in depression and anxiety over time. Results: We observed a significant positive effect of program time on improvement in depression (?=?0.12, P<.001) and anxiety scores (?=?0.10, P<.001). At the end of the 12-week intervention, we observed an average reduction of 3.76 points (95% CI ?4.76 to ?2.76) in PHQ-8 scores. Further reductions in depression were seen at program month 6 (4.75-point reduction, 95% CI ?6.61 to ?2.88) and program month 9 (6.42-point reduction, 95% CI ?8.66 to ?6.55, P<.001). A similar pattern of improvement emerged for anxiety, with a 3.17-point reduction at the end of the 12-week intervention (95% CI ?4.21 to ?2.13). These improvements were maintained at program month 6 (4.87-point reduction, 95% CI ?6.85 to ?2.87) and program month 9 (5.19-point, 95% ?6.85 to 4.81). In addition, greater program engagement during the first 12 weeks predicted a greater reduction in depression (?=?0.29, P<.001) Conclusions: The results suggest that digital interventions can support sustained and clinically meaningful improvements in depression and anxiety. Furthermore, it appears that strong initial digital mental health intervention engagement may facilitate this effect. However, the study was limited by postintervention participant attrition as well as the retrospective observational study design. UR - http://mental.jmir.org/2020/8/e21304/ UR - http://dx.doi.org/10.2196/21304 UR - http://www.ncbi.nlm.nih.gov/pubmed/32845246 ID - info:doi/10.2196/21304 ER - TY - JOUR AU - Brantnell, Anders AU - Woodford, Joanne AU - Baraldi, Enrico AU - van Achterberg, Theo AU - von Essen, Louise PY - 2020/8/12 TI - Views of Implementers and Nonimplementers of Internet-Administered Cognitive Behavioral Therapy for Depression and Anxiety: Survey of Primary Care Decision Makers in Sweden JO - J Med Internet Res SP - e18033 VL - 22 IS - 8 KW - mental health KW - internet-administered CBT KW - self-management KW - implementation KW - barriers and facilitators KW - decision-making KW - eHealth KW - primary care N2 - Background: Internet-administered cognitive behavioral therapy (ICBT) has been demonstrated to be an effective intervention for adults with depression and/or anxiety and is recommended in national guidelines for provision within Swedish primary care. However, the number and type of organizations that have implemented ICBT within primary care in Sweden is currently unclear. Further, there is a lack of knowledge concerning barriers and facilitators to ICBT implementation. Objective: The two primary objectives were to identify and describe primary care organizations providing ICBT in Sweden and compare decision makers? (ie, directors of primary care organizations) views on barriers and facilitators to implementation of ICBT among ICBT implementers (ie, organizations that offered ICBT) and nonimplementers (ie, organizations that did not offer ICBT). Methods: An online survey based on a checklist for identifying barriers and facilitators to implementation was developed and made accessible to decision makers from all primary care organizations in Sweden. The survey consisted of background questions (eg, provision of ICBT and number of persons working with ICBT) and barriers and facilitators relating to the following categories: users, therapists, ICBT programs, organizations, and wider society. Results: The participation rate was 35.75% (404/1130). The majority (250/404, 61.8%) of participants were health care center directors and had backgrounds in nursing. Altogether, 89.8% (363/404) of the participating organizations provided CBT. A minority (83/404, 20.5%) of organizations offered ICBT. Most professionals delivering ICBT were psychologists (67/83, 80%) and social workers (31/83, 37%). The majority (61/83, 73%) of organizations had 1 to 2 persons delivering ICBT interventions. The number of patients treated with ICBT during the last 12 months was 1 to 10 in 65% (54/83) of the organizations, ranging between 1 and 400 treated patients across the whole sample. There were 9 significant (P<.05) differences out of 37 possible between implementers and nonimplementers. For example, more implementers (48/51, 94%) than nonimplementers (107/139, 76.9%) perceived few technical problems (P<.001), and more implementers (53/77, 68%) than nonimplementers (103/215, 47.9%) considered that their organization has resources to offer ICBT programs (P<.001). Conclusions: Despite research demonstrating the effectiveness of ICBT for depression and anxiety and national guidelines recommending its use, ICBT is implemented in few primary care organizations in Sweden. Several interesting differences between implementers and nonimplementers were identified, which may help inform interventions focusing on facilitating the implementation of ICBT. UR - https://www.jmir.org/2020/8/e18033 UR - http://dx.doi.org/10.2196/18033 UR - http://www.ncbi.nlm.nih.gov/pubmed/32784186 ID - info:doi/10.2196/18033 ER - TY - JOUR AU - Zargaran, David AU - Walsh, Caoimhe AU - Koumpa, Stefania Foteini AU - Ashraf, Arsalan Muhammad AU - White, Jayne Amelia AU - Patel, Nikhil AU - Tanna, Ravina AU - Trepekli, Anna AU - Zargaran, Alexander PY - 2020/8/12 TI - Comment on ?Internet-Based Cognitive Behavioral Therapy With Real-Time Therapist Support via Videoconference for Patients With Obsessive-Compulsive Disorder, Panic Disorder, and Social Anxiety Disorder: Pilot Single-Arm Trial? JO - J Med Internet Res SP - e13234 VL - 22 IS - 8 KW - internet KW - CBT KW - cognitive behavioral therapy KW - telemedicine KW - telehealth UR - https://www.jmir.org/2020/8/e13234 UR - http://dx.doi.org/10.2196/13234 UR - http://www.ncbi.nlm.nih.gov/pubmed/32784172 ID - info:doi/10.2196/13234 ER - TY - JOUR AU - Harjumaa, Marja AU - Absetz, Pilvikki AU - Ermes, Miikka AU - Mattila, Elina AU - Männikkö, Reija AU - Tilles-Tirkkonen, Tanja AU - Lintu, Niina AU - Schwab, Ursula AU - Umer, Adil AU - Leppänen, Juha AU - Pihlajamäki, Jussi PY - 2020/8/11 TI - Internet-Based Lifestyle Intervention to Prevent Type 2 Diabetes Through Healthy Habits: Design and 6-Month Usage Results of Randomized Controlled Trial JO - JMIR Diabetes SP - e15219 VL - 5 IS - 3 KW - digital behavior change intervention KW - internet intervention KW - web-based intervention KW - behavior change support system KW - type 2 diabetes, habit N2 - Background: Type 2 diabetes can be prevented through lifestyle changes, but sustainable and scalable lifestyle interventions are still lacking. Habit-based approaches offer an opportunity to induce long-term behavior changes. Objective: The purposes of this study were to describe an internet-based lifestyle intervention for people at risk for type 2 diabetes targeted to support formation of healthy habits and explore its user engagement during the first 6 months of a randomized controlled trial (RCT). Methods: The app provides an online store that offers more than 400 simple and contextualized habit-forming behavioral suggestions triggered by daily life activities. Users can browse, inspect, and select them; report their performances; and reflect on their own activities. Users can also get reminders, information on other users? activities, and information on the prevention of type 2 diabetes. An unblended parallel RCT was carried out to evaluate the effectiveness of the app in comparison with routine care. User engagement is reported for the first 6 months of the trial based on the use log data of the participants, who were 18- to 70-year-old community-dwelling adults at an increased risk of type 2 diabetes. Results: Of 3271 participants recruited online, 2909 were eligible to participate in the RCT. Participants were randomized using a computerized randomization system to the control group (n=971), internet-based intervention (digital, n=967), and internet-based intervention with face-to-face group coaching (F2F+digital, n=971). Mean age of control group participants was 55.0 years, digital group 55.2 years, and F2F+digital 55.2 years. The majority of participants were female, 81.1% (787/971) in the control group, 78.3% (757/967) in the digital group, and 80.7% (784/971) in the F2F+digital group. Of the participants allocated to the digital and F2F+digital groups, 99.53% (1929/1938) logged in to the app at least once, 98.55% (1901/1938) selected at least one habit, and 95.13% (1835/1938) reported at least one habit performance. The app was mostly used on a weekly basis. During the first 6 months, the number of active users on a weekly level varied from 93.05% (1795/1929) on week 1 to 51.79% (999/1929) on week 26. The daily use activity was not as high. The digital and F2F+digital groups used the app on a median of 23.0 and 24.5 days and for 79.4 and 85.1 minutes total duration, respectively. A total of 1,089,555 habit performances were reported during the first 6 months. There were no significant differences in the use metrics between the groups with regard to cumulative use metrics. Conclusions: Results demonstrate that internet-based lifestyle interventions can be delivered to large groups including community-dwelling middle-aged and older adults, many with limited experience in digital app use, without additional user training. This intermediate analysis of use behavior showed relatively good engagement, with the percentage of active weekly users remaining over 50% at 6 months. However, we do not yet know if the weekly engagement was enough to change the lifestyles of the participants. Trial Registration: ClinicalTrials.gov NCT03156478; https://clinicaltrials.gov/ct2/show/NCT03156478 UR - https://diabetes.jmir.org/2020/3/e15219 UR - http://dx.doi.org/10.2196/15219 UR - http://www.ncbi.nlm.nih.gov/pubmed/32779571 ID - info:doi/10.2196/15219 ER - TY - JOUR AU - Vermeir, F. Julie AU - White, J. Melanie AU - Johnson, Daniel AU - Crombez, Geert AU - Van Ryckeghem, L. Dimitri M. PY - 2020/8/10 TI - The Effects of Gamification on Computerized Cognitive Training: Systematic Review and Meta-Analysis JO - JMIR Serious Games SP - e18644 VL - 8 IS - 3 KW - gamification KW - cognition KW - health KW - systematic review KW - meta-analysis N2 - Background: There has been a growing interest in the application of gamification (ie, the use of game elements) to computerized cognitive training. The introduction of targeted gamification features to such tasks may increase motivation and engagement as well as improve intervention effects. However, it is possible that game elements can also have adverse effects on cognitive training (eg, be a distraction), which can outweigh their potential motivational benefits. So far, little is known about the effectiveness of such applications. Objective: This study aims to conduct a systematic review and meta-analysis to investigate the effect of gamification on process outcomes (eg, motivation) and on changes in the training domain (eg, cognition), as well as to explore the role of potential moderators. Methods: We searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ProQuest Psychology, Web of Science, Scopus, PubMed, Science Direct, Excerpta Medica dataBASE, Institute of Electrical and Electronics Engineers Xplore, Association for Computing Machinery, and a range of gray-area literature databases. The searches included papers published between 2008 and 2018. Meta-analyses were performed using a random-effects model. Results: The systematic review identified 49 studies, of which 9 randomized controlled trials were included in the meta-analysis. The results of the review indicated that research in this context is still developing and lacks well-controlled empirical studies. Gamification in cognitive training is applied to a large range of age groups and audiences and is mostly delivered at a research site through computers. Rewards and feedback continue to dominate the gamification landscape, whereas social-oriented features (eg, competition) are underused. The meta-analyses showed that gamified training tasks were more motivating/engaging (Hedges g=0.72) and more demanding/difficult (Hedges g=?0.52) than non- or less-gamified tasks, whereas no effects on the training domain were found. Furthermore, no variables moderated the impact of gamified training tasks. However, meta-analytic findings were limited due to a small number of studies. Conclusions: Overall, this review provides an overview of the existing research in the domain and provides evidence for the effectiveness of gamification in improving motivation/engagement in the context of cognitive training. We discuss the shortcomings in the current literature and provide recommendations for future research. UR - https://games.jmir.org/2020/3/e18644 UR - http://dx.doi.org/10.2196/18644 UR - http://www.ncbi.nlm.nih.gov/pubmed/32773374 ID - info:doi/10.2196/18644 ER - TY - JOUR AU - Brown, Menna AU - Hooper, Nic AU - James, Phillip AU - Scott, Darren AU - Bodger, Owen AU - John, Ann PY - 2020/8/7 TI - A Web-Delivered Acceptance and Commitment Therapy Intervention With Email Reminders to Enhance Subjective Well-Being and Encourage Engagement With Lifestyle Behavior Change in Health Care Staff: Randomized Cluster Feasibility Stud JO - JMIR Form Res SP - e18586 VL - 4 IS - 8 KW - well-being KW - mental health KW - behavior change KW - acceptance and commitment therapy KW - web-delivered intervention KW - gamification KW - adherence and engagement KW - internet-based intervention N2 - Background: Poor mental health and emotional well-being can negatively impact ability to engage in healthy lifestyle behavior change. Health care staff have higher rates of sickness and absence than other public sector staff, which has implications at both individual and societal levels. Individual efforts to self-manage health and well-being which add to the UK mental health prevention agenda need to be supported. Objective: The objective of this study was to establish the feasibility and acceptability of the inclusion of a self-guided, automated, web-based acceptance and commitment therapy intervention in an existing health promotion program, to improve subjective well-being and encourage engagement with lifestyle behavior change. Methods: For this 12-week, 4-armed, randomized controlled cluster feasibility study, we recruited participants offline and randomly allocated them to 1 of 3 intervention arms or control (no well-being intervention) using an automated web-based allocation procedure. Eligibility criteria were current health care staff in 1 Welsh health board, age?18 years, ability to read English, and ability to provide consent. The primary researcher was blinded to cluster allocation. Feasibility outcomes were randomization procedure, acceptance of intervention, and adherence to and engagement with the wider program. We evaluated health and well-being data via self-assessment at 2 time points, registration and postintervention, using the 14-item Warwick-Edinburgh Mental Well-Being Scale, the 4-item Patient Health Questionnaire, and the 7-item Acceptance and Action Questionnaire?Revised. Results: Of 124 participants who provided consent and were randomly allocated, 103 completed full registration and engaged with the program. Most participants (76/103) enrolled in at least one health behavior change module, and 43% (41/96) of those randomly allocated to an intervention arm enrolled in the well-being module. Adherence and engagement was low (7/103, 6.8%), but qualitative feedback was positive. Conclusions: The procedure and randomization process proved feasible, and the addition of the well-being module proved acceptable to health care staff. However, participant engagement was limited, and no one completed the full 12-week program. User feedback should be used to develop the intervention to address poor engagement. Effectiveness should then be evaluated in a full-scale randomized controlled trial, which would be feasible with additional recruitment. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 50074817; http://www.isrctn.com/ISRCTN50074817 UR - https://formative.jmir.org/2020/8/e18586 UR - http://dx.doi.org/10.2196/18586 UR - http://www.ncbi.nlm.nih.gov/pubmed/32763887 ID - info:doi/10.2196/18586 ER - TY - JOUR AU - Tremain, Hailey AU - McEnery, Carla AU - Fletcher, Kathryn AU - Murray, Greg PY - 2020/8/7 TI - The Therapeutic Alliance in Digital Mental Health Interventions for Serious Mental Illnesses: Narrative Review JO - JMIR Ment Health SP - e17204 VL - 7 IS - 8 KW - mental health KW - mHealth KW - eHealth KW - telehealth KW - psychosis KW - bipolar disorder KW - mobile phone N2 - Background: Digital mental health interventions offer unique advantages, and research indicates that these interventions are effective for a range of mental health concerns. Although these interventions are less established for individuals with serious mental illnesses, they demonstrate significant promise. A central consideration in traditional face-to-face therapies is the therapeutic alliance, whereas the nature of a digital therapeutic alliance and its relationship with outcomes requires further attention, particularly for individuals with serious mental illnesses. Objective: This narrative review aims to encourage further consideration and critical evaluation of the therapeutic alliance in digital mental health, specifically for individuals with serious mental illnesses. Methods: A narrative review was conducted by combining 3 main areas of the literature: the first examining the evidence for digital mental health interventions for serious mental illnesses, the second illuminating the nature and role of the therapeutic alliance in digital interventions, and the third surrounding practical considerations to enhance a digital therapeutic alliance. Results: Results indicated that a therapeutic alliance can be cultivated in digital interventions for those with serious mental illnesses, but that it may have unique, yet-to-be-confirmed characteristics in digital contexts. In addition, a therapeutic alliance appears to be less directly associated with outcomes in digital interventions than with those in face-to-face therapies. One possibility is that the digital therapeutic alliance is associated with increased engagement and adherence to digital interventions, through which it appears to influence outcomes. A number of design and implementation considerations may enhance the digital therapeutic alliance, including human support and technological features. Conclusions: More research is required to further understand the nature and specific role of a therapeutic alliance in digital interventions for serious mental illnesses, particularly in informing their design. This review revealed several key research priorities to advance the therapeutic alliance in digital interventions. UR - https://mental.jmir.org/2020/8/e17204 UR - http://dx.doi.org/10.2196/17204 UR - http://www.ncbi.nlm.nih.gov/pubmed/32763881 ID - info:doi/10.2196/17204 ER - TY - JOUR AU - Agarwal, Anish AU - Patel, Mitesh PY - 2020/8/4 TI - Prescribing Behavior Change: Opportunities and Challenges for Clinicians to Embrace Digital and Mobile Health JO - JMIR Mhealth Uhealth SP - e17281 VL - 8 IS - 8 KW - digital health KW - behavior change KW - mobile health KW - patient-centered data collection UR - https://mhealth.jmir.org/2020/8/e17281 UR - http://dx.doi.org/10.2196/17281 UR - http://www.ncbi.nlm.nih.gov/pubmed/32749997 ID - info:doi/10.2196/17281 ER - TY - JOUR AU - Brigden, Amberly AU - Anderson, Emma AU - Linney, Catherine AU - Morris, Richard AU - Parslow, Roxanne AU - Serafimova, Teona AU - Smith, Lucie AU - Briggs, Emily AU - Loades, Maria AU - Crawley, Esther PY - 2020/7/31 TI - Digital Behavior Change Interventions for Younger Children With Chronic Health Conditions: Systematic Review JO - J Med Internet Res SP - e16924 VL - 22 IS - 7 KW - mobile phone KW - mHealth KW - mobile health KW - eHealth KW - electronic health KW - digital health KW - behavior KW - pediatrics KW - chronic illness KW - systematic review N2 - Background: The prevalence of chronic health conditions in childhood is increasing, and behavioral interventions can support the management of these conditions. Compared with face-to-face treatment, the use of digital interventions may be more cost-effective, appealing, and accessible, but there has been inadequate attention to their use with younger populations (children aged 5-12 years). Objective: This systematic review aims to (1) identify effective digital interventions, (2) report the characteristics of promising interventions, and (3) describe the user?s experience of the digital intervention. Methods: A total of 4 databases were searched (Excerpta Medica Database [EMBASE], PsycINFO, Medical Literature Analysis and Retrieval System Online [MEDLINE], and the Cochrane Library) between January 2014 and January 2019. The inclusion criteria for studies were as follows: (1) children aged between 5 and 12 years, (2) interventions for behavior change, (3) randomized controlled trials, (4) digital interventions, and (5) chronic health conditions. Two researchers independently double reviewed papers to assess eligibility, extract data, and assess quality. Results: Searches run in the databases identified 2643 papers. We identified 17 eligible interventions. The most promising interventions (having a beneficial effect and low risk of bias) were 3 targeting overweight or obesity, using exergaming or social media, and 2 for anxiety, using web-based cognitive behavioral therapy (CBT). Characteristics of promising interventions included gaming features, therapist support, and parental involvement. Most were purely behavioral interventions (rather than CBT or third wave), typically using the behavior change techniques (BCTs) feedback and monitoring, shaping knowledge, repetition and substitution, and reward. Three papers included qualitative data on the user?s experience. We developed the following themes: parental involvement, connection with a health professional is important for engagement, technological affordances and barriers, and child-centered design. Conclusions: Of the 17 eligible interventions, digital interventions for anxiety and overweight or obesity had the greatest promise. Using qualitative methods during digital intervention development and evaluation may lead to more meaningful, usable, feasible, and engaging interventions, especially for this underresearched younger population. The following characteristics could be considered when developing digital interventions for younger children: involvement of parents, gaming features, additional therapist support, behavioral (rather than cognitive) approaches, and particular BCTs (feedback and monitoring, shaping knowledge, repetition and substitution, and reward). This review suggests a model for improving the conceptualization and reporting of behavioral interventions involving children and parents. UR - http://www.jmir.org/2020/7/e16924/ UR - http://dx.doi.org/10.2196/16924 UR - http://www.ncbi.nlm.nih.gov/pubmed/32735227 ID - info:doi/10.2196/16924 ER - TY - JOUR AU - McCloud, Tayla AU - Jones, Rebecca AU - Lewis, Gemma AU - Bell, Vaughan AU - Tsakanikos, Elias PY - 2020/7/31 TI - Effectiveness of a Mobile App Intervention for Anxiety and Depression Symptoms in University Students: Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e15418 VL - 8 IS - 7 KW - anxiety KW - depression KW - cognitive behavioral therapy KW - eHealth KW - online intervention KW - mobile apps KW - randomized controlled trial KW - mobile phone N2 - Background: Depression and anxiety symptoms are common among university students, but many do not receive treatment. This is often because of lack of availability, reluctance to seek help, and not meeting the diagnostic criteria required to access services. Internet-based interventions, including smartphone apps, can overcome these issues. However, a large number of apps are available, each with little evidence of their effectiveness. Objective: This study aims to evaluate for the first time the effectiveness of a self-guided mobile app, Feel Stress Free, for the treatment of depression and anxiety symptoms in students. Methods: A web-based randomized controlled trial compared a cognitive behavioral therapy (CBT)?based mobile app Feel Stress Free with a wait-list control. University students self-identified as experiencing symptoms of anxiety or depression and were randomized to 6 weeks of intervention (n=84) or control (n=84), unblinded. The app is self-guided and incorporates behavioral relaxation activities, mood tracking and thought challenging, and minigames. Participants completed the Hospital Anxiety and Depression Scale online at baseline and every fortnight. Results: At week 6, the primary end point, there was evidence that the Feel Stress Free app reduced depression symptoms (mean difference ?1.56; 95% CI ?2.67 to ?0.44; P=.006) but only very weak evidence that it reduced anxiety symptoms (mean difference ?1.36; 95% CI ?2.93 to 0.21; P=.09). At week 4, there was evidence to support the effectiveness of the intervention for anxiety symptoms (mean difference ?1.94; 95% CI ?3.11 to ?0.77; P=.001) and, though weaker, depression symptoms (mean difference ?1.08; 95% CI ?2.12 to ?0.04; P=.04). At week 6, 83% (34/41) of participants indicated that they were using the app weekly or more frequently. Conclusions: The Feel Stress Free app is a promising mobile intervention for treating symptoms of anxiety and depression in students and overcomes many of the barriers to traditional CBT. Further research is needed to establish its effectiveness at and beyond 6 weeks. Trial Registration: ClinicalTrials.gov NCT03032952; https://clinicaltrials.gov/ct2/show/NCT03032952 UR - http://mhealth.jmir.org/2020/7/e15418/ UR - http://dx.doi.org/10.2196/15418 UR - http://www.ncbi.nlm.nih.gov/pubmed/32735221 ID - info:doi/10.2196/15418 ER - TY - JOUR AU - Eccles, Heidi AU - Nannarone, Molly AU - Lashewicz, Bonnie AU - Attridge, Mark AU - Marchand, Alain AU - Aiken, Alice AU - Ho, Kendall AU - Wang, Jianli PY - 2020/7/31 TI - Perceived Effectiveness and Motivations for the Use of Web-Based Mental Health Programs: Qualitative Study JO - J Med Internet Res SP - e16961 VL - 22 IS - 7 KW - prevention KW - mental health KW - depression KW - cognitive behavioral therapy KW - motivators KW - perceived effectiveness KW - internet-based intervention KW - interview N2 - Background: The prevalence of depression is high and has been stable despite increased treatment, research, and dissemination. People encounter barriers to seeking traditional mental health services, which could be mitigated by using web-based prevention methods. Objective: This study aims to understand what people at high risk for depression perceive as effective aspects of web-based mental health programs and what motivates people at high risk for depression to use web-based mental health programs. Methods: We conducted an inductive content analysis using telephone interview data from 77 participants at high risk for depression who were recruited from 2 randomized controlled trials (RCTs). Participants from the first RCT were working men who had been randomly assigned to 1 of the following 3 groups: control group, who had access to general depression information from a website called BroMatters; intervention group 1, who had access to the BroMatters website along with the associated BroHealth web-based mental health program; and intervention group 2, who had access to the BroMatters website, the BroHealth web-based mental health program, and telephone sessions with a life coach. Participants from the second RCT were men and women who had been assigned to the intervention group, who received access to the HardHat web-based mental health program, or the control group, who only received access to the HardHat web-based mental health program following completion of the RCT. Participants for this inductive content analysis study were recruited from the intervention groups in both RCTs. Two groups of participants (n=41 and n=20) were recruited from the BroHealth RCT, and a third group comprised 16 participants that were recruited from the HardHat RCT. Results: We generated four categories regarding the perceived effectiveness of web-based programs and five categories related to what motivates the use of web-based programs. Participants identified awareness, program medium and functionality, program content, and coaches as categories related to the effectiveness of the programs. Categories of motivators to use web-based programs included providing reminders or incentives, promotion of the programs, providing appropriate medium and functionality, appropriate content, and perceived need. The final category related to motivators reflects perceptions of participants who were either unsure about what motivates them or believed that there is no way to motivate use. Conclusions: Conflicting evidence was obtained regarding the perceived effectiveness of aspects of the content and functionality of web-based programs. In general, web-based mental health programs were perceived to help increase mental health awareness, especially when it includes live access to a coach. However, the results also revealed that it is difficult to motivate people to begin using web-based mental health programs. Strategies that may motivate the use of such programs include perceived personal need, effective promotion, providing incentives and reminders, and improving functionality. UR - http://www.jmir.org/2020/7/e16961/ UR - http://dx.doi.org/10.2196/16961 UR - http://www.ncbi.nlm.nih.gov/pubmed/32735216 ID - info:doi/10.2196/16961 ER - TY - JOUR AU - Lee, Ji-Soo AU - Kang, Min-Ah AU - Lee, Soo-Kyoung PY - 2020/7/30 TI - Effects of the e-Motivate4Change Program on Metabolic Syndrome in Young Adults Using Health Apps and Wearable Devices: Quasi-Experimental Study JO - J Med Internet Res SP - e17031 VL - 22 IS - 7 KW - metabolic syndrome KW - telemedicine KW - mobile apps KW - preventive care KW - wearable electronic devices N2 - Background: The health behaviors of young adults lag behind those of other age groups, and active health management is needed to improve health behaviors and prevent chronic diseases. In addition, developing good lifestyle habits earlier in life could reduce the risk of metabolic syndrome (MetS) later on. Objective: The aim of this study is to investigate the effects of the e-Motivate4Change program, for which health apps and wearable devices were selected based on user needs. The program was developed for the prevention and management of MetS in young adults. Methods: This experimental study used a nonequivalent control group. In total, 59 students from 2 universities in Daegu, Korea participated in the study (experimental group n=30; control group n=29). Data were collected over 4 months, from June 1 to September 30, 2018. The experimental group received a 12-week e-Motivate4Change program intervention, and the control group received MetS education and booklets without the e-Motivate4Change program intervention. Results: After the program, the experimental group had significantly higher scores for health-related lifestyle (t=3.86; P<.001) and self-efficacy (t=6.00; P<.001) than did the control group. Concerning BMI, there were significant effects by group (F=1.01; P<.001) and for the group × time interaction (F=4.71; P=.034). Concerning cholesterol, there were significant main effects for group (F=4.32; P=.042) and time (F=9.73; P<.001). Conclusions: The e-Motivate4Change program effectively improved participants? health-related lifestyle scores and self-efficacy, and significantly reduced their BMI and cholesterol levels. The program can be used to identify and prevent MetS among young adults. UR - http://www.jmir.org/2020/7/e17031/ UR - http://dx.doi.org/10.2196/17031 UR - http://www.ncbi.nlm.nih.gov/pubmed/32729838 ID - info:doi/10.2196/17031 ER - TY - JOUR AU - Thomas, Hagan Teresa AU - Sivakumar, Varshini AU - Babichenko, Dmitriy AU - Grieve, B. Victoria L. AU - Klem, Lou Mary PY - 2020/7/30 TI - Mapping Behavioral Health Serious Game Interventions for Adults With Chronic Illness: Scoping Review JO - JMIR Serious Games SP - e18687 VL - 8 IS - 3 KW - review KW - chronic disease KW - behavioral sciences KW - video games N2 - Background: Serious games for health are increasingly being used to address health outcomes in patients with chronic illnesses. These studies vary in their study designs, patient populations, frameworks, outcome variables, and degree of specificity of the serious game intervention. Objective: This scoping review aims to clarify the conceptual features of the existing research related to serious games designed to improve cognitive and behavioral outcomes in adults with chronic illness. Methods: We applied the Preferred Reporting Items of Systematic Reviews and Meta-Analysis for scoping reviews (PRISMA-ScR) methodology, including an a priori research question. We searched 4 electronic databases to identify articles published through November 2019. Inclusion criteria encompassed (1) adults 18 years or older; (2) patients with a diagnosis of chronic illness; (3) a serious game intervention; and (4) defined patient outcomes that assess patients? behavioral, cognitive, or health outcomes. Results: Of the 3305 articles identified, 38 were included in the review. We charted and analyzed the theoretical frameworks, key concepts, and outcome variables of these studies with summaries of features across articles. The majority of studies used a randomized controlled trial design (23/38, 61%), included a custom serious game intervention (22/38, 58%), and lacked a theoretical framework (25/38, 66%). Common outcome variables included quality of life (16/38, 42%), mood (15/38, 39%), cognitive function (13/38, 34%), symptoms (12/38, 32%), and physical activity (9/38, 24%). Key differences between studies included whether or not serious games aimed to train versus teach patients, be widely accessible versus tailored interventions, or replace versus complement current treatments. Conclusions: This scoping review defines the current landscape of research in serious games for health research targeting behavioral and cognitive outcomes in adults with chronic disease. Studies have addressed a variety of patient populations and diverse patient outcomes. Researchers wanting to build on the current research should integrate theoretical frameworks into the design of the intervention and trial to more clearly articulate the active ingredients and mechanisms of serious games. UR - http://games.jmir.org/2020/3/e18687/ UR - http://dx.doi.org/10.2196/18687 UR - http://www.ncbi.nlm.nih.gov/pubmed/32729836 ID - info:doi/10.2196/18687 ER - TY - JOUR AU - Malik, Sumaira AU - Moloney, Clare AU - Koledova, Ekaterina AU - Reston, Jonathan AU - Weinman, John PY - 2020/7/29 TI - Designing a Personalized Digital Patient Support Program for Patients Treated With Growth Hormone: Key Design Considerations JO - J Med Internet Res SP - e18157 VL - 22 IS - 7 KW - growth hormone KW - behavior change wheel KW - somatropin KW - adherence N2 - Background: Recombinant human growth hormone treatment can optimize growth potential; however, optimal outcomes are not always achieved for several reasons, including poor adherence. The overall objective of this project was to design a patient support program to maximize the chances of treatment success for people being treated with somatropin injection. An approach known as the behavior change wheel was used to enhance the development of the patient support program. The behavior change wheel provided a comprehensive framework to support the design of interventions. Objective: The aim of this paper was to describe how the steps of the behavior change wheel were applied to the development of a patient support program for individuals with growth hormone deficiency undergoing treatment with somatropin. Methods: We followed a series of steps that align to tenets of the behavior change wheel, namely, a narrative literature review to identify which behaviors needed to change and the potential drivers of and barriers to the behaviors, the selection of an intervention strategy and discrete behavior change techniques, and, finally, intervention specification. Results: A recent systematic review identified a range of potentially modifiable factors found to have an influence on patient adherence to growth hormone treatment. Insights from the systematic review were used to guide the development of a patient support program. The final design of the patient support program consisted of four elements: (1) a personalization questionnaire to tailor support for each individual, (2) tailored reminder and support SMS text messages, (3) nurse-led phone calls, and (4) Easypod connect, an automated electronic autoinjector drug-delivery device with a transmitter and connection platform for Saizen (somatropin) that allows automatic recording, storage, and transmission of drug-usage data, thus providing insight into suboptimal adherence. Conclusions: The patient support program that was designed is currently being piloted with patients to assess engagement with the program and determine its impact on patient outcomes. Results from the pilot will be used to further refine the program to ensure it meets user needs. UR - http://www.jmir.org/2020/7/e18157/ UR - http://dx.doi.org/10.2196/18157 UR - http://www.ncbi.nlm.nih.gov/pubmed/32723712 ID - info:doi/10.2196/18157 ER - TY - JOUR AU - Jayasinghe, Harshani AU - Short, E. Camille AU - Braunack-Mayer, Annette AU - Merkin, Ashley AU - Hume, Clare PY - 2020/7/29 TI - Evidence Regarding Automatic Processing Computerized Tasks Designed For Health Interventions in Real-World Settings Among Adults: Systematic Scoping Review JO - J Med Internet Res SP - e17915 VL - 22 IS - 7 KW - automatic processing KW - computerized tasks KW - health interventions KW - real-world KW - adult KW - behavior change, mobile phone N2 - Background: Dual process theories propose that the brain uses 2 types of thinking to influence behavior: automatic processing and reflective processing. Automatic processing is fast, immediate, nonconscious, and unintentional, whereas reflective processing focuses on logical reasoning, and it is slow, step by step, and intentional. Most digital psychological health interventions tend to solely target the reflective system, although the automatic processing pathway can have strong influences on behavior. Laboratory-based research has highlighted that automatic processing tasks can create behavior change; however, there are substantial gaps in the field on the design, implementation, and delivery of automatic processing tasks in real-world settings. It is important to identify and summarize the existing literature in this area to inform the translation of laboratory-based research to real-world settings. Objective: This scoping review aims to explore the effectiveness of automatic training tasks, types of training tasks commonly used, mode of delivery, and impacts of gamification on automatic processing tasks designed for digital psychological health interventions in real-world settings among adults. Methods: The scoping review methodology proposed by Arskey and O?Malley and Colquhoun was applied. A scoping review was chosen because of the novelty of the digital automatic processing field and to encompass a broad review of the existing evidence base. Electronic databases and gray literature databases were searched with the search terms ?automatic processing,? ?computerised technologies,? ?health intervention,? ?real-world,? and ?adults? and synonyms of these words. The search was up to date until September 2018. A manual search was also completed on the reference lists of the included studies. Results: A total of 14 studies met all inclusion criteria. There was a wide variety of health conditions targeted, with the most prevalent being alcohol abuse followed by social anxiety. Attention bias modification tasks were the most prevalent type of automatic processing task, and the majority of tasks were most commonly delivered over the web via a personal computer. Of the 14 studies included in the review, 8 demonstrated significant changes to automatic processes and 4 demonstrated significant behavioral changes as a result of changed automatic processes. Conclusions: This is the first review to synthesize the evidence on automatic processing tasks in real-world settings targeting adults. This review has highlighted promising, albeit limited, research demonstrating that automatic processing tasks may be used effectively in a real-world setting to influence behavior change. UR - http://www.jmir.org/2020/7/e17915/ UR - http://dx.doi.org/10.2196/17915 UR - http://www.ncbi.nlm.nih.gov/pubmed/32499213 ID - info:doi/10.2196/17915 ER - TY - JOUR AU - Pihlaja, Satu AU - Lahti, Jari AU - Lipsanen, Olavi Jari AU - Ritola, Ville AU - Gummerus, Eero-Matti AU - Stenberg, Jan-Henry AU - Joffe, Grigori PY - 2020/7/23 TI - Scheduled Telephone Support for Internet Cognitive Behavioral Therapy for Depression in Patients at Risk for Dropout: Pragmatic Randomized Controlled Trial JO - J Med Internet Res SP - e15732 VL - 22 IS - 7 KW - internet CBT KW - depression KW - scheduled telephone support KW - adherence KW - routine clinical practice N2 - Background: Therapist-supported, internet-delivered cognitive behavioral therapy (iCBT) is efficient in the treatment of depression. However, the optimal mode and intensity of therapist support remain to be identified. Scheduled telephone support (STS) may improve adherence and outcomes but, as it is time- and resource-consuming, should be reserved for patients for whom the usual support may be insufficient. Objective: This paper aims to reveal whether add-on STS for patients at risk of dropping out improves treatment adherence and symptoms in iCBT for depression. Methods: Among patients participating in an ongoing large observational routine clinical practice study of iCBT for depression delivered nationwide by Helsinki University Hospital (HUS-iCBT), those demonstrating a ?14-day delay in initiation of treatment received invitations to this subsidiary STS study. A total of 100 consenting patients were randomly allocated to either HUS-iCBT as usual (control group, n=50) or HUS-iCBT plus add-on STS (intervention group, n=50). Proportions of those reaching midtreatment and treatment end point served as the primary outcome; secondary outcomes were change in Beck Depression Inventory (BDI)?measured depressive symptoms and time spent in treatment. Results: Add-on STS raised the proportion of patients reaching midtreatment compared with HUS-iCBT as usual (29/50, 58% vs 18/50, 36%; P=.045) and treatment end point (12/50, 24% vs 3/50, 6%; P=.02). Change in BDI score also favored add-on STS (3.63 points vs 1.1 points; P=.049), whereas duration of treatment did not differ. Conclusions: Add-on STS enhances adherence and symptom improvement of patients at risk of dropping out of iCBT for depression in routine clinical practice. Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 55123131; http://www.isrctn.com/ISRCTN55123131. UR - http://www.jmir.org/2020/7/e15732/ UR - http://dx.doi.org/10.2196/15732 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706658 ID - info:doi/10.2196/15732 ER - TY - JOUR AU - Kumar, Shefali AU - Tran, A. Jennifer L. AU - Ramirez, Ernesto AU - Lee, Wei-Nchih AU - Foschini, Luca AU - Juusola, L. Jessie PY - 2020/7/23 TI - Design, Recruitment, and Baseline Characteristics of a Virtual 1-Year Mental Health Study on Behavioral Data and Health Outcomes: Observational Study JO - JMIR Ment Health SP - e17075 VL - 7 IS - 7 KW - mental health KW - anxiety KW - depression KW - behavioral data N2 - Background: Depression and anxiety greatly impact daily behaviors, such as sleep and activity levels. With the increasing use of activity tracking wearables among the general population, there has been a growing interest in how data collected from these devices can be used to further understand the severity and progression of mental health conditions. Objective: This virtual 1-year observational study was designed with the objective of creating a longitudinal data set combining self-reported health outcomes, health care utilization, and quality of life data with activity tracker and app-based behavioral data for individuals with depression and anxiety. We provide an overview of the study design, report on baseline health and behavioral characteristics of the study population, and provide initial insights into how behavioral characteristics differ between groups of individuals with varying levels of disease severity. Methods: Individuals who were existing members of an online health community (Achievement, Evidation Health Inc) and were 18 years or older who had self-reported a diagnosis of depression or anxiety were eligible to enroll in this virtual 1-year study. Participants agreed to connect wearable activity trackers that captured data related to physical activity and sleep behavior. Mental health outcomes such as the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder Questionnaire (GAD-7), mental health hospitalizations, and medication use were captured with surveys completed at baseline and months 3, 6, 9, and 12. In this analysis, we report on baseline characteristics of the sample, including mental health disease severity and health care utilization. Additionally, we explore the relationship between passively collected behavioral data and baseline mental health status and health care utilization. Results: Of the 1304 participants enrolled in the study, 1277 individuals completed the baseline survey and 1068 individuals had sufficient activity tracker data. Mean age was 33 (SD 9) years, and the majority of the study population was female (77.2%, 994/1288) and identified as Caucasian (88.3%, 1137/1288). At baseline, 94.8% (1211/1277) of study participants reported experiencing depression or anxiety symptoms in the last year. This baseline analysis found that some passively tracked behavioral traits are associated with more severe forms of anxiety or depression. Individuals with depressive symptoms were less active than those with minimal depressive symptoms. Severe forms of depression were also significantly associated with inconsistent sleep patterns and more disordered sleep. Conclusions: These initial findings suggest that longitudinal behavioral and health outcomes data may be useful for developing digital measures of health for mental health symptom severity and progression. UR - http://mental.jmir.org/2020/7/e17075/ UR - http://dx.doi.org/10.2196/17075 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706712 ID - info:doi/10.2196/17075 ER - TY - JOUR AU - Bearne, M. Lindsay AU - Sekhon, Mandeep AU - Grainger, Rebecca AU - La, Anthony AU - Shamali, Mehrdad AU - Amirova, Aliya AU - Godfrey, L. Emma AU - White, M. Claire PY - 2020/7/21 TI - Smartphone Apps Targeting Physical Activity in People With Rheumatoid Arthritis: Systematic Quality Appraisal and Content Analysis JO - JMIR Mhealth Uhealth SP - e18495 VL - 8 IS - 7 KW - rheumatoid arthritis KW - physical activity KW - exercise KW - mobile applications KW - behavior change techniques KW - mobile phone N2 - Background: Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA. Objective: This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise. Methods: A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14). Results: A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified. Conclusions: This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation. UR - http://mhealth.jmir.org/2020/7/e18495/ UR - http://dx.doi.org/10.2196/18495 UR - http://www.ncbi.nlm.nih.gov/pubmed/32706727 ID - info:doi/10.2196/18495 ER - TY - JOUR AU - Rhodes, Alexandra AU - Smith, D. Andrea AU - Chadwick, Paul AU - Croker, Helen AU - Llewellyn, H. Clare PY - 2020/7/10 TI - Exclusively Digital Health Interventions Targeting Diet, Physical Activity, and Weight Gain in Pregnant Women: Systematic Review and Meta-Analysis JO - JMIR Mhealth Uhealth SP - e18255 VL - 8 IS - 7 KW - gestational weight gain KW - digital interventions KW - behavior change techniques KW - user engagement KW - smartphone KW - mobile phone N2 - Background: Interventions to promote a healthy diet, physical activity, and weight management during pregnancy are increasingly embracing digital technologies. Although some interventions have combined digital with interpersonal (face-to-face or telephone) delivery, others have relied exclusively on digital delivery. Exclusively digital interventions have the advantages of greater cost-effectiveness and broader reach and as such can be a valuable resource for health care providers. Objective: This systematic review aims to focus on exclusively digital interventions to determine their effectiveness, identify behavior change techniques (BCTs), and investigate user engagement. Methods: A total of 6 databases (Medical Literature Analysis and Retrieval System Online [MEDLINE], Excerpta Medica dataBASE [EMBASE], PsycINFO, Cumulated Index to Nursing and Allied Health Literature [CINAHL] Plus, Web of Science, and ProQuest) were searched for randomized controlled trials or pilot control trials of exclusively digital interventions to encourage healthy eating, physical activity, or appropriate weight gain during pregnancy. The outcome measures were gestational weight gain (GWG) and changes in physical activity and dietary behaviors. Study quality was assessed using the Cochrane Risk of Bias tool 2.0. Where possible, pooled effect sizes were calculated using a random effects meta-analysis. Results: In total, 11 studies met the inclusion criteria. The risk of bias was mostly high (n=5) or moderate (n=3). Of the 11 studies, 6 reported on GWG as the primary outcome, 4 of which also measured changes in physical activity and dietary behaviors, and 5 studies focused either on dietary behaviors only (n=2) or physical activity only (n=3). The meta-analyses showed no significant benefit of interventions on total GWG for either intention-to-treat data (?0.28 kg; 95% CI ?1.43 to 0.87) or per-protocol data (?0.65 kg; 95% CI ?1.98 to 0.67). Substantial heterogeneity in outcome measures of change in dietary behaviors and physical activity precluded further meta-analyses. BCT coding identified 7 BCTs that were common to all effective interventions. Effective interventions averaged over twice as many BCTs from the goals and planning, and feedback and monitoring domains as ineffective interventions. Data from the 6 studies reporting on user engagement indicated a positive association between high engagement with key BCTs and greater intervention effectiveness. Interventions using proactive messaging and feedback appeared to have higher levels of engagement. Conclusions: In contrast to interpersonal interventions, there is little evidence of the effectiveness of exclusively digital interventions to encourage a healthy diet, physical activity, or weight management during pregnancy. In this review, effective interventions used proactive messaging, such as reminders to engage in BCTs, feedback on progress, or tips, suggesting that interactivity may drive engagement and lead to greater effectiveness. Given the benefits of cost and reach of digital interventions, further research is needed to understand how to use advancing technologies to enhance user engagement and improve effectiveness. UR - https://mhealth.jmir.org/2020/7/e18255 UR - http://dx.doi.org/10.2196/18255 UR - http://www.ncbi.nlm.nih.gov/pubmed/32673251 ID - info:doi/10.2196/18255 ER - TY - JOUR AU - Fija?ko, Nino AU - Gosak, Lucija AU - Cilar, Leona AU - Nov?ak, Alenka AU - Creber, Masterson Ruth AU - Skok, Pavel AU - ?tiglic, Gregor PY - 2020/7/8 TI - The Effects of Gamification and Oral Self-Care on Oral Hygiene in Children: Systematic Search in App Stores and Evaluation of Apps JO - JMIR Mhealth Uhealth SP - e16365 VL - 8 IS - 7 KW - mobile health KW - oral health care KW - gamification KW - mobile store KW - evidence-based dentistry KW - behavior change technique KW - Mobile Application Rating Scale user version N2 - Background: Poor oral hygiene is a great public health problem worldwide. Oral health care education is a public health priority as the maintenance of oral hygiene is integral to overall health. Maintaining optimal oral hygiene among children is challenging and can be supported by using relevant motivational approaches. Objective: The primary aim of this study was to identify mobile smartphone apps that include gamification features focused on motivating children to learn, perform, and maintain optimal oral hygiene. Methods: We searched six online app stores using four search terms (?oral hygiene game,? ?oral hygiene gamification,? ?oral hygiene brush game,? and ?oral hygiene brush gamification?). We identified gamification features, identified whether apps were consistent with evidence-based dentistry, performed a quality appraisal with the Mobile App Rating Scale user version (uMARS), and quantified behavior scores (Behavior Change score, uMARS score, and Coventry, Aberdeen, and London-Refined [CALO-RE] score) using three different instruments that measure behavior change. Results: Of 612 potentially relevant apps included in the analysis, 17 met the inclusion criteria. On average, apps included 6.87 (SD 4.18) out of 31 possible gamification features. The most frequently used gamification features were time pressure (16/17, 94%), virtual characters (14/17, 82%), and fantasy (13/17, 76%). The most common oral hygiene evidence-based recommendation was brushing time (2-3 minutes), which was identified in 94% (16/17) of apps. The overall mean uMARS score for app quality was high (4.30, SD 0.36), with good mean subjective quality (3.79, SD 0.71) and perceived impact (3.58, SD 0.44). Sufficient behavior change techniques based on three taxonomies were detected in each app. Conclusions: The majority of the analyzed oral hygiene apps included gamification features and behavior change techniques to perform and maintain oral hygiene in children. Overall, the apps contained some educational content consistent with evidence-based dentistry and high-quality background for oral self-care in children; however, there is scope for improvement. UR - https://mhealth.jmir.org/2020/7/e16365 UR - http://dx.doi.org/10.2196/16365 UR - http://www.ncbi.nlm.nih.gov/pubmed/32673235 ID - info:doi/10.2196/16365 ER - TY - JOUR AU - Young, D. Sean PY - 2020/6/26 TI - The Adaptive Behavioral Components (ABC) Model for Planning Longitudinal Behavioral Technology-Based Health Interventions: A Theoretical Framework JO - J Med Internet Res SP - e15563 VL - 22 IS - 6 KW - health behavior KW - risk behavior KW - behavioral medicine KW - public health informatics KW - consumer health informatics KW - psychological theory UR - https://www.jmir.org/2020/6/e15563 UR - http://dx.doi.org/10.2196/15563 UR - http://www.ncbi.nlm.nih.gov/pubmed/32589152 ID - info:doi/10.2196/15563 ER - TY - JOUR AU - Lo, Brian AU - Shi, Jenny AU - Hollenberg, Elisa AU - Abi-Jaoudé, Alexxa AU - Johnson, Andrew AU - Wiljer, David PY - 2020/6/25 TI - Surveying the Role of Analytics in Evaluating Digital Mental Health Interventions for Transition-Aged Youth: Scoping Review JO - JMIR Ment Health SP - e15942 VL - 7 IS - 6 KW - user engagement KW - mobile apps KW - mHealth KW - telemedicine KW - mental health KW - adolescent KW - data analytics N2 - Background: Consumer-facing digital health interventions provide a promising avenue to bridge gaps in mental health care delivery. To evaluate these interventions, understanding how the target population uses a solution is critical to the overall validity and reliability of the evaluation. As a result, usage data (analytics) can provide a proxy for evaluating the engagement of a solution. However, there is paucity of guidance on how usage data or analytics should be used to assess and evaluate digital mental health interventions. Objective: This review aimed to examine how usage data are collected and analyzed in evaluations of mental health mobile apps for transition-aged youth (15-29 years). Methods: A scoping review was conducted using the Arksey and O?Malley framework. A systematic search was conducted on 5 journal databases using keywords related to usage and engagement, mental health apps, and evaluation. A total of 1784 papers from 2008 to 2019 were identified and screened to ensure that they included analytics and evaluated a mental health app for transition-aged youth. After full-text screening, 49 papers were included in the analysis. Results: Of the 49 papers included in the analysis, 40 unique digital mental health innovations were evaluated, and about 80% (39/49) of the papers were published over the past 6 years. About 80% involved a randomized controlled trial and evaluated apps with information delivery features. There were heterogeneous findings in the concept that analytics was ascribed to, with the top 3 being engagement, adherence, and acceptability. There was also a significant spread in the number of metrics collected by each study, with 35% (17/49) of the papers collecting only 1 metric and 29% (14/49) collecting 4 or more analytic metrics. The number of modules completed, the session duration, and the number of log ins were the most common usage metrics collected. Conclusions: This review of current literature identified significant variability and heterogeneity in using analytics to evaluate digital mental health interventions for transition-aged youth. The large proportion of publications from the last 6 years suggests that user analytics is increasingly being integrated into the evaluation of these apps. Numerous gaps related to selecting appropriate and relevant metrics and defining successful or high levels of engagement have been identified for future exploration. Although long-term use or adoption is an important precursor to realizing the expected benefits of an app, few studies have examined this issue. Researchers would benefit from clarification and guidance on how to measure and analyze app usage in terms of evaluating digital mental health interventions for transition-aged youth. Given the established role of adoption in the success of health information technologies, understanding how to abstract and analyze user adoption for consumer digital mental health apps is also an emerging priority. UR - https://mental.jmir.org/2020/6/e15942 UR - http://dx.doi.org/10.2196/15942 UR - http://www.ncbi.nlm.nih.gov/pubmed/32348261 ID - info:doi/10.2196/15942 ER - TY - JOUR AU - Weingarden, Hilary AU - Matic, Aleksandar AU - Calleja, Garriga Roger AU - Greenberg, L. Jennifer AU - Harrison, Oliver AU - Wilhelm, Sabine PY - 2020/6/18 TI - Optimizing Smartphone-Delivered Cognitive Behavioral Therapy for Body Dysmorphic Disorder Using Passive Smartphone Data: Initial Insights From an Open Pilot Trial JO - JMIR Mhealth Uhealth SP - e16350 VL - 8 IS - 6 KW - body dysmorphic disorder KW - cognitive behavioral therapy KW - mobile health KW - mobile phone KW - patient engagement N2 - Background: Smartphone-delivered cognitive behavioral therapy (CBT) is becoming more common, but research on the topic remains in its infancy. Little is known about how people typically engage with smartphone CBT or which engagement and mobility patterns may optimize treatment. Passive smartphone data offer a unique opportunity to gain insight into these knowledge gaps. Objective: This study aimed to examine passive smartphone data across a pilot course of smartphone CBT for body dysmorphic disorder (BDD), a psychiatric illness characterized by a preoccupation with a perceived defect in physical appearance, to inform hypothesis generation and the design of subsequent, larger trials. Methods: A total of 10 adults with primary diagnoses of BDD were recruited nationally and completed telehealth clinician assessments with a reliable evaluator. In a 12-week open pilot trial of smartphone CBT, we initially characterized natural patterns of engagement with the treatment and tested how engagement and mobility patterns across treatment corresponded with treatment response. Results: Most participants interacted briefly and frequently with smartphone-delivered treatment. More frequent app usage (r=?0.57), as opposed to greater usage duration (r=?0.084), correlated strongly with response. GPS-detected time at home, a potential digital marker of avoidance, decreased across treatment and correlated moderately with BDD severity (r=0.49). Conclusions: The sample was small in this pilot study; thus, results should be used to inform the hypotheses and design of subsequent trials. The results provide initial evidence that frequent (even if brief) practice of CBT skills may optimize response to smartphone CBT and that mobility patterns may serve as useful passive markers of symptom severity. This is one of the first studies to examine the value that passively collected sensor data may contribute to understanding and optimizing users? response to smartphone CBT. With further validation, the results can inform how to enhance smartphone CBT design. UR - http://mhealth.jmir.org/2020/6/e16350/ UR - http://dx.doi.org/10.2196/16350 UR - http://www.ncbi.nlm.nih.gov/pubmed/32554382 ID - info:doi/10.2196/16350 ER - TY - JOUR AU - Brick, R. Timothy AU - Mundie, James AU - Weaver, Jonathan AU - Fraleigh, Robert AU - Oravecz, Zita PY - 2020/6/17 TI - Low-Burden Mobile Monitoring, Intervention, and Real-Time Analysis Using the Wear-IT Framework: Example and Usability Study JO - JMIR Form Res SP - e16072 VL - 4 IS - 6 KW - smartphone apps KW - ecological momentary assessment KW - real-time analysis KW - behavior change N2 - Background: Mobile health (mHealth) methods often rely on active input from participants, for example, in the form of self-report questionnaires delivered via web or smartphone, to measure health and behavioral indicators and deliver interventions in everyday life settings. For short-term studies or interventions, these techniques are deployed intensively, causing nontrivial participant burden. For cases where the goal is long-term maintenance, limited infrastructure exists to balance information needs with participant constraints. Yet, the increasing precision of passive sensors such as wearable physiology monitors, smartphone-based location history, and internet-of-things devices, in combination with statistical feature selection and adaptive interventions, have begun to make such things possible. Objective: In this paper, we introduced Wear-IT, a smartphone app and cloud framework intended to begin addressing current limitations by allowing researchers to leverage commodity electronics and real-time decision making to optimize the amount of useful data collected while minimizing participant burden. Methods: The Wear-IT framework uses real-time decision making to find more optimal tradeoffs between the utility of data collected and the burden placed on participants. Wear-IT integrates a variety of consumer-grade sensors and provides adaptive, personalized, and low-burden monitoring and intervention. Proof of concept examples are illustrated using artificial data. The results of qualitative interviews with users are provided. Results: Participants provided positive feedback about the ease of use of studies conducted using the Wear-IT framework. Users expressed positivity about their overall experience with the framework and its utility for balancing burden and excitement about future studies that real-time processing will enable. Conclusions: The Wear-IT framework uses a combination of passive monitoring, real-time processing, and adaptive assessment and intervention to provide a balance between high-quality data collection and low participant burden. The framework presents an opportunity to deploy adaptive assessment and intervention designs that use real-time processing and provides a platform to study and overcome the challenges of long-term mHealth intervention. UR - https://formative.jmir.org/2020/6/e16072 UR - http://dx.doi.org/10.2196/16072 UR - http://www.ncbi.nlm.nih.gov/pubmed/32554373 ID - info:doi/10.2196/16072 ER - TY - JOUR AU - Simeon, Rosiane AU - Dewidar, Omar AU - Trawin, Jessica AU - Duench, Stephanie AU - Manson, Heather AU - Pardo Pardo, Jordi AU - Petkovic, Jennifer AU - Hatcher Roberts, Janet AU - Tugwell, Peter AU - Yoganathan, Manosila AU - Presseau, Justin AU - Welch, Vivian PY - 2020/6/11 TI - Behavior Change Techniques Included in Reports of Social Media Interventions for Promoting Health Behaviors in Adults: Content Analysis Within a Systematic Review JO - J Med Internet Res SP - e16002 VL - 22 IS - 6 KW - health behavior KW - taxonomy KW - social media KW - health promotion KW - public health N2 - Background: Social media are an increasingly commonly used platform for delivering health promotion interventions. Although recent research has focused on the effectiveness of social media interventions for health promotion, very little is known about the optimal content within such interventions, and the active ingredients to promote health behavior change using social media are not clear. Identifying which behavior change techniques (BCTs) are reported may help to clarify the content of interventions using a generalizable terminology that may facilitate future intervention development. Objective: This study aimed to identify which BCTs are reported in social media interventions for promoting health behavior change in adults. Methods: We included 71 studies conducted with adult participants (aged ?18 years) and for which social media intervention was considered interactive in a Cochrane review of the effectiveness of such interventions. We developed a coding manual informed by the Behavior Change Technique Taxonomy version 1 (BCTTv1) to identify BCTs in the included studies. We identified BCTs in all study arms (including control) and described BCTs in the group and self-directed components of studies. We characterized the dose of delivery for each BCT by low and high intensity. We used descriptive analyses to characterize the reported BCTs. Results: Our data consisted of 71 studies published from 2001 to 2017, mainly conducted in high-income countries (n=65). Most studies (n=31) used tailored, interactive websites to deliver the intervention; Facebook was the most used mainstream platform. In developing our coding manual, we adapted some BCTTv1 instructions to better capture unique nuances of how BCTs were operationalized in social media with respect to likes, retweets, smiles, congratulations, and badges. Social support (unspecified), instruction on how to perform the behavior, and credible source were most frequently identified BCTs in intervention arms of studies and group-delivery settings, whereas instruction on how to perform the behavior was most commonly applied in self-directed components of studies, control arms, and individual participant settings. Instruction on how to perform the behavior was also the most frequently reported BCT in both intervention and control arms simultaneously. Instruction on how to perform the behavior, social support (unspecified), self-monitoring of behavior, information about health consequences, and credible source were identified in the top 5 BCTs delivered with the highest intensity. Conclusions: This study within a review provides a detailed description of the BCTs and their dose to promote behavior change in web-based, interactive social media interventions. Clarifying active ingredients in social media interventions and the intensity of their delivery may help to develop future interventions that can more clearly build upon the existing evidence. UR - http://www.jmir.org/2020/6/e16002/ UR - http://dx.doi.org/10.2196/16002 UR - http://www.ncbi.nlm.nih.gov/pubmed/32525482 ID - info:doi/10.2196/16002 ER - TY - JOUR AU - Austin, F. Stephen AU - Jansen, Einar Jens AU - Petersen, Juul Charlotte AU - Jensen, Rasmus AU - Simonsen, Erik PY - 2020/6/11 TI - Mobile App Integration Into Dialectical Behavior Therapy for Persons With Borderline Personality Disorder: Qualitative and Quantitative Study JO - JMIR Ment Health SP - e14913 VL - 7 IS - 6 KW - dialectical behavior therapy KW - mobile application KW - blended intervention KW - mHealth KW - app N2 - Background: The advancement of and access to technology such as smartphones has implications for psychotherapeutic health care and how interventions for a range of mental health disorders are provided. Objective: The objective of this study was to describe the experiences of participants while using a mobile phone app that was designed to enhance and support dialectical behavior therapy for personality disorders. Methods: A combination of in-depth interviews and questionnaires were used to capture the experiences of participants who used the app while undergoing dialectical behavior therapy treatment. A mixed methods approach was used; qualitative data from the interviews were analyzed using thematic analysis and were combined with quantitative data from the questionnaires. Results: Participants (N=24) who were receiving dialectical behavior therapy used the trial app. Participants (n=20) completed an evaluation questionnaire and a subset of this group (n=8) participated in semistructured interviews. Major themes that were identified from the interviews were (1) an overall positive experience of using the app?participants perceived that the app facilitated access and implementation of dialectical behavior therapy strategies (to regulate mood and behavior in challenging situations)?and (2) that the app provided a common source of information for patient and therapist interactions?app-based interactions were perceived to facilitate therapeutic alliance. Qualitative themes from the interviews were largely congruent with the quantitative responses from the questionnaires. Conclusions: Participants welcomed the integration of technology as a supplement to clinical treatment. The app was perceived to facilitate and support many of the therapeutic techniques associated with dialectical behavior therapy treatment. The incorporation of technology into psychotherapeutic interventions may facilitate the transfer of knowledge and strategies that are learned in therapy to use in real-world settings thereby promoting recovery from mental health problems. UR - http://mental.jmir.org/2020/6/e14913/ UR - http://dx.doi.org/10.2196/14913 UR - http://www.ncbi.nlm.nih.gov/pubmed/32525488 ID - info:doi/10.2196/14913 ER - TY - JOUR AU - Turnbull, Sophie AU - Cabral, Christie AU - Hay, Alastair AU - Lucas, J. Patricia PY - 2020/6/5 TI - Health Equity in the Effectiveness of Web-Based Health Interventions for the Self-Care of People With Chronic Health Conditions: Systematic Review JO - J Med Internet Res SP - e17849 VL - 22 IS - 6 KW - health equity KW - self-care KW - eHealth KW - intervention KW - diabetes KW - asthma KW - pulmonary disease, chronic obstructive KW - osteoarthritis N2 - Background: Web-based self-care interventions have the potential to reduce health inequalities by removing barriers to access to health care. However, there is a lack of evidence about the equalizing effects of these interventions on chronic conditions. Objective: This study investigated the differences in the effectiveness of web-based behavioral change interventions for the self-care of high burden chronic health conditions (eg, asthma, chronic obstructive pulmonary disease [COPD], diabetes, and osteoarthritis) across socioeconomic and cultural groups. Methods: A systematic review was conducted, following Cochrane review guidelines. We conducted searches in Ovid Medical Literature Analysis and Retrieval System Online and Cumulative Index to Nursing and Allied Health Literature databases. Studies with any quantitative design were included (published between January 1, 2006, and February 20, 2019) if they investigated web-based self-care interventions targeting asthma, COPD, diabetes, and osteoarthritis; were conducted in any high-income country; and reported variations in health, behavior, or psychosocial outcomes across social groups. Study outcomes were investigated for heterogeneity, and the possibility of a meta-analysis was explored. A narrative synthesis was provided together with a novel figure that was developed for this review, displaying heterogeneous outcomes. Results: Overall, 7346 records were screened and 18 studies were included, most of which had a high or critical risk of bias. Important study features and essential data were often not reported. The meta-analysis was not possible due to the heterogeneity of outcomes. There was evidence that intervention effectiveness was modified by participants? social characteristics. Minority ethnic groups were found to benefit more from interventions than majority ethnic groups. Single studies with variable quality showed that those with higher education, who were employed, and adolescents with divorced parents benefited more from interventions. The evidence for differences by age, gender, and health literacy was conflicting (eg, in some instances, older people benefited more, and in others, younger people benefited more). There was no evidence of differences in income, numeracy, or household size. Conclusions: There was evidence that web-based self-care interventions for chronic conditions can be advantageous for some social groups (ie, minority ethnic groups, adolescents with divorced parents) and disadvantageous for other (ie, low education, unemployed) social groups who have historically experienced health inequity. However, these findings should be treated with caution as most of the evidence came from a small number of low-quality studies. The findings for gender and health literacy were mixed across studies on diabetes, and the findings for age were mixed across studies on asthma, COPD, and diabetes. There was no evidence that income, numeracy, or the number of people living in the household modified intervention effectiveness. We conclude that there appear to be interaction effects, which warrant exploration in future research, and recommend a priori consideration of the predicted interaction effects. Trial Registration: PROSPERO CRD42017056163; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=56163 UR - http://www.jmir.org/2020/6/e17849/ UR - http://dx.doi.org/10.2196/17849 UR - http://www.ncbi.nlm.nih.gov/pubmed/32459632 ID - info:doi/10.2196/17849 ER - TY - JOUR AU - Haug, Severin AU - Paz Castro, Raquel AU - Scholz, Urte AU - Kowatsch, Tobias AU - Schaub, Patrick Michael AU - Radtke, Theda PY - 2020/5/26 TI - Assessment of the Efficacy of a Mobile Phone?Delivered Just-in-Time Planning Intervention to Reduce Alcohol Use in Adolescents: Randomized Controlled Crossover Trial JO - JMIR Mhealth Uhealth SP - e16937 VL - 8 IS - 5 KW - alcohol KW - adolescents KW - planning intervention KW - just-in-time intervention KW - crossover trial N2 - Background: Interventions to reduce alcohol use typically include several elements, such as information on the risks of alcohol consumption, planning for sensible drinking, and training of protective behavioral strategies. However, the effectiveness of these individual intervention elements within comprehensive programs has not been addressed so far, but it could provide valuable insights for the development of future interventions. Just-in-time interventions provided via mobile devices are intended to help people make healthy decisions in the moment and thus could influence health behavior. Objective: The aim of this study was to test the proximal effects of a mobile phone?delivered, just-in-time planning intervention to reduce alcohol use in adolescents who reported recent binge drinking. The efficacy of this individual intervention element was tested within a comprehensive intervention program to reduce problem drinking in adolescents. Methods: The study had an AB/BA crossover design, in which participants were randomly allocated to (1) a group receiving the planning intervention (A) in period 1 and assessment only (B) in period 2 or (2) a group receiving assessment only (B) in period 1 and the planning intervention (A) in period 2. The planning intervention included a text message to choose one of two predetermined if-then plans to practice sensible drinking with friends or when going out and a prompt to visualize the chosen plan. There was a washout period of at least 1 week between period 1 and period 2. Results: Out of 633 program participants who recently binge drank, 136 (21.5%) were receptive in both periods of time and provided data on the proximal outcome, which was the number of alcoholic drinks consumed with friends or when going out. After the planning intervention, the number of alcoholic drinks consumed was approximately one standard drink lower compared with the finding without the intervention (P=.01). Conclusions: A mobile phone?delivered, just-in-time, if-then planning intervention to practice sensible drinking with friends or when going out is effective in reducing alcohol consumption among adolescents who report recent binge drinking. Based on the relatively low percentage of participants with self-reported receptivity for the planning intervention, measures to increase the population impact of similar planning interventions should be implemented and tested in future trials. Trial Registration: ISRCTN Registry ISRCTN52150713; http://www.isrctn.com/ISRCTN52150713 UR - http://mhealth.jmir.org/2020/5/e16937/ UR - http://dx.doi.org/10.2196/16937 UR - http://www.ncbi.nlm.nih.gov/pubmed/32452818 ID - info:doi/10.2196/16937 ER - TY - JOUR AU - Arjoranta, Jonne AU - Kari, Tuomas AU - Salo, Markus PY - 2020/5/25 TI - Exploring Features of the Pervasive Game Pokémon GO That Enable Behavior Change: Qualitative Study JO - JMIR Serious Games SP - e15967 VL - 8 IS - 2 KW - Pokémon GO KW - digital gaming KW - behavior change KW - pervasive games KW - augmented reality games KW - location-based games KW - exergames KW - behavior change support system N2 - Background: Digital gaming is one of the most popular forms of entertainment in the world. While prior literature concluded that digital games can enable changes in players? behaviors, there is limited knowledge about different types of behavior changes and the game features driving them. Understanding behavior changes and the game features behind them is important because digital games can motivate players to change their behavior for the better (or worse). Objective: This study investigates the types of behavior changes and their underlying game features within the context of the popular pervasive game Pokémon GO. Methods: We collected data from 262 respondents with a critical incident technique (CIT) questionnaire. We analyzed the responses with applied thematic analysis with ATLAS.ti (ATLAS.ti Scientific Software Development GmbH) software. Results: We discovered 8 types of behavior changes and 13 game features relevant to those behavior changes. The behavior changes included added activity in life, enhancing routines, exploration, increased physical activity, strengthening social bonds, lowering social barriers, increased positive emotional expression and self-treatment. The game features included reaching a higher level, catching new Pokémon, evolving new Pokémon, visiting PokéStops, exploring PokéStops, hatching eggs, fighting in gyms, collaborative fighting, exploiting special events, finding specific Pokémon, using items, Pokémon theme, and game location tied to physical location. The behavior changes were connected to specific game features, with game location tied to physical location and catching new Pokémon being the most common and connected to all behavior changes. Conclusions: Our findings indicate that the surveyed players changed their behaviors while or after playing Pokémon GO. The respondents reported being more social, expressed more positive emotions, found more meaningfulness in their routines, and had increased motivation to explore their surroundings. UR - http://games.jmir.org/2020/2/e15967/ UR - http://dx.doi.org/10.2196/15967 UR - http://www.ncbi.nlm.nih.gov/pubmed/32449689 ID - info:doi/10.2196/15967 ER - TY - JOUR AU - Helweg-Jørgensen, Stig AU - Beck Lichtenstein, Mia AU - Fruzzetti, E. Alan AU - Møller Dahl, Christian AU - Pedersen, S. Susanne PY - 2020/5/25 TI - Daily Self-Monitoring of Symptoms and Skills Learning in Patients With Borderline Personality Disorder Through a Mobile Phone App: Protocol for a Pragmatic Randomized Controlled Trial JO - JMIR Res Protoc SP - e17737 VL - 9 IS - 5 KW - borderline personality disorder KW - dialectical behavior therapy KW - mobile app KW - psychotherapy KW - patient-reported outcome measures KW - mhealth N2 - Background: Patient self-monitoring via mobile phones during psychotherapy can enhance and provide an overview of psychotherapeutic progress by graphically displaying current and previous symptom scores, providing feedback to the patient, delivering psychoeducative material, and providing timely data to the therapist or treatment team. Objective: This study will aim to assess the effects of using a mobile phone to self-monitor symptoms and acquire coping skills instead of using pen and paper during psychotherapy in patients with borderline personality disorder (BPD). Dialectical behavior therapy will be performed to treat BPD. The primary outcome is the mean time needed to learn coping skills directed at emotion regulation; the secondary outcome is changes in the BPD symptom score as measured by the Zanarini Rating Scale for Borderline Personality Disorder. Methods: This study is a pragmatic, multicenter randomized controlled trial. Participants were recruited through five public general psychiatric outpatient treatment facilities in Denmark. Patients are randomly assigned, on a 1:1 basis, to either the mobile phone condition (using the Monsenso mDiary mobile app) or pen-and-paper condition. Patients will complete several self-report questionnaires on symptom severity; assessments by trained raters on BPD severity will be performed as well. Survival analysis with a shared frailty model will be used to assess the primary outcome. Results: Recruitment began in June 2017 and was completed in February 2019 after 80 participants were recruited. The study ended in February 2020. It is expected that the benefits of mobile phone?based self-report compared to the pen-and-paper method will be demonstrated for skill learning speed and registration compliance. To our knowledge, this is the first trial exploring the impact of cloud-based mobile registration in BPD treatment. Conclusions: This trial will report on the effectiveness of mobile phone?based self-monitoring during psychiatric treatment. It has the potential to contribute to evidence-based clinical practice since apps are already in use clinically. Trial Registration: ClinicalTrials.gov NCT03191565; https://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID): DERR1-10.2196/17737 UR - http://www.researchprotocols.org/2020/5/e17737/ UR - http://dx.doi.org/10.2196/17737 UR - http://www.ncbi.nlm.nih.gov/pubmed/32449690 ID - info:doi/10.2196/17737 ER - TY - JOUR AU - Broers, Rosalinde Eva AU - Kop, Johan Willem AU - Denollet, Johan AU - Widdershoven, Jos AU - Wetzels, Mart AU - Ayoola, Idowu AU - Piera-Jimenez, Jordi AU - Habibovic, Mirela PY - 2020/5/22 TI - A Personalized eHealth Intervention for Lifestyle Changes in Patients With Cardiovascular Disease: Randomized Controlled Trial JO - J Med Internet Res SP - e14570 VL - 22 IS - 5 KW - cardiovascular diseases KW - lifestyle KW - habits KW - eHealth KW - mHealth N2 - Background: Behavior change methods involving new ambulatory technologies may improve lifestyle and cardiovascular disease outcomes. Objective: This study aimed to provide proof-of-concept analyses of an intervention aiming to increase (1) behavioral flexibility, (2) lifestyle change, and (3) quality of life. The feasibility and patient acceptance of the intervention were also evaluated. Methods: Patients with cardiovascular disease (N=149; mean age 63.57, SD 8.30 years; 50/149, 33.5% women) were recruited in the Do Cardiac Health Advanced New Generation Ecosystem (Do CHANGE) trial and randomized to the Do CHANGE intervention or care as usual (CAU). The intervention involved a 3-month behavioral program in combination with ecological momentary assessment and intervention technologies. Results: The intervention was perceived to be feasible and useful. A significant increase in lifestyle scores over time was found for both groups (F2,146.6=9.99; P<.001), which was similar for CAU and the intervention group (F1,149.9=0.09; P=.77). Quality of life improved more in the intervention group (mean 1.11, SD 0.11) than CAU (mean ?1.47, SD 0.11) immediately following the intervention (3 months), but this benefit was not sustained at the 6-month follow-up (interaction: P=.02). No significant treatment effects were observed for behavioral flexibility (F1,149.0=0.48; P=.07). Conclusions: The Do CHANGE 1 intervention was perceived as useful and easy to use. However, no long-term treatment effects were found on the outcome measures. More research is warranted to examine which components of behavioral interventions are effective in producing long-term behavior change. Trial Registration: ClinicalTrials.gov NCT02946281; https://www.clinicaltrials.gov/ct2/show/NCT02946281 UR - https://www.jmir.org/2020/5/e14570 UR - http://dx.doi.org/10.2196/14570 UR - http://www.ncbi.nlm.nih.gov/pubmed/32441658 ID - info:doi/10.2196/14570 ER - TY - JOUR AU - Oliffe, L. John AU - Black, Nick AU - Yiu, Jeffrey AU - Flannigan, K. Ryan AU - McCreary, R. Donald AU - Goldenberg, Larry S. PY - 2020/5/15 TI - Mapping Canadian Men?s Recent and Intended Health Behavior Changes Through the Don?t Change Much Electronic Health Program JO - J Med Internet Res SP - e16174 VL - 22 IS - 5 KW - men?s e-Health KW - men?s health behavior change KW - men?s health promotion N2 - Background: Although evaluation studies confirm the strong potential of men?s electronic health (eHealth) programs, there have been calls to more fully understand acceptability, engagement, and behavior change to guide future work. Relatedly, mapping of behavior changes using health promotion theories including the transtheoretical model (or stages of change) has been recommended to build a translatable empirical base to advance design and evaluation considerations for men?s eHealth programs. Objective: This study aimed to use a benchmark sample as a reference group to map the recent and intended health behavior changes in Canadian men who use the Don?t Change Much (DCM) eHealth program. The hypothesis being tested was that increased exposure to DCM would be positively associated with men?s recent and intended health behavior changes. Methods: DCM users (n=863) were sampled for demographic data and self-reported recent and intended health behavior changes. Respondents also reported their usage (frequency and duration) for each of the 3 DCM components (web, newsletter, and social media) and were allocated to limited exposure (257/863, 29.8%), low exposure (431/863, 49.9%), and high exposure (175/863, 20.3%) subgroups. A benchmark sample (n=2000), comprising respondents who had not accessed DCM provided a reference group. Bivariate analysis of recent and intended health behavior changes and DCM exposure levels were used to compute the strength of association between the independent variables (exposure levels) and the 10 categorical dependent variables (recent and intended health behavior changes). Binary logistic regression models were computed for each of the 10 recent and intended health behavior changes. Linear regression was used to model the association between the number of recent and intended changes and the level of exposure to DCM. Results: Compared with the benchmark reference group, DCM high-exposure respondents had significantly increased odds for 9 of the 10 health behavior changes, with the largest effect size observed for Changed diet or Improved eating habits (odds ratio [OR] 5.628, 95% CI 3.932-8.055). High-exposure respondents also had significantly increased odds for 9 intended health changes, with the largest effect sizes observed for Reduce stress level (OR 4.282, 95% CI 3.086-5.941). Moderate effect size (goodness of fit) was observed for increased total number of recent (F12,2850=25.52; P.001; adjusted R2=.093) and intended health behavior changes (F12,2850=36.30; P.001; adjusted R2=.129) among high-exposure respondents. Conclusions: DCM respondents contrasted the predominately precontemplative benchmark sample mapping across the contemplative, preparation, and action stages of the transtheoretical health behavior change model. Almost 10% of variation in the recent and 13% of variation in the intended health behavior changes can be explained by DCM exposure and demographic factors, indicating the acceptability of this men?s eHealth resource. UR - https://www.jmir.org/2020/5/e16174 UR - http://dx.doi.org/10.2196/16174 UR - http://www.ncbi.nlm.nih.gov/pubmed/32412423 ID - info:doi/10.2196/16174 ER - TY - JOUR AU - Bartlett, Kiera Yvonne AU - Farmer, Andrew AU - Rea, Rustam AU - French, P. David PY - 2020/5/13 TI - Use of Brief Messages Based on Behavior Change Techniques to Encourage Medication Adherence in People With Type 2 Diabetes: Developmental Studies JO - J Med Internet Res SP - e15989 VL - 22 IS - 5 KW - behavior change KW - behavior change techniques KW - type 2 diabetes, brief messages KW - mHealth KW - medication adherence N2 - Background: Brief messages are a promising way to improve adherence to medication for people with type 2 diabetes. However, it is often unclear how messages have been developed and their precise content, making it difficult to ascertain why certain messages are successful and some are not. Objective: The goal of the research was to develop messages that have proven fidelity to specified evidence-derived behavior change techniques (BCTs) and are acceptable to people with type 2 diabetes. Methods: Four studies were conducted: (1) a workshop (n=21) where behavioral change researchers and health care professionals developed messages based on specific BCTs or beliefs or concerns related to taking medication, (2) a focus group study with people with type 2 diabetes (n=23) to assess acceptability of the approach, (3) a survey to ascertain the acceptability of a subset of messages to people with type 2 diabetes (n=61) and, (4) a survey with behavior change researchers to assess the fidelity of a subset of messages to their intended BCT (n=18). Results: In study 1, 371 messages based on 38 BCTs and beliefs/concerns were developed. Workshop participants rated BCTs to be relevant to medication adherence (mean 7.12/10 [SD 1.55]) and messages to have good fidelity (mean 7.42/10 [SD 1.19]). In study 2, the approach of providing medication adherence support through text messages was found to be acceptable. In study 3, mean acceptability of all BCTs was found to be above the midpoint (mean 3.49/5 [SD 0.26]). In study 4, mean fidelity for all BCTs was found to be above the midpoint (mean 7.61/10 [SD 1.38]). Conclusions: A library of brief messages acceptable to people with type 2 diabetes and representative of specific evidence-derived BCTs was developed. This approach allowed brief messages to be developed with known content that can be used to test theory. UR - https://www.jmir.org/2020/5/e15989 UR - http://dx.doi.org/10.2196/15989 UR - http://www.ncbi.nlm.nih.gov/pubmed/32401214 ID - info:doi/10.2196/15989 ER - TY - JOUR AU - Babatunde, Omoniyi Folarin AU - MacDermid, Joy AU - Grewal, Ruby AU - Macedo, Luciana AU - Szekeres, Mike PY - 2020/5/6 TI - Development and Usability Testing of a Web-Based and Therapist-Assisted Coping Skills Program for Managing Psychosocial Problems in Individuals With Hand and Upper Limb Injuries: Mixed Methods Study JO - JMIR Hum Factors SP - e17088 VL - 7 IS - 2 KW - usability testing KW - upper extremities KW - psychosocial KW - internet KW - coping skills N2 - Background: Ineffective coping has been linked to prolonged pain, distress, anxiety, and depression after a hand and upper limb injury. Evidence shows that interventions based on cognitive behavioral therapy (CBT) may be effective in improving treatment outcomes, but traditional psychological interventions are resource intensive and unrealistic in busy hand therapy practices. Developing web-based, evidence-based psychological interventions specifically for hand therapy may be feasible in clinical practice and at home with reduced training and travel costs. Hand Therapy Online Coping Skills (HOCOS) is a program developed to supplement traditional hand therapy with therapist-assisted coping skills training based on principles from CBT and the Technology Acceptance Model. Objective: This study aimed to describe the development and assess the usability of HOCOS to support hand therapists in the management of psychosocial problems. Methods: The ADDIE model (Analysis, Design, Development, Implementation, and Evaluation) of system design was applied to create HOCOS. The usability testing of HOCOS involved a 2-stage process. In the first step, heuristic testing with information and communications technology (ICT) experts was completed using two sets of heuristics: Monkman heuristics and the Health Literacy Online (HLO) checklist. The second step involved user testing with hand therapists performing a series of online and face-to-face activities, completing 12 tasks on the website using the think-aloud protocol, completing the system usability scale (SUS) questionnaire, and a semistructured feedback interview in 2 iterative cycles. Descriptive statistics and content analyses were used to organize the data. Results: In total, 4 ICT experts and 12 therapists completed usability testing. The heuristic evaluation revealed 15 of 35 violations on the HLO checklist and 5 of 11 violations on the Monkman heuristics. Initially, hand therapists found 5 tasks to be difficult but were able to complete all 12 tasks after the second cycle of testing. The cognitive interview findings were organized into 6 themes: task performance, navigation, design esthetics, content, functionality and features, and desire for future use. Usability issues identified were addressed in two iterative cycles. There was good agreement on all items of the SUS. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients. Conclusions: We describe the development and usability testing of HOCOS; a new web-based psychosocial intervention for individuals with a hand and upper limb injuries. HOCOS targets psychosocial problems linked to prolonged pain and disability by increasing access to therapist-guided coping skills training. We actively involved target users in the development and usability evaluation of the website. The final website was modified to meet the needs and preferences of the participants. UR - http://humanfactors.jmir.org/2020/2/e17088/ UR - http://dx.doi.org/10.2196/17088 UR - http://www.ncbi.nlm.nih.gov/pubmed/32374265 ID - info:doi/10.2196/17088 ER - TY - JOUR AU - Reidy, Claire AU - Foster, Claire AU - Rogers, Anne PY - 2020/5/1 TI - A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework JO - J Med Internet Res SP - e13980 VL - 22 IS - 5 KW - web-based intervention KW - behavior change wheel KW - type 1 diabetes KW - social support KW - continuous subcutaneous insulin infusion KW - self-management N2 - Background: Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions. Objective: The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM. Methods: Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention. Results: A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information?the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences?taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs?HCPs acknowledge the patient?s need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHS SM support, and they question whether SM support fits into their role. BCTs were identified to address these issues. Conclusions: The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs? apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D. UR - https://www.jmir.org/2020/5/e13980 UR - http://dx.doi.org/10.2196/13980 UR - http://www.ncbi.nlm.nih.gov/pubmed/32356776 ID - info:doi/10.2196/13980 ER - TY - JOUR AU - Kim, Meelim AU - Kim, Youngin AU - Go, Yoonjeong AU - Lee, Seokoh AU - Na, Myeongjin AU - Lee, Younghee AU - Choi, Sungwon AU - Choi, Jin Hyung PY - 2020/4/30 TI - Multidimensional Cognitive Behavioral Therapy for Obesity Applied by Psychologists Using a Digital Platform: Open-Label Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e14817 VL - 8 IS - 4 KW - obesity KW - digital health care KW - cognitive behavioral therapy KW - mobile phone N2 - Background: Developing effective, widely useful, weight management programs is a priority in health care because obesity is a major health problem. Objective: This study developed and investigated a new, comprehensive, multifactorial, daily, intensive, psychologist coaching program based on cognitive behavioral therapy (CBT) modules. The program was delivered via the digital health care mobile services Noom Coach and InBody. Methods: This was an open-label, active-comparator, randomized controlled trial. A total of 70 female participants with BMI scores above 24 kg/m2 and no clinical problems besides obesity were randomized into experimental and control groups. The experimental (ie, digital CBT) group (n=45) was connected with a therapist intervention using a digital health care service that provided daily feedback and assignments for 8 weeks. The control group (n=25) also used the digital health care service, but practiced self-care without therapist intervention. The main outcomes of this study were measured objectively at baseline, 8 weeks, and 24 weeks and included weight (kg) as well as other body compositions. Differences between groups were evaluated using independent t tests and a per-protocol framework. Results: Mean weight loss at 8 weeks in the digital CBT group was significantly higher than in the control group (?3.1%, SD 4.5, vs ?0.7%, SD 3.4, P=.04). Additionally, the proportion of subjects who attained conventional 5% weight loss from baseline in the digital CBT group was significantly higher than in the control group at 8 weeks (32% [12/38] vs 4% [1/21], P=.02) but not at 24 weeks. Mean fat mass reduction in the digital CBT group at 8 weeks was also significantly greater than in the control group (?6.3%, SD 8.8, vs ?0.8%, SD 8.1, P=.02). Mean leptin and insulin resistance in the digital CBT group at 8 weeks was significantly reduced compared to the control group (?15.8%, SD 29.9, vs 7.2%, SD 35.9, P=.01; and ?7.1%, SD 35.1, vs 14.4%, SD 41.2, P=.04). Emotional eating behavior (ie, mean score) measured by questionnaire (ie, the Dutch Eating Behavior Questionnaire) at 8 weeks was significantly improved compared to the control group (?2.8%, SD 34.4, vs 21.6%, SD 56.9, P=.048). Mean snack calorie intake in the digital CBT group during the intervention period was significantly lower than in the control group (135.9 kcal, SD 86.4, vs 208.2 kcal, SD 166.3, P=.02). Lastly, baseline depression, anxiety, and self-esteem levels significantly predicted long-term clinical outcomes (24 weeks), while baseline motivation significantly predicted both short-term (8 weeks) and long-term clinical outcomes. Conclusions: These findings confirm that technology-based interventions should be multidimensional and are most effective with human feedback and support. This study is innovative in successfully developing and verifying the effects of a new CBT approach with a multidisciplinary team based on digital technologies rather than standalone technology-based interventions. Trial Registration: ClinicalTrials.gov NCT03465306; https://clinicaltrials.gov/ct2/show/NCT03465306 UR - http://mhealth.jmir.org/2020/4/e14817/ UR - http://dx.doi.org/10.2196/14817 UR - http://www.ncbi.nlm.nih.gov/pubmed/32352391 ID - info:doi/10.2196/14817 ER - TY - JOUR AU - Summers, Charlotte AU - Curtis, Kristina PY - 2020/3/4 TI - Novel Digital Architecture of a ?Low Carb Program? for Initiating and Maintaining Long-Term Sustainable Health-Promoting Behavior Change in Patients with Type 2 Diabetes JO - JMIR Diabetes SP - e15030 VL - 5 IS - 1 KW - type 2 diabetes KW - behaviour change KW - nutrition KW - digital intervention KW - low carb KW - type 2 diabetes remission KW - eHealth UR - http://diabetes.jmir.org/2020/1/e15030/ UR - http://dx.doi.org/10.2196/15030 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130113 ID - info:doi/10.2196/15030 ER - TY - JOUR AU - Budney, J. Alan AU - Marsch, A. Lisa AU - Aklin, M. Will AU - Borodovsky, T. Jacob AU - Brunette, F. Mary AU - Campbell, T. Andrew AU - Dallery, Jesse AU - Kotz, David AU - Knapp, A. Ashley AU - Lord, E. Sarah AU - Nunes, V. Edward AU - Scherer, A. Emily AU - Stanger, Catherine AU - Torrey, C. William PY - 2020/2/26 TI - Workshop on the Development and Evaluation of Digital Therapeutics for Health Behavior Change: Science, Methods, and Projects JO - JMIR Ment Health SP - e16751 VL - 7 IS - 2 KW - digital health KW - behavioral health KW - mobile technology KW - mHealth KW - digital interventions KW - behavior change KW - behavioral science KW - addiction KW - mental health UR - http://mental.jmir.org/2020/2/e16751/ UR - http://dx.doi.org/10.2196/16751 UR - http://www.ncbi.nlm.nih.gov/pubmed/32130155 ID - info:doi/10.2196/16751 ER - TY - JOUR AU - Milne-Ives, Madison AU - Lam, Ching AU - Van Velthoven, Helena Michelle AU - Meinert, Edward PY - 2020/1/30 TI - Mobile Apps for Health Behavior Change: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e16931 VL - 9 IS - 1 KW - telemedicine KW - mobile health KW - mobile apps KW - cell phone KW - health behavior KW - intervention N2 - Background: The popularity and ubiquity of mobile apps have rapidly expanded in the past decade. With a growing focus on patient interaction with health management, mobile apps are increasingly used to monitor health and deliver behavioral interventions. The considerable variation in these mobile health apps, from their target patient group to their health behavior, and their behavioral change strategy, has resulted in a large but incohesive body of literature. Objective: The purpose of this protocol is to provide an overview of the current landscape, theories behind, and effectiveness of mobile apps for health behavior change. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols will be used to structure this protocol. The focus of the systematic review is guided by a population, intervention, comparator, and outcome framework. A systematic search of Medline, EMBASE, CINAHL, and Web of Science will be conducted. Two authors will independently screen the titles and abstracts of identified references and select studies according to the eligibility criteria. Any discrepancies will then be discussed and resolved. One reviewer will extract data into a standardized form, which will be validated by a second reviewer. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool, and a descriptive analysis will summarize the effectiveness of all the apps. Results: As of November 2019, the systematic review has been completed and is in peer review for publication. Conclusions: This systematic review will summarize the current mobile app technologies and their effectiveness, usability, and coherence with behavior change theory. It will identify areas of improvement (where there is no evidence of efficacy) and help inform the development of more useful and engaging mobile health apps. Trial Registration: PROSPERO CRD42019155604; https://tinyurl.com/sno4lcu International Registered Report Identifier (IRRID): PRR1-10.2196/16931 UR - http://www.researchprotocols.org/2020/1/e16931/ UR - http://dx.doi.org/10.2196/16931 UR - http://www.ncbi.nlm.nih.gov/pubmed/32012109 ID - info:doi/10.2196/16931 ER - TY - JOUR AU - DeSmet, Ann AU - De Bourdeaudhuij, Ilse AU - Chastin, Sebastien AU - Crombez, Geert AU - Maddison, Ralph AU - Cardon, Greet PY - 2019/12/20 TI - Adults? Preferences for Behavior Change Techniques and Engagement Features in a Mobile App to Promote 24-Hour Movement Behaviors: Cross-Sectional Survey Study JO - JMIR Mhealth Uhealth SP - e15707 VL - 7 IS - 12 KW - physical activity KW - sleep KW - sedentary behavior KW - 24-hour movement KW - mobile health KW - mobile apps KW - behavior change technique KW - engagement KW - adult N2 - Background: There is a limited understanding of components that should be included in digital interventions for 24-hour movement behaviors (physical activity [PA], sleep, and sedentary behavior [SB]). For intervention effectiveness, user engagement is important. This can be enhanced by a user-centered design to, for example, explore and integrate user preferences for intervention techniques and features. Objective: This study aimed to examine adult users? preferences for techniques and features in mobile apps for 24-hour movement behaviors. Methods: A total of 86 participants (mean age 37.4 years [SD 9.2]; 49/86, 57% female) completed a Web-based survey. Behavior change techniques (BCTs) were based on a validated taxonomy v2 by Abraham and Michie, and engagement features were based on a list extracted from the literature. Behavioral data were collected using Fitbit trackers. Correlations, (repeated measures) analysis of variance, and independent sample t tests were used to examine associations and differences between and within users by the type of health domain and users? behavioral intention and adoption. Results: Preferences were generally the highest for information on the health consequences of movement behavior self-monitoring, behavioral feedback, insight into healthy lifestyles, and tips and instructions. Although the same ranking was found for techniques across behaviors, preferences were stronger for all but one BCT for PA in comparison to the other two health behaviors. Although techniques fit user preferences for addressing PA well, supplemental techniques may be able to address preferences for sleep and SB in a better manner. In addition to what is commonly included in apps, sleep apps should consider providing tips for sleep. SB apps may wish to include more self-regulation and goal-setting techniques. Few differences were found by users? intentions or adoption to change a particular behavior. Apps should provide more self-monitoring (P=.03), information on behavior health outcome (P=.048), and feedback (P=.04) and incorporate social support (P=.048) to help those who are further removed from healthy sleep. A virtual coach (P<.001) and video modeling (P=.004) may provide appreciated support to those who are physically less active. PA self-monitoring appealed more to those with an intention to change PA (P=.03). Social comparison and support features are not high on users? agenda and may not be needed from an engagement point of view. Engagement features may not be very relevant for user engagement but should be examined in future research with a less reflective method. Conclusions: The findings of this study provide guidance for the design of digital 24-hour movement behavior interventions. As 24-hour movement guidelines are increasingly being adopted in several countries, our study findings are timely to support the design of interventions to meet these guidelines. UR - http://mhealth.jmir.org/2019/12/e15707/ UR - http://dx.doi.org/10.2196/15707 UR - http://www.ncbi.nlm.nih.gov/pubmed/31859680 ID - info:doi/10.2196/15707 ER - TY - JOUR AU - Perski, Olga AU - Lumsden, Jim AU - Garnett, Claire AU - Blandford, Ann AU - West, Robert AU - Michie, Susan PY - 2019/11/20 TI - Assessing the Psychometric Properties of the Digital Behavior Change Intervention Engagement Scale in Users of an App for Reducing Alcohol Consumption: Evaluation Study JO - J Med Internet Res SP - e16197 VL - 21 IS - 11 KW - engagement KW - digital behaviour change interventions KW - mHealth KW - psychometrics KW - self-report scale KW - smartphone apps KW - excessive alcohol consumption N2 - Background: The level and type of engagement with digital behavior change interventions (DBCIs) are likely to influence their effectiveness, but validated self-report measures of engagement are lacking. The DBCI Engagement Scale was designed to assess behavioral (ie, amount, depth of use) and experiential (ie, attention, interest, enjoyment) dimensions of engagement. Objective: We aimed to assess the psychometric properties of the DBCI Engagement Scale in users of a smartphone app for reducing alcohol consumption. Methods: Participants (N=147) were UK-based, adult, excessive drinkers recruited via an online research platform. Participants downloaded the Drink Less app and completed the scale immediately after their first login in exchange for a financial reward. Criterion variables included the objectively recorded amount of use, depth of use, and subsequent login. Five types of validity (ie, construct, criterion, predictive, incremental, divergent) were examined in exploratory factor, correlational, and regression analyses. The Cronbach alpha was calculated to assess the scale?s internal reliability. Covariates included motivation to reduce alcohol consumption. Results: Responses on the DBCI Engagement Scale could be characterized in terms of two largely independent subscales related to experience and behavior. The experiential and behavioral subscales showed high (?=.78) and moderate (?=.45) internal reliability, respectively. Total scale scores predicted future behavioral engagement (ie, subsequent login) with and without adjusting for users? motivation to reduce alcohol consumption (adjusted odds ratio [ORadj]=1.14; 95% CI 1.03-1.27; P=.01), which was driven by the experiential (ORadj=1.19; 95% CI 1.05-1.34; P=.006) but not the behavioral subscale. Conclusions: The DBCI Engagement Scale assesses behavioral and experiential aspects of engagement. The behavioral subscale may not be a valid indicator of behavioral engagement. The experiential subscale can predict subsequent behavioral engagement with an app for reducing alcohol consumption. Further refinements and validation of the scale in larger samples and across different DBCIs are needed. UR - http://www.jmir.org/2019/11/e16197/ UR - http://dx.doi.org/10.2196/16197 UR - http://www.ncbi.nlm.nih.gov/pubmed/31746771 ID - info:doi/10.2196/16197 ER - TY - JOUR AU - Han, Kyu Min AU - Cho, Belong AU - Kwon, Hyuktae AU - Son, Young Ki AU - Lee, Hyejin AU - Lee, Kyung Joo AU - Park, Jinho PY - 2019/11/4 TI - A Mobile-Based Comprehensive Weight Reduction Program for the Workplace (Health-On): Development and Pilot Study JO - JMIR Mhealth Uhealth SP - e11158 VL - 7 IS - 11 KW - weight loss programs KW - smartphone KW - mobile phone KW - workplaces KW - obesity KW - obesity management N2 - Background: There is a growing interest in mobile technology for obesity management. Despite the known effectiveness of workplace-based weight loss programs, there are few studies on mobile phone?delivered interventions. Objective: This study aimed to develop and verify an integrated and personalized mobile technology?based weight control program, named Health-On, optimized for workplaces. Methods: A weight reduction algorithm was developed for calorie prescription, continuous monitoring, periodic feedback and reevaluation, goal resetting, and offline intervention with behavior-changing strategies. A total of 30 obese volunteers (body mass index ?25 kg/m2) participated in the 12-week Health-On pilot program. The primary outcome was weight reduction, and secondary outcomes were improved anthropometric measures, metabolic profiles, and fat computed tomography measures, all assessed pre- and postintervention. Results: Health-On incorporated proprietary algorithms and several strategies intended to maximize adherence, using compatible online and offline interventions. The mean weight of 30 participants decreased by 5.8%, and median weight also decreased from 81.3 kg (interquartile range [IQR] 77.1-87.8) before intervention to 76.6 kg (IQR 70.8-79.5) after the 12-week intervention period (P<.001). The metabolic profiles and fat measures (blood pressure, glycosylated hemoglobin, total cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, alanine aminotransferase, and visceral and subcutaneous adipose tissue; P<.05) also improved significantly. Conclusions: In this single-group evaluation of 30 participants before and after the Health-On program, body weight decreased and metabolic profiles and fat measures improved. Follow-up studies are needed to assess effectiveness and long-term adherence. UR - https://mhealth.jmir.org/2019/11/e11158 UR - http://dx.doi.org/10.2196/11158 UR - http://www.ncbi.nlm.nih.gov/pubmed/31682576 ID - info:doi/10.2196/11158 ER - TY - JOUR AU - Zhang, Melvyn AU - Ying, Jiangbo AU - Song, Guo AU - Fung, S. Daniel S. AU - Smith, Helen PY - 2019/10/24 TI - Web-Based Cognitive Bias Modification Interventions for Psychiatric Disorders: Scoping Review JO - JMIR Ment Health SP - e11841 VL - 6 IS - 10 KW - cognitive bias KW - attention bias KW - psychiatry KW - eHealth N2 - Background: Cognitive biases refer to automatic attentional or interpretational tendencies, which result in individuals with addictive disorders to automatically attend to substance-related stimuli and those with anxiety disorders to attend to threatening stimuli. To date, several studies have examined the efficacy of cognitive bias modification, and meta-analytical studies have synthesized the evidence for overall efficacy. The clinical utility of cognitive bias modification interventions has previously been limited to the confines of a laboratory, but recent advances in Web technologies can change this. Objective: This scoping review aimed to determine the scope of Web-based cognitive bias interventions and highlight their effectiveness. Methods: Databases (PubMed and MEDLINE, EMBASE, PsycINFO, ScienceDirect, and Cochrane Central) were searched from inception to December 5, 2017. The following search terminologies were used: (?attention bias? OR ?cognitive bias? OR ?approach bias? OR ?avoidance bias? OR ?interpretative bias?) AND (?Internet? OR ?Web? OR ?Online?). The methods for this scoping review are based on the previously published protocol. For the synthesis of the evidence, a narrative synthesis was undertaken, as a meta-analysis was not appropriate, given the lack of reported effect sizes and the heterogeneity in the outcomes reported. Results: Of the 2674 unique articles identified, we identified 22 randomized controlled studies that met our inclusion criteria: alcohol use disorder (n=2), tobacco use disorder (n=2), depressive disorder (n=3), anxiety and depressive symptoms in adolescents (n=3), obsessive-compulsive disorder (OCD; n=2), social anxiety disorder (n=9), and anxiety disorder (n=1). The sample sizes of these studies ranged from 16 to 434 participants. There is preliminary evidence to suggest that Web-based interventions could reduce biases among adolescents with heightened symptoms of anxiety and depression and among individuals with OCD. Conclusions: This is the first scoping review that mapped out the scope of cognitive bias modification interventions for psychiatric disorders. Web-based interventions have been applied predominantly for social anxiety and addictive disorders. Larger cohorts must be used in future studies to better determine the effectiveness of Web-based cognitive bias interventions. International Registered Report Identifier (IRRID): RR1-10.2196/10427 UR - http://mental.jmir.org/2019/10/e11841/ UR - http://dx.doi.org/10.2196/11841 UR - http://www.ncbi.nlm.nih.gov/pubmed/31651410 ID - info:doi/10.2196/11841 ER - TY - JOUR AU - Nelligan, K. Rachel AU - Hinman, S. Rana AU - Atkins, Lou AU - Bennell, L. Kim PY - 2019/10/18 TI - A Short Message Service Intervention to Support Adherence to Home-Based Strengthening Exercise for People With Knee Osteoarthritis: Intervention Design Applying the Behavior Change Wheel JO - JMIR Mhealth Uhealth SP - e14619 VL - 7 IS - 10 KW - text messaging KW - mobile phone KW - knee osteoarthritis KW - exercise N2 - Background: Knee osteoarthritis is a chronic condition with no known cure. Treatment focuses on symptom management, with exercise recommended as a core component by all clinical practice guidelines. However, long-term adherence to exercise is poor among many people with knee osteoarthritis, which limits its capacity to provide sustained symptom relief. To improve exercise outcomes, scalable interventions that facilitate exercise adherence are needed. SMS (short message service) interventions show promise in health behavior change. The Behavior Change Wheel (BCW) is a widely used framework that provides a structured approach to designing behavior change interventions and has been used extensively in health behavior change intervention design. Objective: The study aimed to describe the development of, and rationale for, an SMS program to support exercise adherence in people with knee osteoarthritis using the BCW framework. Methods: The intervention was developed in two phases. Phase 1 involved using the BCW to select the target behavior and associated barriers, facilitators, and behavior change techniques (BCTs). Phase 2 involved design of the program functionality and message library. Messages arranged into a 24-week schedule were provided to an external company to be developed into an automated SMS program. Results: The target behavior was identified as participation in self-directed home-based strengthening exercise 3 times a week for 24 weeks. A total of 13 barriers and 9 facilitators of the behavior and 20 BCTs were selected to use in the intervention. In addition, 198 SMS text messages were developed and organized into a 24-week automated program that functions by prompting users to self-report the number of home exercise sessions completed each week. Users who reported ?3 exercise sessions/week (adherent) received positive reinforcement messages. Users who reported <3 exercise sessions/week (nonadherent) were asked to select a barrier (from a list of standardized response options) that best explains why they found performing the exercises challenging in the previous week. This automatically triggers an SMS containing a BCT suggestion relevant to overcoming the selected barrier. Users also received BCT messages to facilitate exercise adherence, irrespective of self-reported adherence. Conclusions: This study demonstrates application of the BCW to guide development of an automated SMS intervention to support exercise adherence in knee osteoarthritis. Future research is needed to assess whether the intervention improves adherence to the prescribed home-based strengthening exercise. UR - https://mhealth.jmir.org/2019/10/e14619 UR - http://dx.doi.org/10.2196/14619 UR - http://www.ncbi.nlm.nih.gov/pubmed/31628786 ID - info:doi/10.2196/14619 ER - TY - JOUR AU - Carbonnel, François AU - Ninot, Gregory PY - 2019/10/16 TI - Identifying Frameworks for Validation and Monitoring of Consensual Behavioral Intervention Technologies: Narrative Review JO - J Med Internet Res SP - e13606 VL - 21 IS - 10 KW - behavioral intervention technology KW - validation KW - surveillance KW - paradigm KW - framework KW - nonpharmacological interventions N2 - Background: Changing health behaviors, such as smoking, unhealthy eating, inactivity, and alcohol abuse, may have a greater impact on population health than any curative strategy. One of the suggested strategies is the use of behavioral intervention technologies (BITs). They open up new opportunities in the area of prevention and therapy and have begun to show benefits in the durable change of health behaviors in patients or those at risk. A consensual and international paradigm was adopted by health authorities for drugs 50 years ago. It guides their development from research units to their authorization and surveillance. BITs? generalization brings into question their upstream evaluation before being placed on the market and their downstream monitoring once on the market; this is especially the case in view of the marketing information provided by manufacturers and the scarcity and methodological limits of scientific studies on these tools. Objective: This study aims to identify and categorize the frameworks for the validation and monitoring of BITs proposed in the literature. Methods: We conducted a narrative literature review using MEDLINE, PsycINFO, and Web of Science. The review items included the following: name, publication year, name of the creator (ie, first author), country, funding organization, health focus, target group, and design (ie, linear, iterative, evolutive, and/or concurrent). The frameworks were then categorized based on (1) translational research thanks to a continuum of steps and (2) the three paradigms that may have inspired the frameworks: biomedical, engineering, and/or behavioral. Results: We identified 46 frameworks besides the classic US Food and Drug Administration (FDA) five-phase drug development model. A total of 57% (26/46) of frameworks were created in the 2010s and 61% (28/46) involved the final user in an early and systematic way. A total of 4% (2/46) of frameworks had a linear-only sequence of their phases, 37% (17/46) had a linear and iterative structure, 33% (15/46) added an evolutive structure, and 24% (11/46) were associated with a parallel process. Only 12 out of 46 (26%) frameworks covered the continuum of steps and 12 (26%) relied on the three paradigms. Conclusions: To date, 46 frameworks of BIT validation and surveillance coexist, besides the classic FDA five-phase drug development model, without the predominance of one of them or convergence in a consensual model. Their number has increased exponentially in the last three decades. Three dangerous scenarios are possible: (1) anarchic continuous development of BITs that depend on companies amalgamating health benefits and usability (ie, user experience, data security, and ergonomics) and limiting implementation to several countries; (2) the movement toward the type of framework for drug evaluation centered on establishing its effectiveness before marketing authorization to guarantee its safety for users, which is heavy and costly; and (3) the implementation of a framework reliant on big data analysis based on a posteriori research and an autoregulation of a market, but that does not address the safety risk for the health user, as the market will not regulate safety or efficacy issues. This paper recommends convergence toward an international validation and surveillance framework based on the specificities of BITs, not equivalent to medical devices, to guarantee their effectiveness and safety for users. UR - https://www.jmir.org/2019/10/e13606 UR - http://dx.doi.org/10.2196/13606 UR - http://www.ncbi.nlm.nih.gov/pubmed/31621638 ID - info:doi/10.2196/13606 ER - TY - JOUR AU - Worm-Smeitink, Margreet AU - van Dam, Arno AU - van Es, Saskia AU - van der Vaart, Rosalie AU - Evers, Andrea AU - Wensing, Michel AU - Knoop, Hans PY - 2019/10/10 TI - Internet-Based Cognitive Behavioral Therapy for Chronic Fatigue Syndrome Integrated in Routine Clinical Care: Implementation Study JO - J Med Internet Res SP - e14037 VL - 21 IS - 10 KW - eHealth KW - cognitive behavioral therapy KW - health plan implementation KW - chronic fatigue syndrome KW - attitudes N2 - Background: In a clinical trial, internet-based cognitive behavioral therapy (I-CBT) embedded in stepped care was established as noninferior to face-to-face cognitive behavioral therapy (CBT) for chronic fatigue syndrome (CFS). However, treatment effects observed in clinical trials may not necessarily be retained after implementation. Objective: This study aimed to investigate whether stepped care for CFS starting with I-CBT, followed by face-to-face CBT, if needed, was also effective in routine clinical care. Another objective was to explore the role of therapists? attitudes toward electronic health (eHealth) and manualized treatment on treatment outcome. Methods: I-CBT was implemented in five mental health care centers (MHCs) with nine treatment sites throughout the Netherlands. All patients with CFS were offered I-CBT, followed by face-to-face CBT if still severely fatigued or disabled after I-CBT. Outcomes were the Checklist Individual Strength, physical and social functioning (Short-Form 36), and limitations in daily functioning according to the Work and Social Adjustment Scale. The change scores (pre to post stepped care) were compared with a benchmark: stepped care from a randomized controlled trial (RCT) testing this treatment format. We calculated correlations of therapists? attitudes toward manualized treatment and eHealth with reduction of fatigue severity. Results: Overall, 100 CFS patients were referred to the centers. Of them, 79 started with I-CBT, 20 commenced directly with face-to-face CBT, and one did not start at all. After I-CBT, 48 patients met step-up criteria; of them, 11 stepped up to face-to-face CBT. Increase in physical functioning (score of 13.4), social functioning (20.4), and reduction of limitations (10.3) after stepped care delivered in routine clinical care fell within the benchmarks of the RCT (95% CIs: 12.8-17.6; 25.2-7.8; and 7.4-9.8, respectively). Reduction of fatigue severity in the MHCs was smaller (12.6) than in the RCT (95% CI 13.2-16.5). After I-CBT only, reduction of fatigue severity (13.2) fell within the benchmark of I-CBT alone (95% CI 11.1-14.2). Twenty therapists treated between one and 18 patients. Therapists were divided into two groups: one with the largest median reduction of fatigue and one with the smallest. Patients treated by the first group had a significantly larger reduction of fatigue severity (15.7 vs 9.0; t=2.42; P=.02). There were no (statistically significant) correlations between therapists? attitudes and reduction in fatigue. Conclusions: This study is one of the first to evaluate stepped care with I-CBT as a first step in routine clinical care. Although fatigue severity and disabilities were reduced, reduction of fatigue severity appeared smaller than in the clinical trial. Further development of the treatment should aim at avoiding dropout and encouraging stepping up after I-CBT with limited results. Median reduction of fatigue severity varied largely between therapists. Further research will help understand the role of therapists? attitudes in treatment outcome. UR - http://www.jmir.org/2019/10/e14037/ UR - http://dx.doi.org/10.2196/14037 UR - http://www.ncbi.nlm.nih.gov/pubmed/31603428 ID - info:doi/10.2196/14037 ER - TY - JOUR AU - Cole-Lewis, Heather AU - Ezeanochie, Nnamdi AU - Turgiss, Jennifer PY - 2019/10/10 TI - Understanding Health Behavior Technology Engagement: Pathway to Measuring Digital Behavior Change Interventions JO - JMIR Form Res SP - e14052 VL - 3 IS - 4 KW - engagement KW - user engagement KW - health behavior KW - health determinants KW - digital behavior change intervention KW - measurements UR - https://formative.jmir.org/2019/4/e14052 UR - http://dx.doi.org/10.2196/14052 UR - http://www.ncbi.nlm.nih.gov/pubmed/31603427 ID - info:doi/10.2196/14052 ER - TY - JOUR AU - Economides, Marcos AU - Ranta, Kristian AU - Nazander, Albert AU - Hilgert, Outi AU - Goldin, R. Philippe AU - Raevuori, Anu AU - Forman-Hoffman, Valerie PY - 2019/08/26 TI - Long-Term Outcomes of a Therapist-Supported, Smartphone-Based Intervention for Elevated Symptoms of Depression and Anxiety: Quasiexperimental, Pre-Postintervention Study JO - JMIR Mhealth Uhealth SP - e14284 VL - 7 IS - 8 KW - digital health KW - depression KW - anxiety KW - mindfulness KW - CBT KW - online intervention KW - smartphone intervention N2 - Background: Depression is one of the most common mental health disorders and severely impacts one?s physical, psychological, and social functioning. To address access barriers to care, we developed Ascend?a smartphone-delivered, therapist-supported, 8-week intervention based on several evidence-based psychological treatments for depression and anxiety. A previous feasibility study with 102 adults with elevated depression reported that Ascend is associated with a postintervention reduction in depression symptoms. Objective: We aimed to examine whether Ascend is associated with a reduction in symptoms of anxiety, and importantly, whether reductions in symptoms of depression and anxiety are maintained up to 12-months postintervention. Methods: We assessed whether the previously reported, end-of-treatment improvements seen in the 102 adults with elevated symptoms of depression extended up to 12 months posttreatment for depression symptoms (measured by the Patient Health Questionnaire-9 [PHQ-9]) and up to 6 months posttreatment for anxiety symptoms (added to the intervention later and measured using the Generalized Anxiety Disorder-7 [GAD-7] scale). We used linear mixed effects models with Tukey contrasts to compare time points and reported intention-to-treat statistics with a sensitivity analysis. Results: The intervention was associated with reductions in symptoms of depression that were maintained 12 months after the program (6.67-point reduction in PHQ-9 score, 95% CI 5.59-7.75; P<.001; Hedges g=1.14, 95% CI 0.78-1.49). A total of 60% of the participants with PHQ-9 scores above the cutoff for major depression at baseline (PHQ?10) reported clinically significant improvement at the 12-month follow-up (at least 50% reduction in PHQ-9 score and postprogram score <10). Participants also reported reductions in symptoms of anxiety that were maintained for at least 6 months after the program (4.26-point reduction in GAD-7 score, 95% CI 3.14-5.38; P<.001; Hedges g=0.91, 95% CI 0.54-1.28). Conclusions: There is limited evidence on whether outcomes associated with smartphone-based interventions for common mental health problems are maintained posttreatment. Participants who enrolled in Ascend experienced clinically significant reductions in symptoms of depression and anxiety that were maintained for up to 1 year and 6 months after the intervention, respectively. Future randomized trials are warranted to test Ascend as a scalable solution to the treatment of depression and anxiety. UR - http://mhealth.jmir.org/2019/8/e14284/ UR - http://dx.doi.org/10.2196/14284 UR - http://www.ncbi.nlm.nih.gov/pubmed/31452521 ID - info:doi/10.2196/14284 ER - TY - JOUR AU - Curtis, Brenda AU - Bergman, Brandon AU - Brown, Austin AU - McDaniel, Jessica AU - Harper, Kristen AU - Eisenhart, Emily AU - Hufnagel, Mariel AU - Heller, Thompson Anne AU - Ashford, Robert PY - 2019/08/26 TI - Characterizing Participation and Perceived Engagement Benefits in an Integrated Digital Behavioral Health Recovery Community for Women: A Cross-Sectional Survey JO - JMIR Ment Health SP - e13352 VL - 6 IS - 8 KW - substance use disorder KW - mHealth KW - mental health KW - substance addiction KW - rehabilitation N2 - Background: Research suggests that digital recovery support services (D-RSSs) may help support individual recovery and augment the availability of in-person supports. Previous studies highlight the use of D-RSSs in supporting individuals in recovery from substance use but have yet to examine the use of D-RSSs in supporting a combination of behavioral health disorders, including substance use, mental health, and trauma. Similarly, few studies on D-RSSs have evaluated gender-specific supports or integrated communities, which may be helpful to women and individuals recovering from behavioral health disorders. Objective: The goal of this study was to evaluate the SHE RECOVERS (SR) recovery community, with the following 3 aims: (1) to characterize the women who engage in SR (including demographics and recovery-related characteristics), (2) describe the ways and frequency in which participants engage with SR, and (3) examine the perception of benefit derived from engagement with SR. Methods: This study used a cross-sectional survey to examine the characteristics of SR participants. Analysis of variance and chi-square tests, as well as univariate logistic regressions, were used to explore each aim. Results: Participants (N=729, mean age 46.83 years; 685/729, 94% Caucasian) reported being in recovery from a variety of conditions, although the most frequent nonexclusive disorder was substance use (86.40%, n=630). Participants had an average length in recovery (LIR) of 6.14 years (SD 7.87), with most having between 1 and 5 years (n=300). The most frequently reported recovery pathway was abstinence-based 12-step mutual aid (38.40%). Participants reported positive perceptions of benefit from SR participation, which did not vary by LIR or recovery pathway. Participants also had high rates of agreement, with SR having a positive impact on their lives, although this too did vary by recovery length and recovery pathway. Participants with 1 to 5 years of recovery used SR to connect with other women in recovery at higher rates, whereas those with less than 1 year used SR to ask for resources at higher rates, and those with 5 or more years used SR to provide support at higher rates. Lifetime engagement with specific supports of SR was also associated with LIR and recovery pathway. Conclusions: Gender-specific and integrated D-RSSs are feasible and beneficial from the perspective of participants. D-RSSs also appear to provide support to a range of recovery typologies and pathways in an effective manner and may be a vital tool for expanding recovery supports for those lacking in access and availability because of geography, social determinants, or other barriers. UR - http://mental.jmir.org/2019/8/e13352/ UR - http://dx.doi.org/10.2196/13352 UR - http://www.ncbi.nlm.nih.gov/pubmed/31452520 ID - info:doi/10.2196/13352 ER - TY - JOUR AU - Swendeman, Dallas AU - Arnold, Mayfield Elizabeth AU - Harris, Danielle AU - Fournier, Jasmine AU - Comulada, Scott W. AU - Reback, Cathy AU - Koussa, Maryann AU - Ocasio, Manuel AU - Lee, Sung-Jae AU - Kozina, Leslie AU - Fernández, Isabel Maria AU - Rotheram, Jane Mary AU - PY - 2019/08/09 TI - Text-Messaging, Online Peer Support Group, and Coaching Strategies to Optimize the HIV Prevention Continuum for Youth: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e11165 VL - 8 IS - 8 KW - adolescents KW - HIV/AIDS KW - mHealth KW - homelessness KW - MSM KW - transgender KW - prevention N2 - Background: America?s increasing HIV epidemic among youth suggests the need to identify novel strategies to leverage services and settings where youth at high risk (YAHR) for HIV can be engaged in prevention. Scalable, efficacious, and cost-effective strategies are needed, which support youth during developmental transitions when risks arise. Evidence-based behavioral interventions (EBIs) have typically relied on time-limited, scripted, and manualized protocols that were often delivered with low fidelity and lacked evidence for effectiveness. Objective: This study aims to examine efficacy, implementation, and cost-effectiveness of easily mountable and adaptable, technology-based behavioral interventions in the context of an enhanced standard of care and study assessments that implement the guidelines of Centers for Disease Control and Prevention (CDC) for routine, repeat HIV, and sexually transmitted infection (STI) testing for high-risk youth. Methods: Youth aged between 12 and 24 years (n=1500) are being recruited from community-based organizations and clinics serving gay, bisexual, and transgender youth, homeless youth, and postincarcerated youth, with eligibility algorithms weighting African American and Latino youth to reflect disparities in HIV incidence. At baseline and 4-month intervals over 24 months (12 months for lower-risk youth), interviewers monitor uptake of HIV prevention continuum steps (linkage to health care, use of pre- or postexposure prophylaxis, condoms, and prevention services) and secondary outcomes of substance use, mental health, and housing security. Assessments include rapid diagnostic tests for HIV, STIs, drugs, and alcohol. The study is powered to detect modest intervention effects among gay or bisexual male and transgender youth with 70% retention. Youth are randomized to 4 conditions: (1) enhanced standard of care of automated text-messaging and monitoring (AMM) and repeat HIV/STI testing assessment procedures (n=690); (2) online group peer support via private social media plus AMM (n=270); (3) coaching that is strengths-based, youth-centered, unscripted, based on common practice elements of EBI, available over 24 months, and delivered by near-peer paraprofessionals via text, phone, and in-person, plus AMM (n=270); and (4) online group peer support plus coaching and AMM (n=270). Results: The project was funded in September 2016 and enrollment began in May 2017. Enrollment will be completed between June and August 2019. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019. Conclusions: This hybrid implementation-effectiveness study examines alternative models for implementing the CDC guidelines for routine HIV/STI testing for YAHR of acquiring HIV and for delivering evidence-based behavioral intervention content in modular elements instead of scripted manuals and available over 24 months of follow-up, while also monitoring implementation, costs, and effectiveness. The greatest impacts are expected for coaching, whereas online group peer support is expected to have lower impact but may be more cost-effective. Trial Registration: ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833 (Archived by WebCite at http://www.webcitation.org/76el0Viw9) International Registered Report Identifier (IRRID): DERR1-10.2196/11165 UR - https://www.researchprotocols.org/2019/8/e11165/ UR - http://dx.doi.org/10.2196/11165 UR - http://www.ncbi.nlm.nih.gov/pubmed/31400109 ID - info:doi/10.2196/11165 ER - TY - JOUR AU - Meeker, Daniella AU - Goldberg, Jordan AU - Kim, K. Katherine AU - Peneva, Desi AU - Campos, Oliveira Hugo De AU - Maclean, Ross AU - Selby, Van AU - Doctor, N. Jason PY - 2019/08/06 TI - Patient Commitment to Health (PACT-Health) in the Heart Failure Population: A Focus Group Study of an Active Communication Framework for Patient-Centered Health Behavior Change JO - J Med Internet Res SP - e12483 VL - 21 IS - 8 KW - heart failure KW - behavioral economics KW - motivational interviewing N2 - Background: Over 6 million Americans have heart failure, and 1 in 8 deaths included heart failure as a contributing cause in 2016. Lifestyle changes and adherence to diet and exercise regimens are important in limiting disease progression. Health coaching and public commitment are two interactive communication strategies that may improve self-management of heart failure. Objective: This study aimed to conduct patient focus groups to gain insight into how best to implement health coaching and public commitment strategies within the heart failure population. Methods: Focus groups were conducted in two locations. We studied 2 patients in Oakland, California, and 5 patients in Los Angeles, California. Patients were referred by local cardiologists and had to have a diagnosis of chronic heart failure. We used a semistructured interview tool to explore several patient-centered themes including medication adherence, exercise habits, dietary habits, goals, accountability, and rewards. We coded focus group data using the a priori coding criteria for these domains. Results: Medication adherence barriers included regimen complexity, forgetfulness, and difficulty coping with side effects. Participants reported that they receive little instruction from care providers on appropriate exercise and dietary habits. They also reported personal and social obstacles to achieving these objectives. Participants were in favor of structured goal setting, use of online social networks, and financial rewards as a means of promoting health lifestyles. Peers were viewed as better motivating agents than family members. Conclusions: An active communication framework involving dissemination of diet- and exercise-related health information, structured goal setting, peer accountability, and financial rewards appears promising in the management of heart failure. UR - http://www.jmir.org/2019/8/e12483/ UR - http://dx.doi.org/10.2196/12483 UR - http://www.ncbi.nlm.nih.gov/pubmed/31389339 ID - info:doi/10.2196/12483 ER - TY - JOUR AU - Chia, Cheng Gladys Lai AU - Anderson, Angelika AU - McLean, Anne Louise PY - 2019/07/23 TI - Behavior Change Techniques Incorporated in Fitness Trackers: Content Analysis JO - JMIR Mhealth Uhealth SP - e12768 VL - 7 IS - 7 KW - behavioral medicine KW - self-management KW - fitness tracker KW - physical activity KW - sedentary behavior N2 - Background: The use of fitness trackers as tools of self-management to promote physical activity is increasing. However, the content of fitness trackers remains unexplored. Objective: The aim of this study was to use the Behavior Change Technique Taxonomy v1 (BCTTv1) to examine if swim-proof fitness trackers below Aus $150 (US$ 105) incorporate behavior change techniques (BCTs) that relate to self-management strategies to increase physical activity and reduce sedentary behavior and to determine if content of the fitness trackers correspond to physical activity guidelines. Methods: A total of two raters used the BCTTv1 to code 6 fitness trackers that met the inclusion criteria. The inclusion criteria were the ability to track activity, be swim proof, be compatible with Android and Apple operating systems, and cost below Aus $150. Results: All fitness trackers contained BCTs known to promote physical activity, with the most frequently used BCTs overlapping with self-management strategies, including goal setting, self-monitoring, and feedback on behavior. Fitbit Flex 2 (Fitbit Inc) contained the most BCTs at 20. Huawei Band 2 Pro (Huawei Technologies) and Misfit Shine 2 (Fossil Group) contained the least BCTs at 11. Conclusions: Fitness trackers contain evidence-based BCTs that overlap with self-management strategies, which have been shown to increase physical activity and reduce sedentary behavior. Fitness trackers offer the prospect for physical activity interventions that are cost-effective and easily accessed by a wide population. UR - http://mhealth.jmir.org/2019/7/e12768/ UR - http://dx.doi.org/10.2196/12768 UR - http://www.ncbi.nlm.nih.gov/pubmed/31339101 ID - info:doi/10.2196/12768 ER - TY - JOUR AU - Elliott, Mark AU - Eck, Felicia AU - Khmelev, Egor AU - Derlyatka, Anton AU - Fomenko, Oleg PY - 2019/07/08 TI - Physical Activity Behavior Change Driven by Engagement With an Incentive-Based App: Evaluating the Impact of Sweatcoin JO - JMIR Mhealth Uhealth SP - e12445 VL - 7 IS - 7 KW - physical activity KW - incentives KW - rewards N2 - Background: Physical inactivity, now the fourth leading cause of death, is a primary element of noncommunicable diseases. Despite a great number of attempts, there is still a lack of effective approaches that can motivate sedentary populations to increase their levels of physical activity over a sustained period. Incentives for exercise can provide an immediate reward for increasing activity levels, but because of limited funding to provide rewards, previous programs using this approach have only shown short-term changes in behavior. Sweatcoin (Sweatco Ltd, UK) is an app-based platform that converts physical movement into virtual currency. The currency can be exchanged for goods and services on their marketplace, providing a continuous incentive to be active. This study investigates the physical activity behavior change observed in Sweatcoin users over a 6-month period of app usage. Objective: The aim of this study was to investigate the change in physical activity (measured using daily step count) of a sample of Sweatcoin users, the longevity of the change, and whether this change can be predicted by demographic and other lifestyle variables. Methods: Activity data from a sample of 5892 Sweatcoin users were used to analyze daily step count. Activity change was measured in terms of the percentage change in average daily step count for each month after registration, relative to that in the 3 months before using the app. Users were grouped according to having no or negative, moderate, or high activity change. A subset of users completed a questionnaire that allowed differences between groups in terms of activity and demographic status to be investigated using regression analyses. Results: Daily step count increased by 19% on average over the 6 months following registration (P<.001). Of the questionnaire respondents, 728 were valid responses. A multinomial logistic regression identified the key drivers of moderate and high activity behavior change relative to no or negative change based on the defined groupings. There was a clear impact of seasonality, with those registering for the app in winter (odds ratio [OR] 4.67; P=.001) and spring (OR 5.05; P=.001) being more likely to show high positive activity behavior change than those registering in summer. More striking were the results identifying those classified as overweight (measured through body mass index [BMI]; OR 1.83; P=.02) and less active (based on a self-reported scale of physical activity; OR 0.88; P=.048), being most likely to show high levels of physical activity change following registration with the app. Conclusions: The results highlight that an incentives-based app can induce significant physical activity behavior change, sustained over a 6-month period. Importantly, the results suggest that those typically lacking motivation to exercise (sedentary and high BMI) are most likely to be incentivized to increase their activity levels. UR - https://mhealth.jmir.org/2019/7/e12445/ UR - http://dx.doi.org/10.2196/12445 UR - http://www.ncbi.nlm.nih.gov/pubmed/31287064 ID - info:doi/10.2196/12445 ER - TY - JOUR AU - Winskell, Kate AU - Sabben, Gaëlle AU - Obong'o, Christopher PY - 2019/05/08 TI - Interactive Narrative in a Mobile Health Behavioral Intervention (Tumaini): Theoretical Grounding and Structure of a Smartphone Game to Prevent HIV Among Young Africans JO - JMIR Serious Games SP - e13037 VL - 7 IS - 2 KW - mHealth KW - serious games KW - games for health KW - narrative KW - HIV KW - adolescence KW - sub-Saharan Africa KW - behavioral theory KW - narrative theory UR - http://games.jmir.org/2019/2/e13037/ UR - http://dx.doi.org/10.2196/13037 UR - http://www.ncbi.nlm.nih.gov/pubmed/31066692 ID - info:doi/10.2196/13037 ER - TY - JOUR AU - Whiteside, Ursula AU - Richards, Julie AU - Huh, David AU - Hidalgo, Rianna AU - Nordhauser, Rebecca AU - Wong, J. Albert AU - Zhang, Xiaoshan AU - Luxton, D. David AU - Ellsworth, Michael AU - Lezine, DeQuincy PY - 2019/05/02 TI - Development and Evaluation of a Web-Based Resource for Suicidal Thoughts: NowMattersNow.org JO - J Med Internet Res SP - e13183 VL - 21 IS - 5 KW - dialectical behavior therapy KW - suicide KW - internet KW - help-seeking behavior KW - behavior therapy KW - crisis intervention KW - primary care KW - integrated health care systems N2 - Background: Nearly half of people who die by suicide see a health care provider in the month before their death. With the release of new care guidelines, detection of suicidal patients will likely increase. Providers need access to suicide-specific resources that can be used as part of immediate, brief interventions with a suicidal patient. Web-based suicide prevention resources have the potential to address this need. Objective: This study aimed to describe the development of the NowMattersNow.org website as a resource for individuals with suicidal thoughts and to evaluate the utility of the site via user experience surveys. Methods: NowMattersNow.org is an online video-based free public resource that provides evidence-based teachings, examples, and resources for managing suicidal thoughts and intense emotions focused largely around skills from dialectical behavior therapy. Developed with assistance from mental health consumers, it is intended to address gaps in access to services for suicidal patients in health care systems. Visitors stay an average of a minute and a half on the website. From March 2015 to December 2017, a user experience survey measured self-reported changes on a 1 (not at all) to 5 (completely overwhelming) scale regarding intensity of suicidal thoughts and negative emotions while on the website. Longitudinal regression analyses using generalized estimating equations evaluated the magnitude and statistical significance of user-reported changes in suicidal ideation and negative emotion. In secondary analyses, user-reported changes specific to subgroups, including men aged 36 to 64 years, mental health care providers, and other health care providers were evaluated. Results: During the period of analysis, there were 138,386 unique website visitors. We analyzed surveys (N=3670) collected during that time. Subsamples included men aged 36 to 64 years (n=512), mental health providers (n=460), and other health care providers (n=308). A total of 28% (1028/3670) of survey completers rated their suicidal thoughts as a 5 or ?completely overwhelming? when they entered the website. We observed significant reductions in self-reported intensity of suicidal thoughts (?0.21, P<.001) and negative emotions (?0.32, P<.001), including decreases for users with the most severe suicidal thoughts (?6.4%, P<.001), most severe negative emotions (?10.9%, P<.001), and for middle-aged men (?0.13, P<001). Results remained significant after controlling for length of visit to website (before the survey) and technology type (mobile, desktop, and tablet). Conclusions: Survey respondents reported measurable reductions in intensity of suicidal thoughts and emotions, including those rating their suicidal thoughts as completely or almost completely overwhelming and among middle-aged men. Although results from this user-experience survey administered at one point in time to a convenience sample of users must be interpreted with caution, results provide preliminary support for the potential effectiveness of the NowMattersNow.org website as a tool for short-term management of suicidal thoughts and negative emotions. UR - http://www.jmir.org/2019/5/e13183/ UR - http://dx.doi.org/10.2196/13183 UR - http://www.ncbi.nlm.nih.gov/pubmed/31045498 ID - info:doi/10.2196/13183 ER - TY - JOUR AU - Lukaschek, Karoline AU - Schneider, Nico AU - Schelle, Mercedes AU - Kirk, Bak Ulrik AU - Eriksson, Tina AU - Kunnamo, Ilkka AU - Rochfort, Andrée AU - Collins, Claire AU - Gensichen, Jochen PY - 2019/04/29 TI - Applicability of Motivational Interviewing for Chronic Disease Management in Primary Care Following a Web-Based E-Learning Course: Cross-Sectional Study JO - JMIR Ment Health SP - e12540 VL - 6 IS - 4 KW - motivational interviewing KW - e-learning KW - web-based learning KW - primary care KW - health behavior change KW - disease management N2 - Background: Motivational interviewing (MI) is an established communication method for enhancing intrinsic motivation for changing health behavior. E-learning can reduce the cost and time involved in providing continuing education and can be easily integrated into individual working arrangements and the daily routines of medical professionals. Thus, a Web-based course was devised to familiarize health professionals with different levels of education and expertise with MI techniques for patients with chronic conditions. Objective: The aim of this study was to report participants? opinion on the practicality of MI (as learned in the course) in daily practice, stratified by the level of education. Methods: Participants (N=607) of the MI Web-based training course evaluated the course over 18 months, using a self-administered questionnaire. The evaluation was analyzed descriptively and stratified for the level of education (medical students, physicians in specialist training [PSTs], and general practitioners [GPs]). Results: Participants rated the applicability of the skills and knowledge gained by the course as positive (medical students: 94% [79/84] good; PSTs: 88.6% [109/123] excellent; and GPs: 51.3% [182/355] excellent). When asked whether they envisage the use of MI in the future, 79% (67/84) of the students stated to a certain extent, 88.6% (109/123) of the PSTs stated to a great extent, and 38.6% (137/355) of GPs stated to a great extent. Participants acknowledged an improvement of communication skills such as inviting (medical students: 85% [72/84]; PSTs: 90.2% [111/123]; GPs: 37.2% [132/355]) and encouraging (medical students: 81% [68/84]; PSTs: 45.5% [56/123]; GPs: 36.3% [129/355]) patients to talk about behavior change and conveying respect for patient?s choices (medical students: 72% [61/84]; PSTs: 50.0% [61/123]; GPs: 23.4% [83/355]). Conclusions: Participants confirmed the practicality of MI. However, the extent to which the practicality of MI was acknowledged as well as its expected benefits depended on the individual?s level of education/expertise. UR - http://mental.jmir.org/2019/4/e12540/ UR - http://dx.doi.org/10.2196/12540 UR - http://www.ncbi.nlm.nih.gov/pubmed/31033446 ID - info:doi/10.2196/12540 ER - TY - JOUR AU - Bendtsen, Marcus AU - McCambridge, Jim PY - 2019/04/18 TI - Reducing Alcohol Consumption Among Risky Drinkers in the General Population of Sweden Using an Interactive Mobile Health Intervention: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e13119 VL - 8 IS - 4 KW - telemedicine KW - alcohol drinking KW - randomized controlled trial N2 - Background: Harmful use of alcohol continues to be a leading contributor to premature deaths globally. Not only does harmful drinking have consequences for the individuals consuming at increased levels, but it may also result in a range of negative consequences for their family members and friends. Interventions delivered via mobile phones (mobile health [mHealth] interventions) could potentially support risky drinkers seeking help to reduce their alcohol consumption. Objective: This protocol describes a randomized controlled trial that aims to validly estimate the effect of a novel mHealth intervention targeting risky drinkers in the general population of Sweden. Nested within the trial are 3 substudies that focus on methodological and user satisfaction research questions. Methods: A 2-arm parallel group randomized controlled trial will be employed to estimate the effect of the novel intervention. Participants will be recruited through Web advertisements and social media. The inclusion criteria are as follows: 18 years or older, ownership of a mobile phone, and being classified as a risky drinker according to Swedish guidelines. Participants allocated to the intervention group will receive a novel mHealth intervention. The intervention consists of weekly screening, personalized feedback on current consumption, functions allowing for planning of future consumption, as well as a series of messages delivered throughout the week. Participants allocated to the control group will receive a short message regarding negative consequences of alcohol consumption and a hyperlink that offers more information. Following 2 and 4 months after randomization, both groups will be asked to complete follow-up questionnaires (2-month interval being primary). Primary outcomes are weekly alcohol consumption and heavy episodic drinking. Participants in the control group will be given access to the novel intervention after completing the 4-month follow-up. The trial includes 3 substudies: We will explore whether the mode of presenting information before participants giving informed consent affects participation rates and recall of trial parameters, investigate if the content of the short message received by the control group affects study outcomes and requests for more information, and explore user satisfaction with the intervention and reactions of the control group. Results: Participant recruitment is planned to begin in April 2019 and to last for a maximum of 24 months. The first dataset will be available approximately 2 months after the final participant has been recruited, and the final dataset will be available approximately 2 months later. No participants had been recruited at the time of submitting this protocol. Conclusions: If found effective, the intervention has the potential to reduce negative consequences of alcohol consumption for individuals. The technology has been designed to have potential for extensive reach among those who may benefit. Trial Registration: ISRCTN Registry ISRCTN48317451; http://www.isrctn.com/ISRCTN48317451 (Archived by WebCite at http://www.webcitation.org/779tKLsu3) International Registered Report Identifier (IRRID): PRR1-10.2196/13119 UR - http://www.researchprotocols.org/2019/4/e13119/ UR - http://dx.doi.org/10.2196/13119 UR - http://www.ncbi.nlm.nih.gov/pubmed/30998221 ID - info:doi/10.2196/13119 ER - TY - JOUR AU - Haas, Karin AU - Hayoz, Stefanie AU - Maurer-Wiesner, Susanne PY - 2019/04/11 TI - Effectiveness and Feasibility of a Remote Lifestyle Intervention by Dietitians for Overweight and Obese Adults: Pilot Study JO - JMIR Mhealth Uhealth SP - e12289 VL - 7 IS - 4 KW - remote consultation KW - obesity KW - weight loss KW - mobile app KW - behavior therapy KW - healthy lifestyle KW - healthy diet N2 - Background: To tackle the problem of obesity and related diseases in Switzerland, cost-efficient, effective, and innovative primary health care interventions for weight management are required. In this context, Oviva has developed a scalable technology for registered dietitians to counsel overweight and obese patients via a mobile phone app. Objective: The aim of this study was to evaluate the effectiveness and feasibility of weight loss counseling by dietitians using a mobile phone app for patients with overweight and obesity. Methods: In this pre- and posttest pilot study, overweight and obese adults participated in a 1-year behavioral intervention to lose weight through remote counseling by dietitians in the German-speaking part of Switzerland. The study started in April 2016 and finished in May 2018. Participants received individual counseling through the app and the exchange with the dietitian focused on regular feedback on photo-based food log, motivation, and education. The contents were tailored to the individual lifestyle goal set. The predefined intensity of remote counseling decreased during the year. Group chat could be used. The outcomes examined were changes in weight (primary outcome), hemoglobin A1c, fasting glucose, fasting insulin, triglyceride, high-density lipoprotein cholesterol, blood pressure (BP), body mass index (BMI), waist circumference, body fat, and responses to a self-administered questionnaire with questions regarding participants? physical activity, dietary assessment, and health-related quality of life. Changes were tested at baseline, after 3 months, and after 12 months, as well as between the third and the 12th month. Results: In total, 36 women and 7 men, with a mean age of 40.6 years, participated and 36 participants completed the study. Median weight change after the first 12 weeks was ?3.8 kg (range: ?15 to 2.4 and P<.001), between week 12 and week 52 it was ?1.1 kg (range: ?9.7 to 7 and P=.08), and the median change during the entire period of intervention was ?4.9 kg (range: ?21.9 to 7.5 and P<.001). Furthermore, changes in BMI, waist circumference, body fat, and BP between baseline and 12 weeks and between baseline and 52 weeks were also significant. Significant changes in certain eating habits were also demonstrated (higher frequency of vegetable, fruit, and breakfast consumption and lower frequency of alcohol, sweet, and fat consumption). Conclusions: In addition to the professional skills of a dietitian, a profession-specific app such as Oviva can provide effective support that meets the needs of dietitians and clients on the long path of behavioral change and sustainable weight reduction. Trial Registration: ClinicalTrials.gov NCT02694614; https://clinicaltrials.gov/ct2/show/NCT02694614 (Archived by WebCite at http://www.webcitation.org/76gYkGOIc) UR - https://mhealth.jmir.org/2019/4/e12289/ UR - http://dx.doi.org/10.2196/12289 UR - http://www.ncbi.nlm.nih.gov/pubmed/30973338 ID - info:doi/10.2196/12289 ER - TY - JOUR AU - Ramsey, T. Alex AU - Satterfield, M. Jason AU - Gerke, R. Donald AU - Proctor, K. Enola PY - 2019/04/08 TI - Technology-Based Alcohol Interventions in Primary Care: Systematic Review JO - J Med Internet Res SP - e10859 VL - 21 IS - 4 KW - alcohol drinking KW - risky health behavior KW - alcohol-related disorders KW - internet KW - computers KW - mobile health KW - primary health care KW - implementation science KW - review N2 - Background: Primary care settings are uniquely positioned to reach individuals at risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches. Objective: The aim of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization or target of the intervention, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy. Methods: We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to December 2018 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 2307 initial records, 42 were included and coded independently by 2 investigators. Results: Compared with the years of 2000 to 2009, published studies on technology-based alcohol interventions in primary care nearly tripled during the years of 2010 to 2018. Of the 42 included studies, 28 (64%) were randomized controlled trials. Furthermore, studies were rated on risk of bias and found to be predominantly low risk (n=18), followed by moderate risk (n=16), and high risk (n=8). Of the 24 studies with primary or secondary efficacy outcomes related to drinking and drinking-related harms, 17 (71%) reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, of the 31 studies with direct comparisons with treatment as usual (TAU), 13 (42%) reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to TAU. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention. Conclusions: Our systematic review has highlighted a pattern of growth in the number of studies evaluating technology-based alcohol interventions in primary care. Although these interventions appear to be largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings. UR - https://www.jmir.org/2019/4/e10859/ UR - http://dx.doi.org/10.2196/10859 UR - http://www.ncbi.nlm.nih.gov/pubmed/30958270 ID - info:doi/10.2196/10859 ER - TY - JOUR AU - Pentikäinen, Saara AU - Tanner, Hannu AU - Karhunen, Leila AU - Kolehmainen, Marjukka AU - Poutanen, Kaisa AU - Pennanen, Kyösti PY - 2019/03/27 TI - Mobile Phone App for Self-Monitoring of Eating Rhythm: Field Experiment JO - JMIR Mhealth Uhealth SP - e11490 VL - 7 IS - 3 KW - mHealth KW - behavior observation KW - self-regulation KW - eating KW - ecological momentary assessment N2 - Background: Temporal aspects of eating are an integral part of healthy eating, and regular eating has been associated with good diet quality and more successful weight control. Unfortunately, irregular eating is becoming more common. Self-monitoring of behavior has been found to be an efficient behavioral change technique, but the solution should be simple enough to ensure long-lasting adherence. Objective: This study aimed to explore the influence of self-monitoring of daily eating pattern with mobile phone app on eating rhythm, eating behavior tendencies, and the underlying motives and attitudes related to eating. Methods: A mobile phone app, Button, was developed for effortless self-monitoring of eating rhythm. The feasibility of the app was tested in a 30-day intervention. The participants (N=74) recorded their eating occasions during the intervention by pressing a button in the app widget. Results: The average interval between meals increased (96 [SD 24] min during the first 10 days vs 109.1[SD 36.4] during the last 10 days) and the number of daily eating occasions decreased (4.9 [SD 0.9] during the first 10 days vs 4.4 [SD 0.9] during the last 10 days). The tendencies for cognitive restraint, emotional eating, and uncontrolled eating increased. Eating-related attitudes and motives remained largely unchanged. Conclusions: These results indicate that a simple self-monitoring tool is able to draw a user?s attention to eating and is a potential tool to aid people to change their eating rhythm. UR - http://mhealth.jmir.org/2019/3/e11490/ UR - http://dx.doi.org/10.2196/11490 UR - http://www.ncbi.nlm.nih.gov/pubmed/30916657 ID - info:doi/10.2196/11490 ER - TY - JOUR AU - Khokhar, Durreajam AU - Nowson, Anne Caryl AU - Margerison, Claire AU - West, Madeline AU - Campbell, J. Karen AU - Booth, Olivia Alison AU - Grimes, Ann Carley PY - 2019/02/25 TI - The Digital Education to Limit Salt in the Home Program Improved Salt-Related Knowledge, Attitudes, and Behaviors in Parents JO - J Med Internet Res SP - e12234 VL - 21 IS - 2 KW - dietary sodium KW - knowledge KW - attitude KW - behavior KW - parent KW - internet KW - family KW - Australia N2 - Background: Currently, Australian children and adults are eating too much salt, increasing their risk of cardiovascular-related conditions. Web-based programs provide an avenue to engage the parents of primary schoolchildren in salt-specific messages, which may positively impact their own salt-related knowledge, attitudes, and behaviors (KABs). Objective: This pilot study aimed to determine whether parents? salt-related KABs improved following participation in the Digital Education to LImit Salt in the Home (DELISH) Web-based education program. Methods: The DELISH program was a 5-week, home-delivered, Web-based intervention, with a pre- and posttest design, targeting schoolchildren aged 7 to 10 years and their parents. Parents received weekly Web-based educational newsletters and text messages and completed online pre- and postprogram surveys assessing salt-related KABs. Upon completion of the program, all parents were also invited to complete an online evaluation survey. Changes in KABs outcomes were assessed using McNemar tests and paired t tests. Results: Of the 80 parents that commenced the program, 73 parents (mean age 41.0, SD 7.0 years; 86% (63/73) females) completed both pre- and postsurveys. Overall, mean score for salt-related knowledge improved (+3.6 [standard error (SE) 0.41] points), and mean behavior score also improved (+4.5 [SE 0.61] points), indicating a higher frequency of engaging in behaviors to reduce salt in the diet, and mean attitude score decreased (?0.7 [SE 0.19] points), representing lower importance of using salt to enhance the taste of food (all P<.001). Following participation, the proportion of parents aware of the daily salt intake recommendation increased from 40% (29/73) to 74% (54/73) (P<.001), and awareness of bread as the main source of salt increased from 58% (42/73) to 95% (69/73) (P<.001). The proportion of parents who agreed that salt should be used in cooking to enhance the flavor of food decreased from 30% (22/73) to 11% (8/73) (P=.002) and the proportion who agreed that sodium information displayed on food labels was difficult to understand decreased from 52% (38/73) to 32% (23/73) (P=.009). There was a reduction in the proportion of parents who reported adding salt during cooking (55% [40/73] vs 41% [30/73]; P=.03) and at the table (32% [23/73] vs 18% [13/73]; P=.002). Of the 16 parents who completed the evaluation survey, 75% (12/16) enjoyed the program, and all parents found the newsletters to be useful. Almost all parents (15/16, 94%) agreed that the DELISH program would be useful to other parents. Conclusions: The improvement in salt-related KABs in the DELISH program indicates the potential for online technology, to disseminate simple salt reduction education messages to families with primary school?aged children. Future work should seek to improve the quality of data collected by including a larger sample size and a control group to integrate the program within the school setting to enable wider dissemination. UR - http://www.jmir.org/2019/2/e12234/ UR - http://dx.doi.org/10.2196/12234 UR - http://www.ncbi.nlm.nih.gov/pubmed/30801255 ID - info:doi/10.2196/12234 ER - TY - JOUR AU - Halse, E. Rhiannon AU - Shoneye, L. Charlene AU - Pollard, M. Christina AU - Jancey, Jonine AU - Scott, A. Jane AU - Pratt, S. Iain AU - Dhaliwal, S. Satvinder AU - Norman, Richard AU - Straker, M. Leon AU - Boushey, J. Carol AU - Delp, J. Edward AU - Zhu, Fengqing AU - Harray, J. Amelia AU - Szybiak, A. Maria AU - Finch, Anne AU - McVeigh, A. Joanne AU - Mullan, Barbara AU - Collins, E. Clare AU - Mukhtar, Aqif Syed AU - Edwards, N. Kieran AU - Healy, D. Janelle AU - Kerr, A. Deborah PY - 2019/02/25 TI - Improving Nutrition and Activity Behaviors Using Digital Technology and Tailored Feedback: Protocol for the Tailored Diet and Activity (ToDAy) Randomized Controlled Trial JO - JMIR Res Protoc SP - e12782 VL - 8 IS - 2 KW - obesity KW - diet KW - physical activity KW - sedentary KW - digital behavioral interventions KW - health behavior KW - wearable activity monitor KW - mHealth KW - eHealth KW - mobile food record N2 - Background: Excess weight is a major risk factor for chronic diseases. In Australia, over 60% of adults are overweight or obese. The overconsumption of energy-dense nutrient-poor (EDNP) foods and low physical activity (PA) levels are key factors contributing to population obesity. New cost-effective approaches to improve population diet and PA behaviors are needed. Objective: This 1-year randomized controlled trial (6-month intervention and 6-month follow-up) aims to investigate whether a tailored intervention using mobile technology can improve diet and PA behaviors leading to weight loss in adults (aged 18-65 years) who are overweight or obese and recruited through a social marketing campaign (LiveLighter). Methods: All eligible participants will provide data on demographics and lifestyle behaviors online at baseline, 6 months, and 12 months. Using two-stage randomization, participants will be allocated into one of three conditions (n=200 per group): tailored feedback delivered via email at seven time points, informed by objective dietary (mobile food record app) and activity (wearable activity monitor) assessment; active control receiving no tailored feedback, but undergoing the same objective assessments as tailored feedback; and online control receiving no tailored feedback or objective assessments. Primary outcome measures at 6 and 12 months are changes in body mass, EDNP food and beverage consumption, and daily moderate-to-vigorous PA (measured via accelerometry). Secondary outcomes include change in fruit and vegetable consumption, daily sedentary behaviors, and cost effectiveness. Results: Enrolment commenced in August 2017. Primary outcomes at 12 months will be available for analysis from September 2019. Conclusions: Tailored email feedback provided to individuals may deliver a cost-effective strategy to overcome existing barriers to improving diet and PA. If found to be successful and cost effective, upscaling this intervention for inclusion in larger-scale interventions is highly feasible. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12617000554369; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=371325&isReview=true International Registered Report Identifier (IRRID): DERR1-10.2196/12782 UR - http://www.researchprotocols.org/2019/2/e12782/ UR - http://dx.doi.org/10.2196/12782 UR - http://www.ncbi.nlm.nih.gov/pubmed/30801257 ID - info:doi/10.2196/12782 ER - TY - JOUR AU - Höchsmann, Christoph AU - Infanger, Denis AU - Klenk, Christopher AU - Königstein, Karsten AU - Walz, P. Steffen AU - Schmidt-Trucksäss, Arno PY - 2019/02/13 TI - Effectiveness of a Behavior Change Technique?Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial JO - JMIR Serious Games SP - e11444 VL - 7 IS - 1 KW - behavior change KW - exercise adherence KW - gamification KW - intrinsic motivation KW - mhealth KW - mobile phone game KW - physical activity KW - type 2 diabetes N2 - Background: Regular physical activity (PA) is an essential component of a successful type 2 diabetes treatment. However, despite the manifest evidence for the numerous health benefits of regular PA, most patients with type 2 diabetes remain inactive, often due to low motivation and lack of PA enjoyment. A recent and promising approach to help overcome these PA barriers and motivate inactive individuals to change their PA behavior is PA-promoting smartphone games. While short-term results of these games are encouraging, the long-term success in effectively changing PA behavior has to date not been confirmed. It is possible that an insufficient incorporation of motivational elements or flaws in gameplay and storyline in these games affect the long-term motivation to play and thereby prevent sustained changes in PA behavior. We aimed to address these design challenges by developing a PA-promoting smartphone game that incorporates established behavior change techniques and specifically targets inactive type 2 diabetes patients. Objective: To investigate if a self-developed, behavior change technique-based smartphone game designed by an interdisciplinary team is able to motivate inactive individuals with type 2 diabetes for regular use and thereby increase their intrinsic PA motivation. Methods: Thirty-six inactive, overweight type 2 diabetes patients (45-70 years of age) were randomly assigned to either the intervention group or the control group (one-time lifestyle counseling). Participants were instructed to play the smartphone game or to implement the recommendations from the lifestyle counseling autonomously during the 24-week intervention period. Intrinsic PA motivation was assessed with an abridged 12-item version of the Intrinsic Motivation Inventory (IMI) before and after the intervention. In addition, adherence to the game-proposed PA recommendations during the intervention period was assessed in the intervention group via the phone-recorded game usage data. Results: Intrinsic PA motivation (IMI total score) increased significantly in the intervention group (+6.4 (SD 4.2; P<.001) points) while it decreased by 1.9 (SD 16.5; P=.623) points in the control group. The adjusted difference between both groups was 8.1 (95% CI 0.9, 15.4; P=.029) points. The subscales ?interest/enjoyment? (+2.0 (SD 1.9) points, P<.001) and ?perceived competence? (+2.4 (SD 2.4) points, P<.001) likewise increased significantly in the intervention group while they did not change significantly in the control group. The usage data revealed that participants in the intervention group used the game for an average of 131.1 (SD 48.7) minutes of in-game walking and for an average of 15.3 (SD 24.6) minutes of strength training per week. We found a significant positive association between total in-game training (min) and change in IMI total score (beta=0.0028; 95% CI 0.0007-0.0049; P=.01). Conclusions: In inactive individuals with type 2 diabetes, a novel smartphone game incorporating established motivational elements and personalized PA recommendations elicits significant increases in intrinsic PA motivation that are accompanied by de-facto improvements in PA adherence over 24 weeks. Trial Registration: ClinicalTrials.gov NCT02657018; https://clinicaltrials.gov/ct2/show/NCT02657018 UR - http://games.jmir.org/2019/1/e11444/ UR - http://dx.doi.org/10.2196/11444 UR - http://www.ncbi.nlm.nih.gov/pubmed/30758293 ID - info:doi/10.2196/11444 ER - TY - JOUR AU - Luk, Tsun Tzu AU - Wong, Wing Sze AU - Lee, Jae Jung AU - Chan, Siu-Chee Sophia AU - Lam, Hing Tai AU - Wang, Ping Man PY - 2019/01/31 TI - Exploring Community Smokers? Perspectives for Developing a Chat-Based Smoking Cessation Intervention Delivered Through Mobile Instant Messaging: Qualitative Study JO - JMIR Mhealth Uhealth SP - e11954 VL - 7 IS - 1 KW - chat intervention KW - instant messaging KW - mHealth KW - mobile phone KW - social media KW - smoking cessation KW - tobacco dependence KW - WhatsApp N2 - Background: Advances in mobile communication technologies provide a promising avenue for the delivery of tobacco dependence treatment. Although mobile instant messaging (IM) apps (eg, WhatsApp, Facebook messenger, and WeChat) are an inexpensive and widely used communication tool, evidence on its use for promoting health behavior, including smoking cessation, is scarce. Objective: This study aims to explore the perception of using mobile IM as a modality to deliver a proposed chat intervention for smoking cessation in community smokers in Hong Kong, where the proportion of smartphone use is among the highest in the world. Methods: We conducted 5 focus group, semistructured qualitative interviews on a purposive sample of 15 male and 6 female current cigarette smokers (age 23-68 years) recruited from the community in Hong Kong. All interviews were audiotaped and transcribed. Two investigators independently analyzed the transcripts using thematic analyses. Results: Participants considered mobile IM as a feasible and acceptable platform for the delivery of a supportive smoking cessation intervention. The ability to provide more personalized and adaptive behavioral support was regarded as the most valued utility of the IM?based intervention. Other perceived utilities included improved perceived psychosocial support and identification of motivator to quit. In addition, participants provided suggestions on the content and design of the intervention, which may improve the acceptability and usability of the IM?based intervention. These include avoiding health warning information, positive messaging, using former smokers as counselors, and adjusting the language style (spoken vs written) according to the recipients? preference. Conclusions: This qualitative study provides the first evidence that mobile IM may be an alternative mobile health platform for the delivery of a smoking cessation intervention. Furthermore, the findings inform the development of a chat-based, IM smoking cessation program being evaluated in a community trial. UR - https://mhealth.jmir.org/2019/1/e11954/ UR - http://dx.doi.org/10.2196/11954 UR - http://www.ncbi.nlm.nih.gov/pubmed/30702431 ID - info:doi/10.2196/11954 ER - TY - JOUR AU - Hermes, DA Eric AU - Lyon, R. Aaron AU - Schueller, M. Stephen AU - Glass, E. Joseph PY - 2019/01/25 TI - Measuring the Implementation of Behavioral Intervention Technologies: Recharacterization of Established Outcomes JO - J Med Internet Res SP - e11752 VL - 21 IS - 1 KW - mobile applications KW - behavior therapy KW - technology KW - internet KW - telemedicine KW - diffusion of innovation KW - translational medical research KW - outcome assessment (health care) KW - review KW - implementation KW - behavioral intervention technology UR - http://www.jmir.org/2019/1/e11752/ UR - http://dx.doi.org/10.2196/11752 UR - http://www.ncbi.nlm.nih.gov/pubmed/30681966 ID - info:doi/10.2196/11752 ER - TY - JOUR AU - McKay, H. Fiona AU - Slykerman, Sarah AU - Dunn, Matthew PY - 2019/01/25 TI - The App Behavior Change Scale: Creation of a Scale to Assess the Potential of Apps to Promote Behavior Change JO - JMIR Mhealth Uhealth SP - e11130 VL - 7 IS - 1 KW - apps KW - smartphone KW - mobile phone KW - mobile app KW - scale development KW - rating N2 - Background: Using mobile phone apps to promote behavior change is becoming increasingly common. However, there is no clear way to rate apps against their behavior change potential. Objective: This study aimed to develop a reliable, theory-based scale that can be used to assess the behavior change potential of smartphone apps. Methods: A systematic review of all studies purporting to investigate app?s behavior change potential was conducted. All scales and measures from the identified studies were collected to create an item pool. From this item pool, 3 health promotion exerts created the App Behavior Change Scale (ABACUS). To test the scale, 70 physical activity apps were rated to provide information on reliability. Results: The systematic review returned 593 papers, the abstracts and titles of all were reviewed, with the full text of 77 papers reviewed; 50 papers met the inclusion criteria. From these 50 papers, 1333 questions were identified. Removing duplicates and unnecessary questions left 130 individual questions, which were then refined into the 21-item scale. The ABACUS demonstrates high percentage agreement among reviewers (over 80%), with 3 questions scoring a Krippendorff alpha that would indicate agreement and a further 7 came close with alphas >.5. The scale overall reported high interrater reliability (2-way mixed interclass coefficient=.92, 95% CI 0.81-0.97) and high internal consistency (Cronbach alpha=.93). Conclusions: The ABACUS is a reliable tool that can be used to determine the behavior change potential of apps. This instrument fills a gap by allowing the evaluation of a large number of apps to be standardized across a range of health categories. UR - http://mhealth.jmir.org/2019/1/e11130/ UR - http://dx.doi.org/10.2196/11130 UR - http://www.ncbi.nlm.nih.gov/pubmed/30681967 ID - info:doi/10.2196/11130 ER - TY - JOUR AU - Wu, Xinghan AU - Guo, Xitong AU - Zhang, Zhiwei PY - 2019/01/15 TI - The Efficacy of Mobile Phone Apps for Lifestyle Modification in Diabetes: Systematic Review and Meta-Analysis JO - JMIR Mhealth Uhealth SP - e12297 VL - 7 IS - 1 KW - smartphone KW - mobile applications KW - diabetes mellitus KW - lifestyle KW - physical activity KW - diet KW - behavior therapy N2 - Background: Diabetes and related complications are estimated to cost US $727 billion worldwide annually. Type 1 diabetes, type 2 diabetes, and gestational diabetes are three subtypes of diabetes that share the same behavioral risk factors. Efforts in lifestyle modification, such as daily physical activity and healthy diets, can reduce the risk of prediabetes, improve the health levels of people with diabetes, and prevent complications. Lifestyle modification is commonly performed in a face-to-face interaction, which can prove costly. Mobile phone apps provide a more accessible platform for lifestyle modification in diabetes. Objective: This review aimed to summarize and synthesize the clinical evidence of the efficacy of mobile phone apps for lifestyle modification in different subtypes of diabetes. Methods: In June 2018, we conducted a literature search in 5 databases (Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, and PsycINFO). We evaluated the studies that passed screening using The Cochrane Collaboration?s risk of bias tool. We conducted a meta-analysis for each subtype on the mean difference (between intervention and control groups) at the posttreatment glycated hemoglobin (HbA1c) level. Where possible, we analyzed subgroups for short-term (3-6 months) and long-term (9-12 months) studies. Heterogeneity was assessed using the I2 statistic. Results: We identified total of 2669 articles through database searching. After the screening, we included 26 articles (23 studies) in the systematic review, of which 18 studies (5 type 1 diabetes, 11 type 2 diabetes, and 2 prediabetes studies) were eligible for meta-analysis. For type 1 diabetes, the overall effect on HbA1c was statistically insignificant (P=.46) with acceptable heterogeneity (I2=39%) in the short-term subgroup (4 studies) and significant heterogeneity between the short-term and long-term subgroups (I2=64%). Regarding type 2 diabetes, the overall effect on HbA1c was statistically significant (P<.01) in both subgroups, and when the 2 subgroups were combined, there was virtually no heterogeneity within and between the subgroups (I2 range 0%-2%). The effect remained statistically significant (P<.01) after adjusting for publication bias using the trim and fill method. For the prediabetes condition, the overall effect on HbA1c was statistically insignificant (P=.67) with a large heterogeneity (I2=65%) between the 2 studies. Conclusions: There is strong evidence for the efficacy of mobile phone apps for lifestyle modification in type 2 diabetes. The evidence is inconclusive for the other diabetes subtypes. UR - http://mhealth.jmir.org/2019/1/e12297/ UR - http://dx.doi.org/10.2196/12297 UR - http://www.ncbi.nlm.nih.gov/pubmed/30664494 ID - info:doi/10.2196/12297 ER - TY - JOUR AU - Griauzde, Dina AU - Kullgren, T. Jeffrey AU - Liestenfeltz, Brad AU - Ansari, Tahoora AU - Johnson, H. Emily AU - Fedewa, Allison AU - Saslow, R. Laura AU - Richardson, Caroline AU - Heisler, Michele PY - 2019/01/09 TI - A Mobile Phone-Based Program to Promote Healthy Behaviors Among Adults With Prediabetes Who Declined Participation in Free Diabetes Prevention Programs: Mixed-Methods Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e11267 VL - 7 IS - 1 KW - autonomous motivation KW - behavioral change KW - mHealth KW - mobile phone KW - prediabetes KW - prevention KW - type 2 diabetes mellitus N2 - Background: Despite evidence that Diabetes Prevention Programs (DPPs) can delay or prevent progression to type 2 diabetes mellitus (T2DM), few individuals with prediabetes enroll in offered programs. This may be in part because many individuals with prediabetes have low levels of autonomous motivation (ie, motivation that arises from internal sources) to prevent T2DM. Objective: This study aims to examine the feasibility and acceptability of a mobile health (mHealth) intervention designed to increase autonomous motivation and healthy behaviors among adults with prediabetes who previously declined participation free DPPs. In addition, the study aims to examine changes in autonomous motivation among adults offered 2 versions of the mHealth program compared with an information-only control group. Methods: In this 12-week, parallel, 3-arm, mixed-methods pilot randomized controlled trial, participants were randomized to (1) a group that received information about prediabetes and strategies to prevent T2DM (control); (2) a group that received a mHealth app that aims to increase autonomous motivation among users (app-only); or (3) a group that received the app plus a physical activity tracker and wireless-enabled digital scale for self-monitoring (app-plus). Primary outcome measures included rates of intervention uptake (number of individuals enrolled/number of individuals assessed for eligibility), retention (number of 12-week survey completers/number of participants), and adherence (number of device-usage days). The secondary outcome measure was change in autonomous motivation (measured using the Treatment Self-Regulation Questionnaire), which was examined using difference-in-difference analysis. Furthermore, we conducted postintervention qualitative interviews with participants. Results: Overall, 28% (69/244) of eligible individuals were randomized; of these, 80% (55/69) completed the 12-week survey. Retention rates were significantly higher among app-plus participants than participants in the other 2 study arms combined (P=.004, ?2). No significant differences were observed in adherence rates between app-only and app-plus participants (43 days vs 37 days; P=.34). Among all participants, mean autonomous motivation measures were relatively high at baseline (6.0 of 7.0 scale), with no statistically significant within- or between-group differences in follow-up scores. In qualitative interviews (n=15), participants identified reasons that they enjoyed using the app (eg, encouraged self-reflection), reasons that they did not enjoy using the app (eg, did not consider personal circumstances), and strategies to improve the intervention (eg, increased interpersonal contact). Conclusions: Among individuals with prediabetes who did not engage in free DPPs, this mHealth intervention was feasible and acceptable. Future work should (1) examine the effectiveness of a refined intervention on clinically relevant outcomes (eg, weight loss) among a larger population of DPP nonenrollees with low baseline autonomous motivation and (2) identify other factors associated with DPP nonenrollment, which may serve as additional potential targets for interventions. Trial Registration: ClinicalTrials.gov NCT03025607; https://clinicaltrials.gov/ct2/show/NCT03025607 (Archived by WebCite at http://www.webcitation.org/73cvaSAie) UR - http://mhealth.jmir.org/2019/1/e11267/ UR - http://dx.doi.org/10.2196/11267 UR - http://www.ncbi.nlm.nih.gov/pubmed/30626566 ID - info:doi/10.2196/11267 ER - TY - JOUR AU - Cushing, C. Christopher AU - Fedele, A. David AU - Brannon, E. Erin AU - Kichline, Tiffany PY - 2018/12/21 TI - Parents? Perspectives on the Theoretical Domains Framework Elements Needed in a Pediatric Health Behavior App: A Crowdsourced Social Validity Study JO - JMIR Mhealth Uhealth SP - e192 VL - 6 IS - 12 KW - mHealth KW - adolescent KW - children KW - parent KW - stakeholder KW - consumer preference N2 - Background: Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health (mHealth) interventions are not meaningfully disseminated after the trial period ends. Consequently, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not based in theory or evidence and may not take stakeholder preferences into account. Objective: The aim was to assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements. Methods: This study was a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into three components: (1) capability, (2) motivation, and (3) opportunity. Parents of children were recruited through Amazon Mechanical Turk. Results: The majority of participants were Caucasian and mean age was 36.9 (SD 8.0) years. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F2,545=5.18, P=.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F2,546=4.04, P=.02). When asked about the value of features to help children develop skills, parents preferred those features for dietary behavior over sleep (F2,546=3.57, P=.03). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F2,545=5.30, P=.005). Incentive features within the app were seen as most useful for physical activity over sleep (F2,546=4.34, P=.01). Conclusions: This study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mHealth intervention. Our approach is innovative in that it took a scientific framework (ie, TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF. UR - https://mhealth.jmir.org/2018/12/e192/ UR - http://dx.doi.org/10.2196/mhealth.9808 UR - http://www.ncbi.nlm.nih.gov/pubmed/30578173 ID - info:doi/10.2196/mhealth.9808 ER - TY - JOUR AU - Kebede, Mihiretu AU - Steenbock, Berit AU - Helmer, Maria Stefanie AU - Sill, Janna AU - Möllers, Tobias AU - Pischke, R. Claudia PY - 2018/12/18 TI - Identifying Evidence-Informed Physical Activity Apps: Content Analysis JO - JMIR Mhealth Uhealth SP - e10314 VL - 6 IS - 12 KW - guidelines KW - mHealth KW - mobile apps KW - physical activity KW - mobile phone N2 - Background: Regular moderate to vigorous physical activity is essential for maintaining health and preventing the onset of chronic diseases. Both global rates of smartphone ownership and the market for physical activity and fitness apps have grown rapidly in recent years. The use of physical activity and fitness apps may assist the general population in reaching evidence-based physical activity recommendations. However, it remains unclear whether there are evidence-informed physical activity apps and whether behavior change techniques (BCTs) previously identified as effective for physical activity promotion are used in these apps. Objective: This study aimed to identify English and German evidence-informed physical activity apps and BCT employment in those apps. Methods: We identified apps in a systematic search using 25 predefined search terms in the Google Play Store. Two reviewers independently screened the descriptions of apps and screenshots applying predefined inclusion and exclusion criteria. Apps were included if (1) their description contained information about physical activity promotion; (2) they were in English or German; (3) physical activity recommendations of the World Health Organization or the American College of Sports Medicine were mentioned; and (4) any kind of objective physical activity measurement was included. Two researchers downloaded and tested apps matching the inclusion criteria for 2 weeks and coded their content using the Behavioral Change Technique Taxonomy v1 (BCTTv1). Results: The initial screening in the Google Play Store yielded 6018 apps, 4108 of which were not focused on physical activity and were not in German or English. The descriptions of 1216 apps were further screened for eligibility. Duplicate apps and light versions (n=694) and those with no objective measurement of physical activity, requiring additional equipment, or not outlining any physical activity guideline in their description (n=1184) were excluded. Of the remaining 32 apps, 4 were no longer available at the time of the download. Hence, 28 apps were downloaded and tested; of these apps, 14 did not contain any physical activity guideline as an app feature, despite mentioning it in the description, 5 had technical problems, and 3 did not provide objective physical activity measurement. Thus, 6 were included in the final analyses. Of 93 individual BCTs of the BCTTv1, on average, 9 (SD 5) were identified in these apps. Of 16 hierarchical clusters, on average, 5 (SD 3) were addressed. Only BCTs of the 2 hierarchical clusters ?goals and planning? and ?feedback and monitoring? were identified in all apps. Conclusions: Despite the availability of several thousand physical activity and fitness apps for Android platforms, very few addressed evidence-based physical activity guidelines and provided objective physical activity measurement. Furthermore, available descriptions did not accurately reflect the app content and only a few evidence-informed physical activity apps incorporated several BCTs. Future apps should address evidence-based physical activity guidelines and a greater scope of BCTs to further increase their potential impact for physical activity promotion. UR - https://mhealth.jmir.org/2018/12/e10314/ UR - http://dx.doi.org/10.2196/10314 UR - http://www.ncbi.nlm.nih.gov/pubmed/30563810 ID - info:doi/10.2196/10314 ER - TY - JOUR AU - Tran, Xuan Bach AU - Zhang, WB Melvyn AU - Le, Thi Huong AU - Nguyen, Duc Hinh AU - Nguyen, Hoang Long AU - Nguyen, Thi Quyen Le AU - Tran, Dinh Tho AU - Latkin, A. Carl AU - Ho, CM Roger PY - 2018/11/30 TI - What Drives Young Vietnamese to Use Mobile Health Innovations? Implications for Health Communication and Behavioral Interventions JO - JMIR Mhealth Uhealth SP - e194 VL - 6 IS - 11 KW - youth KW - adolescent KW - Vietnam KW - mHealth KW - mobile phone KW - app N2 - Background: Mobile phone use in Vietnam has become increasingly popular in recent years, with youth (people aged 15-24 years) being one of the groups with the heaviest use. Health-related apps on mobile phones (mobile health [mHealth] apps) appear to be a feasible approach for disease and health management, especially for self-management. However, there has been a scarcity of research on mobile phone usage for health care among youth and adolescents. Objective: This study aims to identify the patterns of usage of mobile phone apps and the preferences for functionalities of mobile phone-based health-related apps among Vietnamese youth. Methods: An online cross-sectional study was conducted in Vietnam in August to October 2015. Web-based respondent-driven sampling technique was adopted to recruit participants. The online questionnaire was developed and distributed using Google Forms. Chi square and Mann-Whitney tests were used to investigate the difference in attitude and preference for mobile phone apps between the two genders. Results: Among 356 youths (age from 15 to 25 years) sampled, low prevalence was found of using mHealth apps such as beauty counseling (6.5%, 23/356), nutrition counseling (7.9%, 28/356), disease prevention (9.8%, 35/356), and disease treatment (7.6%, 27/356). The majority of users found the app(s) they used to be useful (72.7%, 48/356) and reported satisfaction with these apps (61.9%, 39/356). No significant differences were found between the genders in their perception of the usefulness of apps and their satisfaction with mobile health apps. Most of the participants (68.2%, 238/356) preferred apps which are conceptualized and designed to run on a mobile phone compared to Web-based apps, and 50% (176/356) preferred visual materials. Approximately 53.9% (188/356) reported that it was integral for the mobile phone apps to have a sharing/social network functionality. Participants with a higher perceived stress score and EuroQol-5 Dimensions (EQ-5D) index were significantly less likely to use mHealth apps. Conclusions: This study found a low proportion using mHealth-related mobile phone apps, but a high level of receptiveness and satisfaction among Vietnamese youth. Acceptance level and preferences toward mHealth apps as well as specifically preferred functionalities discovered in this study are essential not only in conceptualizing and developing appropriate mobile phone interventions targeting youth and adolescents, but also in the application of technically advanced solutions in disease prevention and health management. UR - http://mhealth.jmir.org/2018/11/e194/ UR - http://dx.doi.org/10.2196/mhealth.6490 UR - http://www.ncbi.nlm.nih.gov/pubmed/30251704 ID - info:doi/10.2196/mhealth.6490 ER - TY - JOUR AU - Bidargaddi, Niranjan AU - Almirall, Daniel AU - Murphy, Susan AU - Nahum-Shani, Inbal AU - Kovalcik, Michael AU - Pituch, Timothy AU - Maaieh, Haitham AU - Strecher, Victor PY - 2018/11/29 TI - To Prompt or Not to Prompt? A Microrandomized Trial of Time-Varying Push Notifications to Increase Proximal Engagement With a Mobile Health App JO - JMIR Mhealth Uhealth SP - e10123 VL - 6 IS - 11 KW - mobile applications KW - smartphone KW - self report KW - health promotion KW - lifestyle KW - ubiquitous computing KW - push notification N2 - Background: Mobile health (mHealth) apps provide an opportunity for easy, just-in-time access to health promotion and self-management support. However, poor user engagement with these apps remains a significant unresolved challenge. Objective: This study aimed to assess the effect of sending versus not sending a push notification containing a contextually tailored health message on proximal engagement, measured here as self-monitoring via the app. Secondary aims were to examine whether this effect varies by the number of weeks enrolled in the program or by weekday versus weekend. An exploratory aim was to describe how the effect on proximal engagement differs between weekday versus weekend by the time of day. Methods: The study analyzes the causal effects of push notifications on proximal engagement in 1255 users of a commercial workplace well-being intervention app over 89 days. The app employs a microrandomized trial (MRT) design to send push notifications. At 1 of 6 times per day (8:30 am, 12:30 pm, 5:30 pm, 6:30 pm, 7:30 pm, and 8:30 pm; selected randomly), available users were randomized with equal probability to be sent or not sent a push notification containing a tailored health message. The primary outcome of interest was whether the user self-monitored behaviors and feelings at some time during the next 24 hours via the app. A generalization of log-linear regression analysis, adapted for use with data arising from an MRT, was used to examine the effect of sending a push notification versus not sending a push notification on the probability of engagement over the next 24 hours. Results: Users were estimated to be 3.9% more likely to engage with the app in the next 24 hours when a tailored health message was sent versus when it was not sent (risk ratio 1.039; 95% CI 1.01 to 1.08; P<.05). The effect of sending the message attenuated over the course of the study, but this effect was not statistically significant (P=.84). The effect of sending the message was greater on weekends than on weekdays, but the difference between these effects was not statistically significant (P=.18). When sent a tailored health message on weekends, the users were 8.7% more likely to engage with the app (95% CI 1.01 to 1.17), whereas on weekdays, the users were 2.5% more likely to engage with the app (95% CI 0.98 to 1.07). The effect of sending a tailored health message was greatest at 12:30 pm on weekends, when the users were 11.8% more likely to engage (90% CI 1.02 to 1.13). Conclusions: Sending a push notification containing a tailored health message was associated with greater engagement in an mHealth app. Results suggested that users are more likely to engage with the app within 24 hours when push notifications are sent at mid-day on weekends. UR - http://mhealth.jmir.org/2018/11/e10123/ UR - http://dx.doi.org/10.2196/10123 UR - http://www.ncbi.nlm.nih.gov/pubmed/30497999 ID - info:doi/10.2196/10123 ER - TY - JOUR AU - Warren, Ian AU - Meads, Andrew AU - Whittaker, Robyn AU - Dobson, Rosie AU - Ameratunga, Shanthi PY - 2018/11/26 TI - Behavior Change for Youth Drivers: Design and Development of a Smartphone-Based App (BackPocketDriver) JO - JMIR Formativ Res SP - e25 VL - 2 IS - 2 KW - smartphone KW - public health KW - telemedicine KW - telemetry N2 - Background: The over-representation of youth in road crash injury and fatality rates is a major public health issue globally. In New Zealand, youth drivers are most vulnerable in the restricted license period when they can drive without the requirement for supervision by an experienced adult. Behavioral change interventions delivered using mobile phone technology to young drivers could serve as a useful mechanism to develop safe driving skills, but this potential remains to be fully explored. Objective: This study aimed to apply behavioral change principles to design and develop a smartphone-based intervention with the aim of helping youth drivers to develop and hone safe driving skills. Methods: An iterative process was used to support development of the smartphone intervention. We reviewed behavioral change literature, identifying fundamental principles and exploring use of behavior change techniques (BCTs) in other areas of public health. We engaged with key stakeholders, including young drivers, government agencies, and relevant organizations. We also took into account technology adoption considerations when designing the app. Results: We developed BackPocketDriver (BPD), an Android smartphone app that uses in-built sensors to monitor and infer driver behavior. The app implements features that were identified during the design process and are traceable to BCTs and theory. A key feature is messaging, which is used to instruct, motivate, educate, and relay feedback to participants. In addition, messaging addresses attitudes and beliefs. Other features include journey feedback summaries, goal setting, achievements, and leaderboards. Conclusions: BPD?s design rests on a sound foundation of theory and evidence. With explicit links between theory and features, the app aims to be an effective intervention to change and improve youth driver behavior. The next phase of this study is to run a small pilot study to assess BPD?s effectiveness. UR - http://formative.jmir.org/2018/2/e25/ UR - http://dx.doi.org/10.2196/formative.9660 UR - http://www.ncbi.nlm.nih.gov/pubmed/30684435 ID - info:doi/10.2196/formative.9660 ER - TY - JOUR AU - Schembre, M. Susan AU - Liao, Yue AU - O'Connor, G. Sydney AU - Hingle, D. Melanie AU - Shen, Shu-En AU - Hamoy, G. Katarina AU - Huh, Jimi AU - Dunton, F. Genevieve AU - Weiss, Rick AU - Thomson, A. Cynthia AU - Boushey, J. Carol PY - 2018/11/20 TI - Mobile Ecological Momentary Diet Assessment Methods for Behavioral Research: Systematic Review JO - JMIR Mhealth Uhealth SP - e11170 VL - 6 IS - 11 KW - diet surveys KW - diet records KW - mobile phone KW - mobile apps KW - ecological momentary assessment N2 - Background: New methods for assessing diet in research are being developed to address the limitations of traditional dietary assessment methods. Mobile device?assisted ecological momentary diet assessment (mEMDA) is a new dietary assessment method that has not yet been optimized and has the potential to minimize recall biases and participant burden while maximizing ecological validity. There have been limited efforts to characterize the use of mEMDA in behavioral research settings. Objective: The aims of this study were to summarize mEMDA protocols used in research to date, to characterize key aspects of these assessment approaches, and to discuss the advantages and disadvantages of mEMDA compared with the traditional dietary assessment methods as well as implications for future mEMDA research. Methods: Studies that used mobile devices and described mEMDA protocols to assess dietary intake were included. Data were extracted according to Preferred Reporting of Systematic Reviews and Meta-Analyses and Cochrane guidelines and then synthesized narratively. Results: The review included 20 studies with unique mEMDA protocols. Of these, 50% (10/20) used participant-initiated reports of intake at eating events (event-contingent mEMDA), and 50% (10/20) used researcher-initiated prompts requesting that participants report recent dietary intake (signal-contingent mEMDA). A majority of the study protocols (60%, 12/20) enabled participants to use mobile phones to report dietary data. Event-contingent mEMDA protocols most commonly assessed diet in real time, used dietary records for data collection (60%, 6/10), and provided estimates of energy and nutrient intake (60%, 6/10). All signal-contingent mEMDA protocols used a near real-time recall approach with unannounced (ie, random) abbreviated diet surveys. Most signal-contingent protocols (70%, 7/10) assessed the frequency with which (targeted) foods or food groups were consumed. Relatively few (30%, 6/20) studies compared mEMDA with the traditional dietary assessment methods. Conclusions: This review demonstrates that mEMDA has the potential to reduce participant burden and recall bias, thus advancing the field beyond current dietary assessment methods while maximizing ecological validity. UR - http://mhealth.jmir.org/2018/11/e11170/ UR - http://dx.doi.org/10.2196/11170 UR - http://www.ncbi.nlm.nih.gov/pubmed/30459148 ID - info:doi/10.2196/11170 ER - TY - JOUR AU - Duan, Ping Yan AU - Liang, Wei AU - Guo, Lan AU - Wienert, Julian AU - Si, Yan Gang AU - Lippke, Sonia PY - 2018/11/19 TI - Evaluation of a Web-Based Intervention for Multiple Health Behavior Changes in Patients With Coronary Heart Disease in Home-Based Rehabilitation: Pilot Randomized Controlled Trial JO - J Med Internet Res SP - e12052 VL - 20 IS - 11 KW - eHealth KW - physical activity KW - diet KW - cardiac rehabilitation KW - health resources N2 - Background: Web-based and theory-based interventions for multiple health behaviors appears to be a promising approach with respect to the adoption and maintenance of a healthy lifestyle in cardiac patients who have been discharged from the hospital. Until now, no randomized controlled trials have tested this assumption among Chinese rehabilitation patients with coronary heart disease using a Web-based intervention. Objective: The study aim was to evaluate the effect of an 8-week Web-based intervention in terms of physical activity (PA), fruit and vegetable consumption (FVC), lifestyle changes, social-cognitive outcomes, and health outcomes compared with a waiting control group in Chinese cardiac patients. The intervention content was theory-based on the health action process approach. Self-reported data were evaluated, including PA, FVC, healthy lifestyle (the synthesis of PA and FVC), internal resources (combination of intention, self-efficacy, and planning), and an external resource (social support) of PA and FVC behaviors, as well as perceived health outcomes (body mass index, quality of life, and depression). Methods: In a randomized controlled trial, 136 outpatients with coronary heart disease from the cardiac rehabilitation center of a hospital in China were recruited. After randomization and exclusion of unsuitable participants, 114 patients were assigned to 1 of the 2 groups: (1) the intervention group: first 4 weeks on PA and subsequent 4 weeks on FVC and (2) the waiting control group. A total of 2 Web-based assessments were conducted, including 1 at the beginning of the intervention (T1, N=114), and 1 at the end of the 8-week intervention (T2, N=83). The enrollment and follow-up took place from December 2015 to May 2016. Results: The Web-based intervention outperformed the control condition for PA, FVC, internal resources of PA and FVC, and an external resource of FVC, with an eta-squared effect size ranging from 0.06 to 0.43. Furthermore, the intervention effect was seen in the improvement of quality of life (F1,79=16.36, P<.001, ?2=.17). When predicting a healthy lifestyle at follow-up, baseline lifestyle (odds ratio, OR 145.60, 95% CI 11.24-1886; P<.001) and the intervention (OR 21.32, 95% CI 2.40-189.20; P=.006) were found to be significant predictors. Internal resources for FVC mediated the effect of the intervention on the adoption of a healthy lifestyle (R2adj=.29; P=.001), indicating that if the intervention increased the internal resource of behavior, the adoption of a healthy lifestyle was more likely. Conclusions: Patients? psychological resources such as motivation, self-efficacy, planning, and social support as well as lifestyle can be improved by a Web-based intervention that focuses on both PA and FVC. Such an intervention enriches extended rehabilitation approaches for cardiac patients to be active and remain healthy in daily life after hospital discharge. Trial Registration: ClinicalTrials.gov NCT01909349; https://clinicaltrials.gov/ct2/show/NCT01909349 (Archived by WebCite at http://www.webcitation.org/6pHV1A0G1) UR - http://www.jmir.org/2018/11/e12052/ UR - http://dx.doi.org/10.2196/12052 UR - http://www.ncbi.nlm.nih.gov/pubmed/30455167 ID - info:doi/10.2196/12052 ER - TY - JOUR AU - Zhang, Melvyn AU - Ying, Jiangbo AU - Amron, B. Syidda AU - Mahreen, Zaakira AU - Song, Guo AU - Fung, SS Daniel AU - Smith, Helen PY - 2018/11/19 TI - A Smartphone Attention Bias Intervention for Individuals With Addictive Disorders: Protocol for a Feasibility Study JO - JMIR Res Protoc SP - e11822 VL - 7 IS - 11 KW - addiction KW - approach bias KW - attention bias KW - bias modification KW - feasibility KW - pilot KW - psychiatry KW - mobile phone KW - mHealth KW - eHealth N2 - Background: Substance use disorders are highly prevalent globally. Relapse rates following conventional psychological interventions for substance use disorders remain high. Recent reviews have highlighted attentional and approach or avoidance biases to be responsible for multiple relapses. Other studies have reported the efficacy of interventions to modify biases. With advances in technologies, there are now mobile versions of conventional bias modification interventions. However, to date, no study has evaluated bias modification in a substance-using, non-Western sample. Existing evaluations of mobile technologies for the delivery of bias interventions are also limited to alcohol or tobacco use disorders. Objective: This study aims to examine the feasibility of mobile-based attention bias modification intervention among treatment-seeking individuals with substance use and alcohol use disorders. Methods: This is a feasibility study, in which inpatients who are in their rehabilitation phase of clinical management will be recruited. On each day that they are in the study, they will be required to complete a craving visual analogue scale and undertake both a visual probe-based assessment and and modification task in a smartphone app . Reaction time data will be collated for the computation of baseline attentional biases and to determine whether there is a reduction of attentional bias across the interventions. Feasibility will be determined by the number of participants recruited and participants? adherence to the planned interventions up until the completion of their rehabilitation program and by the ability of the app in detecting baseline biases and changes in biases. Acceptability of the intervention will be assessed by a short questionnaire of users? perceptions of the intervention. Statistical analyses will be performed using SPSS version 22.0, while qualitative analysis of the perspectives will be performed using NVivo version 10.0. Results: This study was approved by the National Healthcare Group Domain Specific Research Board, with approval number (2018/00316). Results will be disseminated by means of conferences and publications.Currently, we are in the process of recruitment for this study. Conclusions: To the best of our knowledge, this is the first study to evaluate the feasibility and acceptability of a mobile attention bias modification intervention for individuals with substance use disorders. The data pertaining to the feasibility and acceptability are undoubtedly crucial because they imply the potential use of mobile technologies in retraining attentional biases among inpatients admitted for medical-assisted detoxification and rehabilitation. Participants? feedback pertaining to the ease of use, interactivity, and motivation to continue using the app is crucial because it will determine whether a codesign approach might be warranted to design an app that is acceptable for participants and that participants themselves would be motivated to use. International Registered Report Identifier (IRRID): PRR1-10.2196/11822 UR - http://www.researchprotocols.org/2018/11/e11822/ UR - http://dx.doi.org/10.2196/11822 UR - http://www.ncbi.nlm.nih.gov/pubmed/30455170 ID - info:doi/10.2196/11822 ER - TY - JOUR AU - Short, E. Camille AU - DeSmet, Ann AU - Woods, Catherine AU - Williams, L. Susan AU - Maher, Carol AU - Middelweerd, Anouk AU - Müller, Matthias Andre AU - Wark, A. Petra AU - Vandelanotte, Corneel AU - Poppe, Louise AU - Hingle, D. Melanie AU - Crutzen, Rik PY - 2018/11/16 TI - Measuring Engagement in eHealth and mHealth Behavior Change Interventions: Viewpoint of Methodologies JO - J Med Internet Res SP - e292 VL - 20 IS - 11 KW - telemedicine KW - internet KW - health promotion KW - evaluation studies KW - treatment adherence and compliance KW - outcome and process assessment (health care) UR - http://www.jmir.org/2018/11/e292/ UR - http://dx.doi.org/10.2196/jmir.9397 UR - http://www.ncbi.nlm.nih.gov/pubmed/30446482 ID - info:doi/10.2196/jmir.9397 ER - TY - JOUR AU - de Korte, Elsbeth AU - Wiezer, Noortje AU - Bakhuys Roozeboom, Maartje AU - Vink, Peter AU - Kraaij, Wessel PY - 2018/10/03 TI - Behavior Change Techniques in mHealth Apps for the Mental and Physical Health of Employees: Systematic Assessment JO - JMIR Mhealth Uhealth SP - e167 VL - 6 IS - 10 KW - behavior change techniques KW - mHealth KW - mental health KW - physical health KW - lifestyle KW - workplace KW - app KW - employee KW - work N2 - Background: Employees remain at risk of developing physical and mental health problems. To improve the lifestyle, health, and productivity many workplace interventions have been developed. However, not all of these interventions are effective. Mobile and wireless technology to support health behavior change (mobile health [mHealth] apps) is a promising, but relatively new domain for the occupational setting. Research on mHealth apps for the mental and physical health of employees is scarce. Interventions are more likely to be useful if they are rooted in health behavior change theory. Evaluating the presence of specific combinations of behavior change techniques (BCTs) in mHealth apps might be used as an indicator of potential quality and effectiveness. Objective: The aim of this study was to assess whether mHealth apps for the mental and physical health of employees incorporate BCTs and, if so, which BCTs can be identified and which combinations of BCTs are present. Methods: An assessment was made of apps aiming to reduce the risk of physical and psychosocial work demands and to promote a healthy lifestyle for employees. A systematic search was performed in iTunes and Google Play. Forty-five apps were screened and downloaded. BCTs were identified using a taxonomy applied in similar reviews. The mean and ranges were calculated. Results: On average, the apps included 7 of the 26 BCTs (range 2-18). Techniques such as ?provide feedback on performance,? ?provide information about behavior-health link,? and ?provide instruction? were used most frequently. Techniques that were used least were ?relapse prevention,? ?prompt self-talk,? ?use follow-up prompts,? and ?provide information about others? approval.? ?Stress management,? ?prompt identification as a role model,? and ?agree on behavioral contract? were not used by any of the apps. The combination ?provide information about behavior-health link? with ?prompt intention formation? was found in 7/45 (16%) apps. The combination ?provide information about behavior-health link? with ?provide information on consequences,? and ?use follow-up prompts? was found in 2 (4%) apps. These combinations indicated potential effectiveness. The least potentially effective combination ?provide feedback on performance? without ?provide instruction? was found in 13 (29%) apps. Conclusions: Apps for the occupational setting might be substantially improved to increase potential since results showed a limited presence of BCTs in general, limited use of potentially successful combinations of BCTs in apps, and use of potentially unsuccessful combinations of BCTs. Increasing knowledge on the effectiveness of BCTs in apps might be used to develop guidelines for app developers and selection criteria for companies and individuals. Also, this might contribute to decreasing the burden of work-related diseases. To achieve this, app developers, health behavior change professionals, experts on physical and mental health, and end-users should collaborate when developing apps for the working context. UR - https://mhealth.jmir.org/2018/10/e167/ UR - http://dx.doi.org/10.2196/mhealth.6363 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/mhealth.6363 ER - TY - JOUR AU - Kyrios, Michael AU - Ahern, Claire AU - Fassnacht, B. Daniel AU - Nedeljkovic, Maja AU - Moulding, Richard AU - Meyer, Denny PY - 2018/08/08 TI - Therapist-Assisted Internet-Based Cognitive Behavioral Therapy Versus Progressive Relaxation in Obsessive-Compulsive Disorder: Randomized Controlled Trial JO - J Med Internet Res SP - e242 VL - 20 IS - 8 KW - obsessive-compulsive disorder KW - mental health KW - cognitive behavioral therapy KW - CBT KW - online intervention N2 - Background: Obsessive-compulsive disorder (OCD) is a highly disabling psychological disorder with a chronic course if left untreated. Cognitive behavioral therapy (CBT) has been shown to be an effective treatment, but access to face-to-face CBT is not always possible. Internet-based CBT (iCBT) has become an increasingly viable option. However, no study has compared iCBT to an analogous control condition using a randomized controlled trial (RCT). Objective: A 2-armed RCT was used to compare a therapist-assisted 12-module iCBT to an analogous active attention control condition (therapist-assisted internet-based standard progressive relaxation training, iPRT) in adult OCD. This paper reports pre-post findings for OCD symptom severity. Method: In total, 179 participants (117 females, 65.7%) were randomized (stratified by gender) into iCBT or iPRT. The iCBT intervention included psychoeducation, mood and behavioral management, exposure and response prevention (ERP), cognitive therapy, and relapse prevention; the iPRT intervention included psychoeducation and relaxation techniques as a way of managing OCD-related anxiety but did not incorporate ERP or other CBT elements. Both treatments included audiovisual content, case stories, demonstrations of techniques, downloadable audio content and worksheets, and expert commentary. All participants received 1 weekly email, with a maximum 15-minute preparation time per client from a remote therapist trained in e-therapy. Emails aimed to monitor progress, provide support and encouragement, and assist in individualizing the treatment. Participants were assessed for baseline and posttreatment OCD severity with the telephone-administered clinician-rated Yale-Brown Obsessive-Compulsive Scale and other measures by assessors who were blinded to treatment allocation. Results: No pretreatment differences were found between the 2 conditions. Intention-to-treat analysis revealed significant pre-post improvements in OCD symptom severity for both conditions (P<.001). However, relative to iPRT, iCBT showed significantly greater symptom severity improvement (P=.001); Cohen d for iCBT was 1.05 (95% CI 0.72-1.37), whereas for iPRT it was 0.48 (95% CI 0.22-0.73). The iCBT condition was superior in regard to reliable improvement (25/51, 49% vs 16/55, 29%; P=.04) and clinically significant pre-post-treatment changes (17/51, 33% vs 6/55, 11%; P=.005). Those undertaking iCBT post completion of iPRT showed further significant symptom amelioration (P<.001), although the sequential treatment was no more efficacious than iCBT alone (P=.63). Conclusion: This study is the first to compare a therapist-assisted iCBT program for OCD to an analogous active attention control condition using iPRT. Our findings demonstrate the large magnitude effect of iCBT for OCD; interestingly, iPRT was also moderately efficacious, albeit significantly less so than the iCBT intervention. The findings are compared to previous internet-based and face-to-face CBT treatment programs for OCD. Future directions for technology-enhanced programs for the treatment of OCD are outlined. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12611000321943; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336704 (Archived by WebCite at http://www.webcitation.org/70ovUiOmd) UR - http://www.jmir.org/2018/8/e242/ UR - http://dx.doi.org/10.2196/jmir.9566 UR - http://www.ncbi.nlm.nih.gov/pubmed/30089607 ID - info:doi/10.2196/jmir.9566 ER - TY - JOUR AU - Winskell, Kate AU - Sabben, Gaëlle AU - Akelo, Victor AU - Ondeng'e, Ken AU - Obong'o, Christopher AU - Stephenson, Rob AU - Warhol, David AU - Mudhune, Victor PY - 2018/08/01 TI - A Smartphone Game-Based Intervention (Tumaini) to Prevent HIV Among Young Africans: Pilot Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e10482 VL - 6 IS - 8 KW - HIV KW - youth KW - Sub-Saharan Africa KW - Kenya KW - serious game KW - narrative KW - smartphone KW - pilot study KW - randomized controlled trial KW - mhealth KW - prevention N2 - Background: There is a pressing need to ensure that youth in high HIV prevalence settings are prepared for a safer sexual debut. Smartphone ownership is increasing dramatically in low-income and middle-income countries. Smartphone games that are appropriately grounded in behavioral theory and evidence-based practice have the potential to become valuable tools in youth HIV prevention efforts in Sub-Saharan Africa. Objective: To pilot-test a theory-based, empirically grounded smartphone game for young Kenyans designed to increase age and condom use at first sex, aiming to establish directionality of effects on behavior change. Methods: Tumaini (?hope for the future? in Swahili) is an interactive, narrative-based game grounded in social cognitive theory. A randomized controlled pilot study was conducted in Kisumu, Western Kenya, from April to June 2017 with 60 participants aged 11-14 (mean 12.7) years. Intervention arm participants (n=30) were provided with an Android smartphone with Tumaini installed on it and were instructed to play the game for at least 1 hour a day for 16 days; control arm participants (n=30) received no intervention. All participants completed a survey on behavioral mediators, delivered via an audio computer-assisted self-interview system at baseline (T1), post intervention (T2), and at 6 weeks postintervention (T3). The postintervention survey for intervention arm participants included questions eliciting feedback on the game. Intervention arm participants and their parents participated in 8 postintervention focus group discussions. Game log files were analyzed to calculate the length of exposure to the game. Behavioral survey data were analyzed using two-sample t tests to compare mean change from T1 to T2 and to T3 for intervention versus control arm participants. Descriptive statistics on game feedback questions were computed. Focus group transcripts were uploaded to MAXQDA software, where they were labeled with deductive and inductive codes. Data were analyzed thematically and compared across demographics. Results: Intervention arm participants played Tumaini for a mean of approximately 27 hours. The intervention arm showed significant gains in sexual health-related knowledge and self-efficacy (both P<.001), behavioral intention for risk-avoidance strategies and sexual risk communication (P=.006), and overall survey scores (P<.001) compared with the control arm at T3. The postintervention survey revealed high subjective measures of the game?s value, relevance, and appeal. Focus groups identified a wide range of knowledge and skills the participants had gained, including setting goals and planning how to achieve them, which was perceived as a key motivator for avoiding or reducing risk. Conclusions: The study supports the need for further research to assess the efficacy of the game-based intervention. If proven efficacious, smartphone games have the potential to dramatically increase the reach of culturally adapted behavioral interventions while ensuring fidelity to intervention design. Trial Registration: ClinicalTrials.gov NCT03054051; http://clinicaltrials.gov/ct2/show/NCT03054051 (Archived by WebCite at http://www.webcitation.org/70U2gCNtW) UR - http://mhealth.jmir.org/2018/8/e10482/ UR - http://dx.doi.org/10.2196/10482 UR - http://www.ncbi.nlm.nih.gov/pubmed/30068501 ID - info:doi/10.2196/10482 ER - TY - JOUR AU - Grant, Sean AU - Spears, Asya AU - Pedersen, R. Eric PY - 2018/07/26 TI - Video Games as a Potential Modality for Behavioral Health Services for Young Adult Veterans: Exploratory Analysis JO - JMIR Serious Games SP - e15 VL - 6 IS - 3 KW - behavioral health KW - replication KW - veterans KW - video games N2 - Background: Improving the reach of behavioral health services to young adult veterans is a policy priority. Objective: The objective of our study was to explore differences in video game playing by behavioral health need for young adult veterans to identify potential conditions for which video games could be used as a modality for behavioral health services. Methods: We replicated analyses from two cross-sectional, community-based surveys of young adult veterans in the United States and examined the differences in time spent playing video games by whether participants screened positive for behavioral health issues and received the required behavioral health services. Results: Pooling data across studies, participants with a positive mental health screen for depression or posttraumatic stress disorder (PTSD) spent 4.74 more hours per week (95% CI 2.54-6.94) playing video games. Among participants with a positive screen for a substance use disorder, those who had received substance use services since discharge spent 0.75 more days per week (95% CI 0.28-1.21) playing video games than participants who had not received any substance use services since discharge. Conclusions: We identified the strongest evidence that participants with a positive PTSD or depression screen and participants with a positive screen for a substance use disorder who also received substance use services since their discharge from active duty spent more time playing video games. Future development and evaluation of video games as modalities for enhancing and increasing access to behavioral health services should be explored for this population. UR - http://games.jmir.org/2018/3/e15/ UR - http://dx.doi.org/10.2196/games.9327 UR - http://www.ncbi.nlm.nih.gov/pubmed/30049668 ID - info:doi/10.2196/games.9327 ER - TY - JOUR AU - Springer, Aaron AU - Venkatakrishnan, Anusha AU - Mohan, Shiwali AU - Nelson, Lester AU - Silva, Michael AU - Pirolli, Peter PY - 2018/07/19 TI - Leveraging Self-Affirmation to Improve Behavior Change: A Mobile Health App Experiment JO - JMIR Mhealth Uhealth SP - e157 VL - 6 IS - 7 KW - mHealth KW - self-affirmation KW - behavior change KW - attrition KW - adherence KW - health behavior KW - telemedicine KW - treatment adherence and compliance N2 - Background: mHealth interventions can help to improve the physical well-being of participants. Unfortunately, mHealth interventions often have low adherence and high attrition. One possible way to increase adherence is instructing participants to complete self-affirmation exercises. Self-affirmation exercises have been effective in increasing many types of positive behaviors. However, self-affirmation exercises often involve extensive essay writing, a task that is not easy to complete on mobile platforms. Objective: This study aimed to adapt a self-affirmation exercise to a form better suited for delivery through a mobile app targeting healthy eating behaviors, and to test the effect of differing self-affirmation doses on adherence to behavior change goals over time. Methods: We examined how varied self-affirmation doses affected behavior change in an mHealth app targeting healthy eating that participants used for 28 days. We divided participants into the 4 total conditions using a 2×2 factorial design. The first independent variable was whether the participant received an initial self-affirmation exercise. The second independent variable was whether the participant received ongoing booster self-affirmations throughout the 28-day study. To examine possible mechanisms through which self-affirmation may cause positive behavior change, we analyzed three aspects of self-affirmation effects in our research. First, we analyzed how adherence was affected by self-affirmation exercises. Second, we analyzed whether self-affirmation exercises reduced attrition rates from the app. Third, we examined a model for self-affirmation behavior change. Results: Analysis of 3556 observations from 127 participants indicated that higher doses of self-affirmation resulted in improved adherence to mHealth intervention goals (coefficient 1.42, SE 0.71, P=.04). This increased adherence did not seem to translate to a decrease in participant attrition (P value range .61-.96), although our definition of attrition was conservative. Finally, we examined the mechanisms by which self-affirmation may have affected intentions of behavior change; we built a model of intention (R2=.39, P<.001), but self-affirmation did not directly affect final intentions (P value range .09-.93). Conclusions: Self-affirmations can successfully increase adherence to recommended diet and health goals in the context of an mHealth app. However, this increase in adherence does not seem to reduce overall attrition. The self-affirmation exercises we developed were simple to implement and had a low cost for both users and developers. While this study focused on an mHealth app for healthy eating, we recommend that other mHealth apps integrate similar self-affirmation exercises to examine effectiveness in other behaviors and contexts. UR - http://mhealth.jmir.org/2018/7/e157/ UR - http://dx.doi.org/10.2196/mhealth.9151 UR - http://www.ncbi.nlm.nih.gov/pubmed/30026179 ID - info:doi/10.2196/mhealth.9151 ER - TY - JOUR AU - Chan, Phoebe AU - Bhar, Sunil AU - Davison, E. Tanya AU - Doyle, Colleen AU - Knight, G. Bob AU - Koder, Deborah AU - Laidlaw, Kenneth AU - Pachana, A. Nancy AU - Wells, Yvonne AU - Wuthrich, M. Viviana PY - 2018/07/04 TI - Characteristics of Cognitive Behavioral Therapy for Older Adults Living in Residential Care: Protocol for a Systematic Review JO - JMIR Res Protoc SP - e164 VL - 7 IS - 7 KW - cognitive behavioural therapy KW - older adults KW - residential care KW - delivery KW - characteristics KW - systematic review N2 - Background: The prevalence rates of depressive and anxiety disorders are high in residential aged care settings. Older adults in such settings might be prone to these disorders because of losses associated with transitioning to residential care, uncertainty about the future, as well as a decline in personal autonomy, health, and cognition. Cognitive behavioral therapy (CBT) is efficacious in treating late-life depression and anxiety. However, there remains a dearth of studies examining CBT in residential settings compared with community settings. Typically, older adults living in residential settings have higher care needs than those living in the community. To date, no systematic reviews have been conducted on the content and the delivery characteristics of CBT for older adults living in residential aged care settings. Objective: The objective of this paper is to describe the systematic review protocol on the characteristics of CBT for depression and/or anxiety for older adults living in residential aged care settings. Methods: This protocol was developed in compliance with the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). Studies that fulfill the inclusion criteria will be identified by systematically searching relevant electronic databases, reference lists, and citation indexes. In addition, the PRISMA flowchart will be used to record the selection process. A pilot-tested data collection form will be used to extract and record data from the included studies. Two reviewers will be involved in screening the titles and abstracts of retrieved records, screening the full text of potentially relevant reports, and extracting data. Then, the delivery and content characteristics of different CBT programs of the included studies, where available, will be summarized in a table. Furthermore, the Downs and Black checklist will be used to assess the methodological quality of the included studies. Results: Systematic searches will commence in May 2018, and data extraction is expected to commence in July 2018. Data analyses and writing will happen in October 2018. Conclusions: In this section, the limitations of the systematic review will be outlined. Clinical implications for treating late-life depression and/or anxiety, and implications for residential care facilities will be discussed. Trial Registration: PROSPERO 42017080113; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=80113 (Archived by WebCite at http://www.webcitation.org/70dV4Qf54) Registered Report Identifier: RR1-10.2196/9902 UR - http://www.researchprotocols.org/2018/7/e164/ UR - http://dx.doi.org/10.2196/resprot.9902 UR - http://www.ncbi.nlm.nih.gov/pubmed/29973335 ID - info:doi/10.2196/resprot.9902 ER - TY - JOUR AU - March, Sonja AU - Spence, H. Susan AU - Donovan, L. Caroline AU - Kenardy, A. Justin PY - 2018/07/04 TI - Large-Scale Dissemination of Internet-Based Cognitive Behavioral Therapy for Youth Anxiety: Feasibility and Acceptability Study JO - J Med Internet Res SP - e234 VL - 20 IS - 7 KW - adolescent KW - child KW - anxiety disorders KW - cognitive behavioral therapy KW - eHealth KW - public health N2 - Background: Internet-based cognitive behavioral therapy (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but it has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs could be a promising first-step, low-intensity intervention that can be easily accessed by young people. Objective: The objective of our study was to examine the feasibility and acceptability of a publicly available online, self-help iCBT program (BRAVE Self-Help) through exploration of program adherence, satisfaction, and changes in anxiety. Methods: This study was an open trial involving the analysis of data collected from 4425 children and adolescents aged 7-17 years who presented with elevated anxiety at registration (baseline) for the iCBT program that was delivered through an open-access portal with no professional support. We assessed the program satisfaction via a satisfaction scale and measured adherence via the number of completed sessions. In addition, anxiety severity was assessed via scores on the Children?s Anxiety Scale, 8-item (CAS-8) at four time points: baseline, Session 4, Session 7, and Session 10. Results: Participants reported moderate satisfaction with the program and 30% completed three or more sessions. Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed six or more sessions, there was an average 4-point improvement in CAS-8 scores (Cohen d=0.87, children; Cohen d=0.81, adolescents), indicating a moderate to large effect size. Among participants who completed nine sessions, 57.7% (94/163) achieved recovery into nonelevated levels of anxiety and 54.6% (89/163) achieved statistically reliable reductions in anxiety. Conclusions: Participant feedback was positive, and the program was acceptable to most young people. Furthermore, significant and meaningful reductions in anxiety symptoms were achieved by many children and adolescents participating in this completely open-access and self-directed iCBT program. Our results suggest that online self-help CBT may offer a feasible and acceptable first step for service delivery to children and adolescents with anxiety. UR - http://www.jmir.org/2018/7/e234/ UR - http://dx.doi.org/10.2196/jmir.9211 UR - http://www.ncbi.nlm.nih.gov/pubmed/29973338 ID - info:doi/10.2196/jmir.9211 ER - TY - JOUR AU - Nes, Gonçalves Andréa Aparecida AU - van Dulmen, Sandra AU - Brembo, Andreas Espen AU - Eide, Hilde PY - 2018/07/03 TI - An mHealth Intervention for Persons with Diabetes Type 2 Based on Acceptance and Commitment Therapy Principles: Examining Treatment Fidelity JO - JMIR Mhealth Uhealth SP - e151 VL - 6 IS - 7 KW - diabetes mellitus type 2 KW - Acceptance and Commitment Therapy KW - mobile phone KW - Web-based KW - treatment fidelity KW - mHealth N2 - Background: Web-based interventions are becoming an alternative of treatment aimed to support behavioral changes and several advantages over traditional treatments are reported. New ways of delivering an intervention may result in new challenges regarding monitoring of treatment fidelity (TF) which is essential to ensure internal and external validity. Despite the importance of the theme, only a few studies in this field are reported. Objective: To examine TF of a mobile phone delivered intervention based on Acceptance and Commitment Therapy (ACT) with electronic diaries and written situational feedback for persons with diabetes mellitus type 2, the recommendations from the Behavior Change Consortium (BCC) established by The National Institutes of Health (NHI) were applied. To analyze fidelity, they recommend 5 areas to be investigated (1) design of the study, (2) provider training, (3) delivery of treatment, (4) receipt of treatment, and (5) enactment of treatment. In the current study, these areas were examined based on the analysis of therapists? adherence to the treatment protocol and participants? and therapists? experience with the intervention. Methods: To investigate the therapists? adherence to the treatment protocol, a total of 251 written feedback text messages were divided into text segments. Qualitative thematic analyses were then performed to examine how ACT and other therapeutic processes were used in the feedback by the therapists. For the therapists? and participants? experience analysis, participants answered a self-reported questionnaire and participated in 2 interviews. The therapists continuously reported their experiences to the researcher responsible for the project. Results: The results show high adherence to the TF strategies 20/21 (95%) applicable items of the fidelity checklist recommended by NHI BCC were identified in the present study. Measured provider skill acquisition post-training was the only item absent in the fidelity checklist. The results also show high therapists? adherence to the treatment protocol. All ACT processes (values, committed action, acceptance, contact with the present moment, self as context and cognitive defusion) were found in the coded text segments of the feedback in addition to communication and motivation strategies. For 336/730 (46%) of total possible text segments coded independently by 2 researchers, the interrater reliability measured by Cohen?s kappa was .85. The evaluation of participants? and therapists? experience with the intervention was generally positive. Conclusions: Based on the analyses of therapists? adherence to the treatment protocol grounded by ACT-principles and participants? and therapists? experience with the intervention, the 5 areas of TF recommended by NHI BCC were analyzed indicating a high level of TF. These results ensure an appropriate level of internal and external validity of the study and reliable intervention results and facilitate a precise replication of this intervention concept. Web-based psychological interventions to support people with chronic conditions are becoming increasingly more common. This study supports the results from a previous study which indicated that ACT could be reliably delivered in a written web-based format. Trial Registration: ClinicalTrials.gov NCT01297049; https://clinicaltrials.gov/ct2/show/NCT01297049 (Archived by WebCite at http://www.webcitation.org/70WC4Cm4T) UR - http://mhealth.jmir.org/2018/7/e151/ UR - http://dx.doi.org/10.2196/mhealth.9942 UR - http://www.ncbi.nlm.nih.gov/pubmed/29970357 ID - info:doi/10.2196/mhealth.9942 ER - TY - JOUR AU - Albarracin, Dolores AU - Romer, Daniel AU - Jones, Christopher AU - Hall Jamieson, Kathleen AU - Jamieson, Patrick PY - 2018/06/29 TI - Misleading Claims About Tobacco Products in YouTube Videos: Experimental Effects of Misinformation on Unhealthy Attitudes JO - J Med Internet Res SP - e229 VL - 20 IS - 6 KW - health communication KW - tobacco N2 - Background: Recent content analyses of YouTube postings reveal a proliferation of user generated videos with misleading statements about the health consequences of various types of nontraditional tobacco use (eg, electronic cigarettes; e-cigarettes). Objective: This research was aimed at obtaining evidence about the potential effects of YouTube postings about tobacco products on viewers' attitudes toward these products. Methods: A sample of young adults recruited online (N=350) viewed one of four highly viewed YouTube videos containing misleading health statements about chewing tobacco, e-cigarettes, hookahs, and pipe smoking, as well as a control YouTube video unrelated to tobacco products. Results: The videos about e-cigarettes and hookahs led to more positive attitudes toward the featured products than did control videos. However, these effects did not fully translate into attitudes toward combustive cigarette smoking, although the pipe video led to more positive attitudes toward combustive smoking than did the chewing and the hookah videos, and the e-cigarette video led to more positive attitudes toward combustive cigarette smoking than did the chewing video. Conclusions: This research revealed young people?s reactions to misleading claims about tobacco products featured in popular YouTube videos. Policy implications are discussed. UR - http://www.jmir.org/2018/6/e229/ UR - http://dx.doi.org/10.2196/jmir.9959 UR - http://www.ncbi.nlm.nih.gov/pubmed/29959113 ID - info:doi/10.2196/jmir.9959 ER - TY - JOUR AU - Pagoto, Sherry AU - Tulu, Bengisu AU - Agu, Emmanuel AU - Waring, E. Molly AU - Oleski, L. Jessica AU - Jake-Schoffman, E. Danielle PY - 2018/06/20 TI - Using the Habit App for Weight Loss Problem Solving: Development and Feasibility Study JO - JMIR Mhealth Uhealth SP - e145 VL - 6 IS - 6 KW - mobile app KW - mHealth KW - weight loss KW - obesity KW - problem solving N2 - Background: Reviews of weight loss mobile apps have revealed they include very few evidence-based features, relying mostly on self-monitoring. Unfortunately, adherence to self-monitoring is often low, especially among patients with motivational challenges. One behavioral strategy that is leveraged in virtually every visit of behavioral weight loss interventions and is specifically used to deal with adherence and motivational issues is problem solving. Problem solving has been successfully implemented in depression mobile apps, but not yet in weight loss apps. Objective: This study describes the development and feasibility testing of the Habit app, which was designed to automate problem-solving therapy for weight loss. Methods: Two iterative single-arm pilot studies were conducted to evaluate the feasibility and acceptability of the Habit app. In each pilot study, adults who were overweight or obese were enrolled in an 8-week intervention that included the Habit app plus support via a private Facebook group. Feasibility outcomes included retention, app usage, usability, and acceptability. Changes in problem-solving skills and weight over 8 weeks are described, as well as app usage and weight change at 16 weeks. Results: Results from both pilots show acceptable use of the Habit app over 8 weeks with on average two to three uses per week, the recommended rate of use. Acceptability ratings were mixed such that 54% (13/24) and 73% (11/15) of participants found the diet solutions helpful and 71% (17/24) and 80% (12/15) found setting reminders for habits helpful in pilots 1 and 2, respectively. In both pilots, participants lost significant weight (P=.005 and P=.03, respectively). In neither pilot was an effect on problem-solving skills observed (P=.62 and P=.27, respectively). Conclusions: Problem-solving therapy for weight loss is feasible to implement in a mobile app environment; however, automated delivery may not impact problem-solving skills as has been observed previously via human delivery. Trial Registration: ClinicalTrials.gov NCT02192905; https://clinicaltrials.gov/ct2/show/NCT02192905 (Archived by WebCite at http://www.webcitation.org/6zPQmvOF2) UR - http://mhealth.jmir.org/2018/6/e145/ UR - http://dx.doi.org/10.2196/mhealth.9801 UR - http://www.ncbi.nlm.nih.gov/pubmed/29925496 ID - info:doi/10.2196/mhealth.9801 ER - TY - JOUR AU - Kotz, David AU - Lord, E. Sarah AU - O'Malley, James A. AU - Stark, Luke AU - Marsch, A. Lisa PY - 2018/06/20 TI - Workshop on Emerging Technology and Data Analytics for Behavioral Health JO - JMIR Res Protoc SP - e158 VL - 7 IS - 6 KW - behavioral health KW - mobile technology KW - wearable devices KW - data analytics KW - mHealth UR - http://www.researchprotocols.org/2018/6/e158/ UR - http://dx.doi.org/10.2196/resprot.9589 UR - http://www.ncbi.nlm.nih.gov/pubmed/29925493 ID - info:doi/10.2196/resprot.9589 ER - TY - JOUR AU - Merlo, Gianluca AU - Chiazzese, Giuseppe AU - Taibi, Davide AU - Chifari, Antonella PY - 2018/05/31 TI - Development and Validation of a Functional Behavioural Assessment Ontology to Support Behavioural Health Interventions JO - JMIR Med Inform SP - e37 VL - 6 IS - 2 KW - ontology KW - behavioral interventions KW - functional behavioral assessment KW - eHealth care KW - evidence-based practice N2 - Background: In the cognitive-behavioral approach, Functional Behavioural Assessment is one of the most effective methods to identify the variables that determine a problem behavior. In this context, the use of modern technologies can encourage the collection and sharing of behavioral patterns, effective intervention strategies, and statistical evidence about antecedents and consequences of clusters of problem behaviors, encouraging the designing of function-based interventions. Objective: The paper describes the development and validation process used to design a specific Functional Behavioural Assessment Ontology (FBA-Ontology). The FBA-Ontology is a semantic representation of the variables that intervene in a behavioral observation process, facilitating the systematic collection of behavioral data, the consequential planning of treatment strategies and, indirectly, the scientific advancement in this field of study. Methods: The ontology has been developed deducing concepts and relationships of the ontology from a gold standard and then performing a machine-based validation and a human-based assessment to validate the Functional Behavioural Assessment Ontology. These validation and verification processes were aimed to verify how much the ontology is conceptually well founded and semantically and syntactically correct. Results: The Pellet reasoner checked the logical consistency and the integrity of classes and properties defined in the ontology, not detecting any violation of constraints in the ontology definition. To assess whether the ontology definition is coherent with the knowledge domain, human evaluation of the ontology was performed asking 84 people to fill in a questionnaire composed by 13 questions assessing concepts, relations between concepts, and concepts? attributes. The response rate for the survey was 29/84 (34.52%). The domain experts confirmed that the concepts, the attributes, and the relationships between concepts defined in the FBA-Ontology are valid and well represent the Functional Behavioural Assessment process. Conclusions: The new ontology developed could be a useful tool to design new evidence-based systems in the Behavioral Interventions practices, encouraging the link with other Linked Open Data datasets and repositories to provide users with new models of eHealth focused on the management of problem behaviors. Therefore, new research is needed to develop and implement innovative strategies to improve the poor reproducibility and translatability of basic research findings in the field of behavioral assessment. UR - http://medinform.jmir.org/2018/2/e37/ UR - http://dx.doi.org/10.2196/medinform.7799 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/medinform.7799 ER - TY - JOUR AU - Tanaka, Rika AU - Nolan, P. Robert PY - 2018/05/11 TI - Psychobehavioral Profiles to Assist Tailoring of Interventions for Patients With Hypertension: Latent Profile Analysis JO - J Med Internet Res SP - e149 VL - 20 IS - 5 KW - hypertension KW - depression KW - health behavior KW - lifestyle KW - counseling N2 - Background: Practice guidelines advocate combining pharmacotherapy with lifestyle counseling for patients with hypertension. To allow for appropriate tailoring of interventions to meet individual patient needs, a comprehensive understanding of baseline patient characteristics is essential. However, few studies have empirically assessed behavioral profiles of hypertensive patients in Web-based lifestyle counseling programs. Objective: The objectives of this study were to (1) specify baseline psychobehavioral profiles of patients with hypertension who were enrolled in a Web-based lifestyle counseling trial, and (2) examine mean differences among the identified profile groups in demographics, psychological distress, self-reported self-care behaviors, physiological outcomes, and program engagement to determine prognostic implications. Methods: Participants (N=264; mean age 57.5 years; 154/264, 58.3% female; 193/264, 73.1% white) were recruited into a longitudinal, double-blind, randomized controlled trial, designed to evaluate an online lifestyle intervention for hypertensive patients. A series of latent profile analyses identified psychobehavioral profiles, indicated by baseline measures of mood, motivation, and health behaviors. Mean differences between profile groups were then explored. Results: A 2-class solution provided the best model fit (the Bayesian information criterion (BIC) is 10,133.11; sample-size adjusted BIC is 10,006.54; Lo-Mendell-Rubin likelihood ratio test is 65.56, P=.001). The 2 profile groups were (1) adaptive adjustment, marked by low distress, high motivation, and somewhat satisfactory engagement in health behaviors and (2) affectively distressed, marked by clinically significant distress. At baseline, on average, affectively distressed patients had lower income, higher body mass index, and endorsed higher stress compared with their adaptive adjustment counterparts. At 12-months post intervention, treatment effects were sustained for systolic blood pressure and Framingham risk index in the adaptive adjustment group, and those in the adaptive adjustment group were 2.4 times more likely to complete the 12-month intervention study, compared with their affectively distressed counterparts. Conclusions: Interventions for patients who are adaptively adjusted may differ in focus from those designed for the affectively distressed patients. As such, this study underscores the importance of identifying psychobehavioral profiles, as they allow for evidence-based tailoring of lifestyle counseling programs for patients with hypertension. Trial Registration: ClinicalTrials.gov NCT01541540; https://clinicaltrials.gov/ct2/show/NCT01541540 (Archived by WebCite at http://www.webcitation.org/6yzZYZcWF) UR - http://www.jmir.org/2018/5/e149/ UR - http://dx.doi.org/10.2196/jmir.8757 UR - http://www.ncbi.nlm.nih.gov/pubmed/29752248 ID - info:doi/10.2196/jmir.8757 ER - TY - JOUR AU - Pramana, Gede AU - Parmanto, Bambang AU - Lomas, James AU - Lindhiem, Oliver AU - Kendall, C. Philip AU - Silk, Jennifer PY - 2018/05/10 TI - Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial JO - JMIR Serious Games SP - e9 VL - 6 IS - 2 KW - gamification KW - mobile health KW - ecological momentary intervention KW - cognitive behavioral therapy KW - child anxiety treatment KW - SmartCAT KW - childhood anxiety disorders N2 - Background: Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective: The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods: We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results: Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions: The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment. UR - http://games.jmir.org/2018/2/e9/ UR - http://dx.doi.org/10.2196/games.8902 UR - http://www.ncbi.nlm.nih.gov/pubmed/29748165 ID - info:doi/10.2196/games.8902 ER - TY - JOUR AU - Mehra, Sumit AU - Visser, Bart AU - Dadema, Tessa AU - van den Helder, Jantine AU - Engelbert, HH Raoul AU - Weijs, JM Peter AU - Kröse, JA Ben PY - 2018/05/02 TI - Translating Behavior Change Principles Into a Blended Exercise Intervention for Older Adults: Design Study JO - JMIR Res Protoc SP - e117 VL - 7 IS - 5 KW - frail elderly KW - aged KW - activities of daily living KW - exercise KW - telemedicine KW - remote consultation KW - mobile devices KW - tablet computers KW - behavior control KW - health behavior KW - treatment adherence and compliance N2 - Background: Physical activity can prevent or delay age-related impairments and prolong the ability of older adults to live independently. Community-based programs typically offer classes where older adults can exercise only once a week under the guidance of an instructor. The health benefits of such programs vary. Exercise frequency and the duration of the program play a key role in realizing effectiveness. An auxiliary home-based exercise program can provide older adults the opportunity to exercise more regularly over a prolonged period of time in the convenience of their own homes. Furthermore, mobile electronic devices can be used to motivate and remotely guide older adults to exercise in a safe manner. Such a blended intervention, where technology is combined with personal guidance, needs to incorporate behavior change principles to ensure effectiveness. Objective: The aim of this study was to identify theory-based components of a blended intervention that supports older adults to exercise at home. Methods: The Medical Research Council framework was used to develop the blended intervention. Insights from focus group, expert panels, and literature were combined into leading design considerations. Results: A client-server system had been developed that combined a tablet app with a database in the cloud and a Web-based dashboard that can be used by a personal coach to remotely monitor and guide older adults. The app contains several components that facilitate behavior change?an interactive module for goal setting, the ability to draw up a personal training schedule from a library containing over 50 exercise videos, progress monitoring, and possibilities to receive remote feedback and guidance of a personal coach. Conclusions: An evidence-based blended intervention was designed to promote physical activity among older adults. The underlying design choices were underpinned by behavior change techniques that are rooted in self-regulation. Key components of the tablet-supported intervention were a tailored program that accommodates individual needs, demonstrations of functional exercises, monitoring, and remote feedback. The blended approach combines the convenience of a home-based exercise program for older adults with the strengths of mobile health and personal guidance. UR - http://www.researchprotocols.org/2018/5/e117/ UR - http://dx.doi.org/10.2196/resprot.9244 UR - http://www.ncbi.nlm.nih.gov/pubmed/29720358 ID - info:doi/10.2196/resprot.9244 ER - TY - JOUR AU - Duff, Orlaith AU - Walsh, Deirdre AU - Malone, Shauna AU - McDermott, Lauri AU - Furlong, Brona AU - O'Connor, Noel AU - Moran, Kieran AU - Woods, Catherine PY - 2018/04/27 TI - MedFit App, a Behavior-Changing, Theoretically Informed Mobile App for Patient Self-Management of Cardiovascular Disease: User-Centered Development JO - JMIR Formativ Res SP - e8 VL - 2 IS - 1 KW - app development KW - cardiac rehabilitation KW - telemedicine KW - exercise KW - mHealth KW - focus groups KW - usability testing N2 - Background: The MedFit app is designed to facilitate participation of people with cardiovascular disease (CVD) in an exercise-based rehabilitation program remotely. This paper details the development for the MedFit app. Objective: The aim of this research was to develop a behavior change, theoretically informed exercise rehabilitation mobile app for adults with CVD by following the early stages of the formative research: development and feasibility testing. Methods: Adhering to the mobile health (mHealth) development evaluation framework, the stages of the formative research process including (1) development and (2) feasibility were undertaken. The content and format of the MedFit app were developed based on (1) theory, (2) usability testing, and (3) content design. Results: A systematic review of the literature was undertaken to identify the most appropriate theories from which to develop the app. This led to the creation of the MedFit app. The app went through iterative rounds of usability focus group testing with adults with CVD to provide feedback on the app. This process was framed by the unified theory of acceptance and use of technology model. Feedback was then translated into feasible technical improvements to be executed through close collaboration with the technical team, who adapted and made modifications to the app based on this codesign process. Conclusions: The formative research process of the app development involved theoretical underpinning, usability testing, and content design. mHealth interventions may play a key role in the future of health care, potentially addressing the barriers to participation in cardiac rehabilitation. This work will provide guidance for future research aiming to develop mobile apps by incorporating a best practice framework for mHealth intervention development and a user-centered design approach. UR - http://formative.jmir.org/2018/1/e8/ UR - http://dx.doi.org/10.2196/formative.9550 UR - http://www.ncbi.nlm.nih.gov/pubmed/30684426 ID - info:doi/10.2196/formative.9550 ER - TY - JOUR AU - Rozental, Alexander AU - Shafran, Roz AU - Wade, D. Tracey AU - Kothari, Radha AU - Egan, J. Sarah AU - Ekberg, Linda AU - Wiss, Maria AU - Carlbring, Per AU - Andersson, Gerhard PY - 2018/04/26 TI - Guided Web-Based Cognitive Behavior Therapy for Perfectionism: Results From Two Different Randomized Controlled Trials JO - J Med Internet Res SP - e154 VL - 20 IS - 4 KW - cognitive behavior therapy KW - internet KW - perfectionism KW - follow-up studies KW - cognitive therapy N2 - Background: Perfectionism can become a debilitating condition that may negatively affect functioning in multiple areas, including mental health. Prior research has indicated that internet-based cognitive behavioral therapy can be beneficial, but few studies have included follow-up data. Objective: The objective of this study was to explore the outcomes at follow-up of internet-based cognitive behavioral therapy with guided self-help, delivered as 2 separate randomized controlled trials conducted in Sweden and the United Kingdom. Methods: In total, 120 participants randomly assigned to internet-based cognitive behavioral therapy were included in both intention-to-treat and completer analyses: 78 in the Swedish trial and 62 in the UK trial. The primary outcome measure was the Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the 9-item Patient Health Questionnaire (PHQ-9; Swedish trial), the 7-item Generalized Anxiety Disorder scale (GAD-7; Swedish trial), and the 21-item Depression Anxiety Stress Scale (DASS-21; UK trial). Follow-up occurred after 6 months for the UK trial and after 12 months for the Swedish trial. Results: Analysis of covariance revealed a significant difference between pretreatment and follow-up in both studies. Intention-to-treat within-group Cohen d effect sizes were 1.21 (Swedish trial; 95% CI 0.86-1.54) and 1.24 (UK trial; 95% CI 0.85-1.62) for the FMPS CM. Furthermore, 29 (59%; Swedish trial) and 15 (43%; UK trial) of the participants met the criteria for recovery on the FMPS CM. Improvements were also significant for the CPQ, with effect sizes of 1.32 (Swedish trial; 95% CI 0.97-1.66) and 1.49 (UK trial; 95% CI 1.09-1.88); the PHQ-9, effect size 0.60 (95% CI 0.28-0.92); the GAD-7, effect size 0.67 (95% CI 0.34-0.99); and the DASS-21, effect size 0.50 (95% CI 0.13-0.85). Conclusions: The results are promising for the use of internet-based cognitive behavioral therapy as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition. UR - http://www.jmir.org/2018/4/e154/ UR - http://dx.doi.org/10.2196/jmir.9823 UR - http://www.ncbi.nlm.nih.gov/pubmed/29699968 ID - info:doi/10.2196/jmir.9823 ER - TY - JOUR AU - Tudor-Sfetea, Carina AU - Rabee, Riham AU - Najim, Muhammad AU - Amin, Nima AU - Chadha, Mehak AU - Jain, Minal AU - Karia, Kishan AU - Kothari, Varun AU - Patel, Tejus AU - Suseeharan, Melanie AU - Ahmed, Maroof AU - Sherwani, Yusuf AU - Siddiqui, Sarim AU - Lin, Yuting AU - Eisingerich, B. Andreas PY - 2018/04/18 TI - Evaluation of Two Mobile Health Apps in the Context of Smoking Cessation: Qualitative Study of Cognitive Behavioral Therapy (CBT) Versus Non-CBT-Based Digital Solutions JO - JMIR Mhealth Uhealth SP - e98 VL - 6 IS - 4 KW - smoking cessation KW - mHealth KW - mobile health KW - health behavior change KW - cognitive behavioral therapy KW - public health KW - health policy N2 - Background: Mobile health (mHealth) apps can offer users numerous benefits, representing a feasible and acceptable means of administering health interventions such as cognitive behavioral therapy (CBT). CBT is commonly used in the treatment of mental health conditions, where it has a strong evidence base, suggesting that it represents an effective method to elicit health behavior change. More importantly, CBT has proved to be effective in smoking cessation, in the context of smoking-related costs to the National Health Service (NHS) having been estimated to be as high as £2.6bn in 2015. Although the evidence base for computerized CBT in mental health is strong, there is limited literature on its use in smoking cessation. This, combined with the cost-effectiveness of mHealth interventions, advocates a need for research into the effectiveness of CBT-based smoking cessation apps. Objective: The objective of this study was, first, to explore participants? perceptions of 2 mHealth apps, a CBT-based app, Quit Genius, and a non-CBT-based app, NHS Smokefree, over a variety of themes. Second, the study aimed to investigate the perceptions and health behavior of users of each app with respect to smoking cessation. Methods: A qualitative short-term longitudinal study was conducted, using a sample of 29 smokers allocated to one of the 2 apps, Quit Genius or Smokefree. Each user underwent 2 one-to-one semistructured interviews, 1 week apart. Thematic analysis was carried out, and important themes were identified. Descriptive statistics regarding participants? perceptions and health behavior in relation to smoking cessation are also provided. Results: The thematic analysis resulted in five higher themes and several subthemes. Participants were generally more positive about Quit Genius?s features, as well as about its design and information engagement and quality. Quit Genius users reported increased motivation to quit smoking, as well as greater willingness to continue using their allocated app after 1 week. Moreover, these participants demonstrated preliminary changes in their smoking behavior, although this was in the context of our limited sample, not yet allowing for the finding to be generalizable. Conclusions: Our findings underscore the use of CBT in the context of mHealth apps as a feasible and potentially effective smoking cessation tool. mHealth apps must be well developed, preferably with an underlying behavioral change mechanism, to promote positive health behavior change. Digital CBT has the potential to become a powerful tool in overcoming current health care challenges. The present results should be replicated in a wider sample using the apps for a longer period so as to allow for generalizability. Further research is also needed to focus on the effect of greater personalization on behavioral change and on understanding the psychological barriers to the adoption of new mHealth solutions. UR - http://mhealth.jmir.org/2018/4/e98/ UR - http://dx.doi.org/10.2196/mhealth.9405 UR - http://www.ncbi.nlm.nih.gov/pubmed/29669708 ID - info:doi/10.2196/mhealth.9405 ER - TY - JOUR AU - Chiang, Nicole AU - Guo, Michael AU - Amico, Rivet K. AU - Atkins, Lou AU - Lester, T. Richard PY - 2018/04/12 TI - Interactive Two-Way mHealth Interventions for Improving Medication Adherence: An Evaluation Using The Behaviour Change Wheel Framework JO - JMIR Mhealth Uhealth SP - e87 VL - 6 IS - 4 KW - mHealth KW - chronic disease KW - medication adherence KW - primary health care KW - disease management N2 - Background: Medication adherence is an important but highly complex set of behaviors, which for life-threatening and infectious diseases such as HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, particularly two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. However, mechanisms of action have not been well defined. The Behavior Change Wheel is a comprehensive framework for behavior change that includes an all-encompassing model of behavior known as Capability Opportunity Motivation-Behavior and is complemented by a taxonomy of behavior change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up. Objective: This study aimed to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the Behavior Change Wheel to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy. Methods: To characterize how WelTel may promote medication adherence, we applied the Behavior Change Wheel to systematically (1) generate a behavioral diagnosis through mapping known antiretroviral therapy adherence barriers onto the Capability Opportunity Motivation-Behavior model of behavior, (2) specify the behavior change techniques that WelTel delivers, (3) link identified behavior change techniques to corresponding intervention functions of the Behavior Change Wheel, and (4) connect these behavior change techniques and intervention functions to respective Capability Opportunity Motivation-Behavior influences on behavior to determine potential mechanisms of action. Results: Our evaluation of WelTel using the Behavior Change Wheel suggests that most of its impact is delivered primarily through its personalized communication component, in which 8 different behavior change techniques were identified and linked with 5 intervention functions (environmental restructuring, enablement, education, persuasion, and training). Its mechanisms of action in promoting antiretroviral therapy adherence may involve addressing all Capability Opportunity Motivation-Behavior influences on behavior (physical and psychological capability, physical and social opportunity, reflective and automatic motivation). Conclusions: Systematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored, and targeted approaches. Evaluating WelTel using the Behavior Change Wheel has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both nonintentional and intentional forms of nonadherence. The application of the Behavior Change Wheel for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behavior. UR - http://mhealth.jmir.org/2018/4/e87/ UR - http://dx.doi.org/10.2196/mhealth.9187 UR - http://www.ncbi.nlm.nih.gov/pubmed/29650504 ID - info:doi/10.2196/mhealth.9187 ER - TY - JOUR AU - Santarossa, Sara AU - Kane, Deborah AU - Senn, Y. Charlene AU - Woodruff, J. Sarah PY - 2018/04/11 TI - Exploring the Role of In-Person Components for Online Health Behavior Change Interventions: Can a Digital Person-to-Person Component Suffice? JO - J Med Internet Res SP - e144 VL - 20 IS - 4 KW - digital person-to-person KW - in-person KW - online intervention KW - behavior change KW - health, digital media KW - health care UR - http://www.jmir.org/2018/4/e144/ UR - http://dx.doi.org/10.2196/jmir.8480 UR - http://www.ncbi.nlm.nih.gov/pubmed/29643048 ID - info:doi/10.2196/jmir.8480 ER - TY - JOUR AU - Macready, L. Anna AU - Fallaize, Rosalind AU - Butler, T. Laurie AU - Ellis, A. Judi AU - Kuznesof, Sharron AU - Frewer, J. Lynn AU - Celis-Morales, Carlos AU - Livingstone, M. Katherine AU - Araújo-Soares, Vera AU - Fischer, RH Arnout AU - Stewart-Knox, J. Barbara AU - Mathers, C. John AU - Lovegrove, A. Julie PY - 2018/04/09 TI - Application of Behavior Change Techniques in a Personalized Nutrition Electronic Health Intervention Study: Protocol for the Web-Based Food4Me Randomized Controlled Trial JO - JMIR Res Protoc SP - e87 VL - 7 IS - 4 KW - behavior KW - behavior change technique KW - personalized nutrition KW - dietary management KW - nutrition KW - health KW - Web-based N2 - Background: To determine the efficacy of behavior change techniques applied in dietary and physical activity intervention studies, it is first necessary to record and describe techniques that have been used during such interventions. Published frameworks used in dietary and smoking cessation interventions undergo continuous development, and most are not adapted for Web-based delivery. The Food4Me study (N=1607) provided the opportunity to use existing frameworks to describe standardized Web-based techniques employed in a large-scale, internet-based intervention to change dietary behavior and physical activity. Objective: The aims of this study were (1) to describe techniques embedded in the Food4Me study design and explain the selection rationale and (2) to demonstrate the use of behavior change technique taxonomies, develop standard operating procedures for training, and identify strengths and limitations of the Food4Me framework that will inform its use in future studies. Methods: The 6-month randomized controlled trial took place simultaneously in seven European countries, with participants receiving one of four levels of personalized advice (generalized, intake-based, intake+phenotype?based, and intake+phenotype+gene?based). A three-phase approach was taken: (1) existing taxonomies were reviewed and techniques were identified a priori for possible inclusion in the Food4Me study, (2) a standard operating procedure was developed to maintain consistency in the use of methods and techniques across research centers, and (3) the Food4Me behavior change technique framework was reviewed and updated post intervention. An analysis of excluded techniques was also conducted. Results: Of 46 techniques identified a priori as being applicable to Food4Me, 17 were embedded in the intervention design; 11 were from a dietary taxonomy, and 6 from a smoking cessation taxonomy. In addition, the four-category smoking cessation framework structure was adopted for clarity of communication. Smoking cessation texts were adapted for dietary use where necessary. A posteriori, a further 9 techniques were included. Examination of excluded items highlighted the distinction between techniques considered appropriate for face-to-face versus internet-based delivery. Conclusions: The use of existing taxonomies facilitated the description and standardization of techniques used in Food4Me. We recommend that for complex studies of this nature, technique analysis should be conducted a priori to develop standardized procedures and training and reviewed a posteriori to audit the techniques actually adopted. The present framework description makes a valuable contribution to future systematic reviews and meta-analyses that explore technique efficacy and underlying psychological constructs. This was a novel application of the behavior change taxonomies and was the first internet-based personalized nutrition intervention to use such a framework remotely. Trial Registration: ClinicalTrials.gov NCT01530139; https://clinicaltrials.gov/ct2/show/NCT01530139 (Archived by WebCite at http://www.webcitation.org/6y8XYUft1) UR - http://www.researchprotocols.org/2018/4/e87/ UR - http://dx.doi.org/10.2196/resprot.8703 UR - http://www.ncbi.nlm.nih.gov/pubmed/29631993 ID - info:doi/10.2196/resprot.8703 ER - TY - JOUR AU - Schembre, M. Susan AU - Liao, Yue AU - Robertson, C. Michael AU - Dunton, Fridlund Genevieve AU - Kerr, Jacqueline AU - Haffey, E. Meghan AU - Burnett, Taylor AU - Basen-Engquist, Karen AU - Hicklen, S. Rachel PY - 2018/03/22 TI - Just-in-Time Feedback in Diet and Physical Activity Interventions: Systematic Review and Practical Design Framework JO - J Med Internet Res SP - e106 VL - 20 IS - 3 KW - health behavior KW - diet KW - exercise KW - task performance and analysis KW - Internet KW - mHealth KW - accelerometer KW - activity monitor KW - self-tracking KW - wearable sensors N2 - Background: The integration of body-worn sensors with mobile devices presents a tremendous opportunity to improve just-in-time behavioral interventions by enhancing bidirectional communication between investigators and their participants. This approach can be used to deliver supportive feedback at critical moments to optimize the attainment of health behavior goals. Objective: The goals of this systematic review were to summarize data on the content characteristics of feedback messaging used in diet and physical activity (PA) interventions and to develop a practical framework for designing just-in-time feedback for behavioral interventions. Methods: Interventions that included just-in-time feedback on PA, sedentary behavior, or dietary intake were eligible for inclusion. Feedback content and efficacy data were synthesized descriptively. Results: The review included 31 studies (15/31, 48%, targeting PA or sedentary behavior only; 13/31, 42%, targeting diet and PA; and 3/31, 10%, targeting diet only). All studies used just-in-time feedback, 30 (97%, 30/31) used personalized feedback, and 24 (78%, 24/31) used goal-oriented feedback, but only 5 (16%, 5/31) used actionable feedback. Of the 9 studies that tested the efficacy of providing feedback to promote behavior change, 4 reported significant improvements in health behavior. In 3 of these 4 studies, feedback was continuously available, goal-oriented, or actionable. Conclusions: Feedback that was continuously available, personalized, and actionable relative to a known behavioral objective was prominent in intervention studies with significant behavior change outcomes. Future research should determine whether all or some of these characteristics are needed to optimize the effect of feedback in just-in-time interventions. UR - http://www.jmir.org/2018/3/e106/ UR - http://dx.doi.org/10.2196/jmir.8701 UR - http://www.ncbi.nlm.nih.gov/pubmed/29567638 ID - info:doi/10.2196/jmir.8701 ER - TY - JOUR AU - Bondaronek, Paulina AU - Alkhaldi, Ghadah AU - Slee, April AU - Hamilton, L. Fiona AU - Murray, Elizabeth PY - 2018/03/21 TI - Quality of Publicly Available Physical Activity Apps: Review and Content Analysis JO - JMIR Mhealth Uhealth SP - e53 VL - 6 IS - 3 KW - exercise KW - health behavior KW - mobile applications KW - health promotion KW - mHealth KW - eHealth review N2 - Background: Within the new digital health landscape, the rise of health apps creates novel prospects for health promotion. The market is saturated with apps that aim to increase physical activity (PA). Despite the wide distribution and popularity of PA apps, there are limited data on their effectiveness, user experience, and safety of personal data. Objective: The purpose of this review and content analysis was to evaluate the quality of the most popular PA apps on the market using health care quality indicators. Methods: The top-ranked 400 free and paid apps from iTunes and Google Play stores were screened. Apps were included if the primary behavior targeted was PA, targeted users were adults, and the apps had stand-alone functionality. The apps were downloaded on mobile phones and assessed by 2 reviewers against the following quality assessment criteria: (1) users? data privacy and security, (2) presence of behavior change techniques (BCTs) and quality of the development and evaluation processes, and (3) user ratings and usability. Results: Out of 400 apps, 156 met the inclusion criteria, of which 65 apps were randomly selected to be downloaded and assessed. Almost 30% apps (19/65) did not have privacy policy. Every app contained at least one BCT, with an average number of 7 and a maximum of 13 BCTs. All but one app had commercial affiliation, 12 consulted an expert, and none reported involving users in the app development. Only 12 of 65 apps had a peer-reviewed study connected to the app. User ratings were high, with only a quarter of the ratings falling below 4 stars. The median usability score was excellent?86.3 out of 100. Conclusions: Despite the popularity of PA apps available on the commercial market, there were substantial shortcomings in the areas of data safety and likelihood of effectiveness of the apps assessed. The limited quality of the apps may represent a missed opportunity for PA promotion. UR - http://mhealth.jmir.org/2018/3/e53/ UR - http://dx.doi.org/10.2196/mhealth.9069 UR - http://www.ncbi.nlm.nih.gov/pubmed/29563080 ID - info:doi/10.2196/mhealth.9069 ER - TY - JOUR AU - König, M. Laura AU - Sproesser, Gudrun AU - Schupp, T. Harald AU - Renner, Britta PY - 2018/03/13 TI - Describing the Process of Adopting Nutrition and Fitness Apps: Behavior Stage Model Approach JO - JMIR Mhealth Uhealth SP - e55 VL - 6 IS - 3 KW - mHealth KW - eating KW - physical activity KW - exercise KW - smartphone KW - mobile applications KW - health promotion N2 - Background: Although mobile technologies such as smartphone apps are promising means for motivating people to adopt a healthier lifestyle (mHealth apps), previous studies have shown low adoption and continued use rates. Developing the means to address this issue requires further understanding of mHealth app nonusers and adoption processes. This study utilized a stage model approach based on the Precaution Adoption Process Model (PAPM), which proposes that people pass through qualitatively different motivational stages when adopting a behavior. Objective: To establish a better understanding of between-stage transitions during app adoption, this study aimed to investigate the adoption process of nutrition and fitness app usage, and the sociodemographic and behavioral characteristics and decision-making style preferences of people at different adoption stages. Methods: Participants (N=1236) were recruited onsite within the cohort study Konstanz Life Study. Use of mobile devices and nutrition and fitness apps, 5 behavior adoption stages of using nutrition and fitness apps, preference for intuition and deliberation in eating decision-making (E-PID), healthy eating style, sociodemographic variables, and body mass index (BMI) were assessed. Results: Analysis of the 5 behavior adoption stages showed that stage 1 (?unengaged?) was the most prevalent motivational stage for both nutrition and fitness app use, with half of the participants stating that they had never thought about using a nutrition app (52.41%, 533/1017), whereas less than one-third stated they had never thought about using a fitness app (29.25%, 301/1029). ?Unengaged? nonusers (stage 1) showed a higher preference for an intuitive decision-making style when making eating decisions, whereas those who were already ?acting? (stage 4) showed a greater preference for a deliberative decision-making style (F4,1012=21.83, P<.001). Furthermore, participants differed widely in their readiness to adopt nutrition and fitness apps, ranging from having ?decided to? but not yet begun to act (stage 2; nutrition: 6.88%, 70/1017; fitness: 9.23%, 95/1029) to being ?disengaged? following previous adoption (stage 5; nutrition: 13.77%, 140/1017; fitness: 15.06%, 155/1029). Conclusions: Using a behavior stage model approach to describe the process of adopting nutrition and fitness apps revealed motivational stage differences between nonusers (being ?unengaged,? having ?decided not to act,? having ?decided to act,? and being ?disengaged?), which might contribute to a better understanding of the process of adopting mHealth apps and thus inform the future development of digital interventions. This study highlights that new user groups might be better reached by apps designed to address a more intuitive decision-making style. UR - http://mhealth.jmir.org/2018/3/e55/ UR - http://dx.doi.org/10.2196/mhealth.8261 UR - http://www.ncbi.nlm.nih.gov/pubmed/29535078 ID - info:doi/10.2196/mhealth.8261 ER - TY - JOUR AU - Elaheebocus, Ally Sheik Mohammad Roushdat AU - Weal, Mark AU - Morrison, Leanne AU - Yardley, Lucy PY - 2018/02/22 TI - Peer-Based Social Media Features in Behavior Change Interventions: Systematic Review JO - J Med Internet Res SP - e20 VL - 20 IS - 2 KW - systematic review KW - social media KW - behavior control KW - health behavior KW - behavioral medicine KW - eHealth N2 - Background: Incorporating social media features into digital behavior change interventions (DBCIs) has the potential to contribute positively to their success. However, the lack of clear design principles to describe and guide the use of these features in behavioral interventions limits cross-study comparisons of their uses and effects. Objective: The aim of this study was to provide a systematic review of DBCIs targeting modifiable behavioral risk factors that have included social media features as part of their intervention infrastructure. A taxonomy of social media features is presented to inform the development, description, and evaluation of behavioral interventions. Methods: Search terms were used in 8 databases to identify DBCIs that incorporated social media features and targeted tobacco smoking, diet and nutrition, physical activities, or alcohol consumption. The screening and review process was performed by 2 independent researchers. Results: A total of 5264 articles were screened, and 143 articles describing a total of 134 studies were retained for full review. The majority of studies (70%) reported positive outcomes, followed by 28% finding no effects with regard to their respective objectives and hypothesis, and 2% of the studies found that their interventions had negative outcomes. Few studies reported on the association between the inclusion of social media features and intervention effect. A taxonomy of social media features used in behavioral interventions has been presented with 36 social media features organized under 7 high-level categories. The taxonomy has been used to guide the analysis of this review. Conclusions: Although social media features are commonly included in DBCIs, there is an acute lack of information with respect to their effect on outcomes and a lack of clear guidance to inform the selection process based on the features? suitability for the different behaviors. The proposed taxonomy along with the set of recommendations included in this review will support future research aimed at isolating and reporting the effects of social media features on DBCIs, cross-study comparisons, and evaluations. UR - http://www.jmir.org/2018/2/e20/ UR - http://dx.doi.org/10.2196/jmir.8342 UR - http://www.ncbi.nlm.nih.gov/pubmed/29472174 ID - info:doi/10.2196/jmir.8342 ER - TY - JOUR AU - Yom-Tov, Elad AU - Brunstein-Klomek, Anat AU - Mandel, Or AU - Hadas, Arie AU - Fennig, Silvana PY - 2018/02/22 TI - Inducing Behavioral Change in Seekers of Pro-Anorexia Content Using Internet Advertisements: Randomized Controlled Trial JO - JMIR Ment Health SP - e6 VL - 5 IS - 1 KW - anorexia nervosa KW - bulimia nervosa KW - eating disorders KW - online advertising KW - online behavior KW - Pro-ana N2 - Background: The influence of pro-anorexia (pro-ana) websites is debated, with studies indicating both negative and positive effects, as well as significant variation in the effects of different websites for those suffering from eating disorders (EDs) and the general population. Online advertising, known to induce behavioral change both online and in the physical world, has not been used so far to modify the search behavior of people seeking pro-ana content. Objective: The objective of this randomized controlled trial (RCT) was to examine if online advertisements (ads) can change online search behaviors of users who are looking for online pro-ana content. Methods: Using the Bing Ads system, we conducted an RCT to randomly expose the searchers for pro-ana content to 10 different ads referring people to one of the three websites: the National Eating Disorders Association, the National Institutes of Mental Health, and MyProAna. MyProAna is a pro-ana website that was found in a previous study to be associated with less pathological online behaviors than other pro-ana websites. We followed participants exposed and unexposed to the ads to explore their past and future online searches. The ads were shown 25,554 times and clicked on 217 times. Results: Exposure to the ads was associated with a decrease in searches for pro-ana and self-harm content. Reductions were greatest among those referred to MyProAna (reduction of 34.0% [73/215] and 37.2% [80/215] for pro-ana and self-harm, respectively) compared with users who were referred elsewhere (reduction of 15.47% [410/2650] and 3.21% [85/2650], respectively), and with users who were not shown the ads, who increased their behaviors (increase of 57.12% [6462/11,314] and 4.07% [461/11,314], respectively). In addition, those referred to MyProAna increased their search for treatment, as did control users, who did so to a lesser extent. However, users referred elsewhere decreased their searches for this content. Conclusions: We found that referring users interested in ED-related content to specific pro-ana communities might lessen their maladaptive online search behavior. This suggests that those who are preoccupied with EDs can be redirected to less pathological online searches through appropriate pathways. Trial Registration: ClinicalTrials.gov NCT03439553; https://clinicaltrials.gov/show/NCT03439553 (Archived by WebCite at http://www.webcitation.org/6xNYnxYlw) UR - http://mental.jmir.org/2018/1/e6/ UR - http://dx.doi.org/10.2196/mental.8212 UR - http://www.ncbi.nlm.nih.gov/pubmed/29472176 ID - info:doi/10.2196/mental.8212 ER - TY - JOUR AU - Marcolino, Soriano Milena AU - Oliveira, Queiroz João Antonio AU - D'Agostino, Marcelo AU - Ribeiro, Luiz Antonio AU - Alkmim, Moreira Maria Beatriz AU - Novillo-Ortiz, David PY - 2018/01/17 TI - The Impact of mHealth Interventions: Systematic Review of Systematic Reviews JO - JMIR Mhealth Uhealth SP - e23 VL - 6 IS - 1 KW - telemedicine KW - medical informatics KW - mobile phones N2 - Background: Mobile phone usage has been rapidly increasing worldwide. mHealth could efficiently deliver high-quality health care, but the evidence supporting its current effectiveness is still mixed. Objective: We performed a systematic review of systematic reviews to assess the impact or effectiveness of mobile health (mHealth) interventions in different health conditions and in the processes of health care service delivery. Methods: We used a common search strategy of five major scientific databases, restricting the search by publication date, language, and parameters in methodology and content. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews (AMSTAR) checklist. Results: The searches resulted in a total of 10,689 articles. Of these, 23 systematic reviews (371 studies; more than 79,665 patients) were included. Seventeen reviews included studies performed in low- and middle-income countries. The studies used diverse mHealth interventions, most frequently text messaging (short message service, SMS) applied to different purposes (reminder, alert, education, motivation, prevention). Ten reviews were rated as low quality (AMSTAR score 0-4), seven were rated as moderate quality (AMSTAR score 5-8), and six were categorized as high quality (AMSTAR score 9-11). A beneficial impact of mHealth was observed in chronic disease management, showing improvement in symptoms and peak flow variability in asthma patients, reducing hospitalizations and improving forced expiratory volume in 1 second; improving chronic pulmonary diseases symptoms; improving heart failure symptoms, reducing deaths and hospitalization; improving glycemic control in diabetes patients; improving blood pressure in hypertensive patients; and reducing weight in overweight and obese patients. Studies also showed a positive impact of SMS reminders in improving attendance rates, with a similar impact to phone call reminders at reduced cost, and improved adherence to tuberculosis and human immunodeficiency virus therapy in some scenarios, with evidence of decrease of viral load. Conclusions: Although mHealth is growing in popularity, the evidence for efficacy is still limited. In general, the methodological quality of the studies included in the systematic reviews is low. For some fields, its impact is not evident, the results are mixed, or no long-term studies exist. Exceptions include the moderate quality evidence of improvement in asthma patients, attendance rates, and increased smoking abstinence rates. Most studies were performed in high-income countries, implying that mHealth is still at an early stage of development in low-income countries. UR - http://mhealth.jmir.org/2018/1/e23/ UR - http://dx.doi.org/10.2196/mhealth.8873 UR - http://www.ncbi.nlm.nih.gov/pubmed/29343463 ID - info:doi/10.2196/mhealth.8873 ER - TY - JOUR AU - Furukawa, A. Toshi AU - Horikoshi, Masaru AU - Fujita, Hirokazu AU - Tsujino, Naohisa AU - Jinnin, Ran AU - Kako, Yuki AU - Ogawa, Sei AU - Sato, Hirotoshi AU - Kitagawa, Nobuki AU - Shinagawa, Yoshihiro AU - Ikeda, Yoshio AU - Imai, Hissei AU - Tajika, Aran AU - Ogawa, Yusuke AU - Akechi, Tatsuo AU - Yamada, Mitsuhiko AU - Shimodera, Shinji AU - Watanabe, Norio AU - Inagaki, Masatoshi AU - Hasegawa, Akio PY - 2018/01/11 TI - Cognitive and Behavioral Skills Exercises Completed by Patients with Major Depression During Smartphone Cognitive Behavioral Therapy: Secondary Analysis of a Randomized Controlled Trial JO - JMIR Ment Health SP - e4 VL - 5 IS - 1 KW - major depressive disorder KW - smartphone KW - cognitive therapy KW - telemedicine N2 - Background: A strong and growing body of evidence has demonstrated the effectiveness of cognitive behavioral therapy (CBT), either face-to-face, in person, or as self-help via the Internet, for depression. However, CBT is a complex intervention consisting of several putatively effective components, and how each component may or may not contribute to the overall effectiveness of CBT is poorly understood. Objective: The aim of this study was to investigate how the users of smartphone CBT use and benefit from various components of the program. Methods: This is a secondary analysis from a 9-week, single-blind, randomized controlled trial that has demonstrated the effectiveness of adjunctive use of smartphone CBT (Kokoro-App) over antidepressant pharmacotherapy alone among patients with drug-resistant major depressive disorder (total n=164, standardized mean difference in depression severity at week 9=0.40, J Med Internet Res). Kokoro-App consists of three cognitive behavioral skills of self-monitoring, behavioral activation, and cognitive restructuring, with corresponding worksheets to fill in. All activities of the participants learning each session of the program and completing each worksheet were uploaded onto Kokoro-Web, which each patient could use for self-check. We examined what use characteristics differentiated the more successful users of the CBT app from the less successful ones, split at the median of change in depression severity. Results: A total of 81 patients with major depression were allocated to the smartphone CBT. On average, they completed 7.0 (standard deviation [SD] 1.4) out of 8 sessions of the program; it took them 10.8 (SD 4.2) days to complete one session, during which they spent 62 min (SD 96) on the app. There were no statistically significant differences in the number of sessions completed, time spent for the program, or the number of completed self-monitoring worksheets between the beneficiaries and the nonbeneficiaries. However, the former completed more behavioral activation tasks, engaged in different types of activities, and also filled in more cognitive restructuring worksheets than the latter. Activities such as ?test-drive a new car,? ?go to a coffee shop after lunch,? or ?call up an old friend? were found to be particularly rewarding. All cognitive restructuring strategies were found to significantly decrease the distress level, with ?What would be your advice to a friend who has a similar problem?? found more helpful than some other strategies. Conclusions: The CBT program offered via smartphone and connected to the remote server is not only effective in alleviating depression but also opens a new avenue in gathering information of what and how each participant may utilize the program. The activities and strategies found useful in this analysis will provide valuable information in brush-ups of the program itself and of mobile health (mHealth) in general. Trial Registration: Japanese Clinical Trials Registry UMIN CTR 000013693; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ ctr_view.cgi?recptno=R000015984 (Archived by WebCite at http://www.webcitation.org/6u6pxVwik) UR - http://mental.jmir.org/2018/1/e4/ UR - http://dx.doi.org/10.2196/mental.9092 UR - http://www.ncbi.nlm.nih.gov/pubmed/29326098 ID - info:doi/10.2196/mental.9092 ER - TY - JOUR AU - Baron, Glazer Kelly AU - Duffecy, Jennifer AU - Reid, Kathryn AU - Begale, Mark AU - Caccamo, Lauren PY - 2018/01/10 TI - Technology-Assisted Behavioral Intervention to Extend Sleep Duration: Development and Design of the Sleep Bunny Mobile App JO - JMIR Ment Health SP - e3 VL - 5 IS - 1 KW - sleep duration KW - wearable KW - obesity KW - technology KW - behavioral intervention N2 - Background: Despite the high prevalence of short sleep duration (29.2% of adults sleep <6 hours on weekdays), there are no existing theory-based behavioral interventions to extend sleep duration. The popularity of wearable sleep trackers provides an opportunity to engage users in interventions. Objective: The objective of this study was to outline the theoretical foundation and iterative process of designing the ?Sleep Bunny,? a technology-assisted sleep extension intervention including a mobile phone app, wearable sleep tracker, and brief telephone coaching. We conducted a two-step process in the development of this intervention, which was as follows: (1) user testing of the app and (2) a field trial that was completed by 2 participants with short sleep duration and a cardiovascular disease risk factor linked to short sleep duration (body mass index [BMI] >25). Methods: All participants had habitual sleep duration <6.5 hours verified by 7 days of actigraphy. A total of 6 individuals completed initial user testing in the development phase, and 2 participants completed field testing. Participants in the user testing and field testing responded to open-ended surveys about the design and utility of the app. Participants in the field testing completed the Epworth Sleepiness Scale and also wore an actigraph for a 1-week baseline period and during the 4-week intervention period. Results: The feedback suggests that users enjoyed the wearable sleep tracker and found the app visually pleasing, but they suggested improvements to the notification and reminder features of the app. The 2 participants who completed the field test demonstrated significant improvements in sleep duration and daytime sleepiness. Conclusions: Further testing is needed to determine effects of this intervention in populations at risk for the mental and physical consequences of sleep loss. UR - http://mental.jmir.org/2018/1/e3/ UR - http://dx.doi.org/10.2196/mental.8634 UR - http://www.ncbi.nlm.nih.gov/pubmed/29321122 ID - info:doi/10.2196/mental.8634 ER - TY - JOUR AU - Gibson, Bryan AU - Yingling, Leah AU - Bednarchuk, Alisa AU - Janamatti, Ashwini AU - Oakley-Girvan, Ingrid AU - Allen, Nancy PY - 2018/01/09 TI - An Interactive Simulation to Change Outcome Expectancies and Intentions in Adults With Type 2 Diabetes: Within-Subjects Experiment JO - JMIR Diabetes SP - e2 VL - 3 IS - 1 KW - diabetes mellitus, type 2 KW - computer simulation KW - beliefs KW - intention N2 - Background: Computerized simulations are underutilized to educate or motivate patients with chronic disease. Objective: The aim of this study was to test the efficacy of an interactive, personalized simulation that demonstrates the acute effect of physical activity on blood glucose. Our goal was to test its effects on physical activity-related outcome expectancies and behavioral intentions among adults with type 2 diabetes mellitus (T2DM). Methods: In this within-subjects experiment, potential participants were emailed a link to the study website and directed through 7 tasks: (1) consent; (2) demographics, baseline intentions, and self-reported walking; (3) orientation to the diurnal glucose curve; (4) baseline outcome expectancy, measured by a novel drawing task in which participants use their mouse to draw the expected difference in the diurnal glucose curve if they had walked; (5) interactive simulation; (6) postsimulation outcome expectancy measured by a second drawing task; and (7) final measures of intentions and impressions of the website. To test our primary hypothesis that participants? outcome expectancies regarding walking would shift toward the outcome presented in the interactive simulation, we used a paired t test to compare the difference of differences between the change in area under the curve in the simulation and participants? two drawings. To test whether intentions to walk increased, we used paired t tests. To assess the intervention?s usability, we collected both quantitative and qualitative data on participants? perceptions of the drawing tasks and simulation. Results: A total of 2019 individuals visited the website and 1335 (566 males, 765 females, and 4 others) provided complete data. Participants were largely late middle-aged (mean=59.8 years; standard deviation=10.5), female 56.55% (755/1335), Caucasian 77.45% (1034/1335), lower income 64.04% (855/1335) t1334=3.4, P ?.001). Our second hypothesis, that participants? intentions to walk in the coming week would increase, was also supported; general intention (mean difference=0.31/7, t1001=10.8, P<.001) and minutes of walking last week versus planned for coming week (mean difference=33.5 min, t1334=13.2, P<.001) both increased. Finally, an examination of qualitative feedback and drawing task data suggested that some participants had difficulty understanding the website. This led to a post-hoc subset analysis. In this analysis, effects for our hypothesis regarding outcome expectancies were markedly stronger, suggesting that further work is needed to determine moderators of the efficacy of this simulation. Conclusions: A novel interactive simulation is efficacious in changing the outcome expectancies and behavioral intentions of adults with T2DM. We discuss applications of our results to the design of mobile health (mHealth) interventions. UR - http://diabetes.jmir.org/2018/1/e2/ UR - http://dx.doi.org/10.2196/diabetes.8069 UR - http://www.ncbi.nlm.nih.gov/pubmed/30291077 ID - info:doi/10.2196/diabetes.8069 ER - TY - JOUR AU - Young, D. Myles AU - Morgan, J. Philip PY - 2018/01/09 TI - Effect of a Gender-Tailored eHealth Weight Loss Program on the Depressive Symptoms of Overweight and Obese Men: Pre-Post Study JO - JMIR Ment Health SP - e1 VL - 5 IS - 1 KW - male KW - weight loss KW - depression KW - behavior change KW - obesity KW - gender-sensitive N2 - Background: Obesity and depression are of two of the largest contributors to the global burden of disease in men. Although lifestyle behavior change programs can improve participants? weight and depressive symptoms, the evidence is limited by a lack of male participants and a reliance on face-to-face treatment approaches, which are not accessible or appealing for many men. Objective: This study examined the effect of a gender-tailored electronic health (eHealth) program on the depressive symptoms of a community sample of overweight and obese men with or without depression. A secondary aim was to determine whether the eHealth, self-directed format of the program was a feasible and acceptable treatment approach for the subgroup of men with depression at baseline. Methods: In total, 209 overweight/obese men from the Hunter Region of Australia were assessed before and after completing a self-administered eHealth weight loss program over 3 months. To increase engagement, most program elements were socio-culturally targeted to appeal specifically to men and included printed materials, a DVD, motivational text messages, online- or app-based self-monitoring, and other weight loss tools (eg, pedometer). Depressive symptoms were measured with the validated 8-item Patient Health Questionnaire (PHQ-8). Program feasibility and acceptability were assessed with a process questionnaire plus recruitment and retention rates. Changes in depressive symptoms and weight were examined using intention-to-treat linear mixed models, adjusted for the centered baseline score and other covariates. Effect sizes were estimated with Cohen?s d. Results: At baseline, the mean weight and age of the sample was 105.7 kg (standard deviation [SD] 14.0) and 46.6 years (SD 11.3), respectively. Overall, 36 men (36/209, 17.2%) were experiencing depression (PHQ-8 score ?10). Retention rates were comparable between men with and without depression (32/36, 88.9% vs 145/173, 83.8%; P=.44). At posttest, depressive symptoms had reduced by 1.8 units (95% CI 1.3 to 2.3; P<.001; d=0.5) for the whole sample. These improvements were particularly notable in the subgroup of men with depression (-5.5 units; P<.001; d=1.0) and 72.2% (26/36) of this subgroup no longer met the criterion for depression at posttest. A corresponding, albeit smaller, intervention effect on depressive symptoms was also observed in men without depression (-1.0 units; P<.001; d=0.4). The overall intervention effect on weight was -4.7 kg (d=1.3), which did not vary significantly by depression status. Program acceptability, feasibility, and online engagement metrics were also comparable between men with and without depression. Conclusions: A gender-tailored eHealth lifestyle program generated short-term improvements in the mental health of overweight and obese men, particularly for men with depression at baseline. Despite receiving no personalized support, men with depression reported high levels of satisfaction and engagement with the program. As such, a longer-term controlled trial testing an adapted version of the program for this subgroup is warranted. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12612000749808; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=362575 (Archived by WebCite at http://www.webcitation.org/6wJvbRsNW) UR - http://mental.jmir.org/2018/1/e1/ UR - http://dx.doi.org/10.2196/mental.8920 UR - http://www.ncbi.nlm.nih.gov/pubmed/29317379 ID - info:doi/10.2196/mental.8920 ER - TY - JOUR AU - Kloek, Corelien AU - Bossen, Daniël AU - de Bakker, H. Dinny AU - Veenhof, Cindy AU - Dekker, Joost PY - 2017/12/21 TI - Blended Interventions to Change Behavior in Patients With Chronic Somatic Disorders: Systematic Review JO - J Med Internet Res SP - e418 VL - 19 IS - 12 KW - telemedicine KW - chronic disease KW - behavior N2 - Background: Blended behavior change interventions combine therapeutic guidance with online care. This new way of delivering health care is supposed to stimulate patients with chronic somatic disorders in taking an active role in their disease management. However, knowledge about the effectiveness of blended behavior change interventions and how they should be composed is scattered. Objective: This comprehensive systematic review aimed to provide an overview of characteristics and effectiveness of blended behavior change interventions for patients with chronic somatic disorders. Methods: We searched for randomized controlled trials published from 2000 to April 2017 in PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the Cochrane Collaboration tool. Study characteristics, intervention characteristics, and outcome data were extracted. Studies were sorted based on their comparison group. A best-evidence synthesis was conducted to summarize the effectiveness. Results: A total of 25 out of the 29 included studies were of high quality. Most studies (n=21; 72%) compared a blended intervention with no intervention. The majority of interventions focused on changing pain behavior (n=17; 59%), and the other interventions focused on lifestyle change (n=12; 41%). In addition, 26 studies (90%) focused on one type of behavior, whereas 3 studies (10%) focused on multiple behaviors. A total of 23 studies (79%) mentioned a theory as basis for the intervention. The therapeutic guidance in most studies (n=18; 62%) was non face-to-face by using email, phone, or videoconferencing, and in the other studies (partly), it was face-to-face (n=11; 38%). In 26 studies (90%), the online care was provided via a website, and in 3 studies (10%) via an app. In 22 studies (76%), the therapeutic guidance and online care were integrated instead of two separate aspects. A total of 26 outcome measures were included in the evidence synthesis comparing blended interventions with no intervention: for the coping strategy catastrophizing, we found strong evidence for a significant effect. In addition, 1 outcome measure was included in the evidence synthesis comparing blended interventions with face-to-face interventions, but no evidence for a significant effect was found. A total of 6 outcome measures were included in the evidence synthesis comparing blended interventions with online interventions, but no evidence for a significant effect was found. Conclusions: Blended behavior change interventions for patients with chronic somatic disorders show variety in the type of therapeutic guidance, the type of online care, and how these two delivery modes are integrated. The evidence of the effectiveness of blended interventions is inconsistent and nonsignificant for most outcome measures. Future research should focus on which type of blended intervention works for whom. UR - http://www.jmir.org/2017/12/e418/ UR - http://dx.doi.org/10.2196/jmir.8108 UR - http://www.ncbi.nlm.nih.gov/pubmed/29269338 ID - info:doi/10.2196/jmir.8108 ER - TY - JOUR AU - Frith, Emily AU - Loprinzi, Paul PY - 2017/12/08 TI - Can Facebook Reduce Perceived Anxiety Among College Students? Randomized Controlled Exercise Trial Using the Transtheoretical Model of Behavior Change JO - JMIR Ment Health SP - e50 VL - 4 IS - 4 KW - mental health KW - physical activity behavior change KW - social media N2 - Background: Recent studies suggest social media may be an attractive strategy to promote mental health and wellness. There remains a need to examine the utility for individually tailored wellness messages posted to social media sites such as Facebook to facilitate positive psychological outcomes. Objective: Our aim was to extend the growing body of evidence supporting the potential for social media to enhance mental health. We evaluated the influence of an 8-week social media intervention on anxiety in college students and examined the impact of dynamic (active) versus static (passive) Facebook content on physical activity behaviors. Methods: Participants in the static group (n=21) accessed a Facebook page featuring 96 statuses. Statuses were intended to engage cognitive processes followed by behavioral processes of change per the transtheoretical model of behavior change. Content posted on the static Facebook page was identical to the dynamic page; however, the static group viewed all 96 statuses on the first day of the study, while the dynamic group received only 1 to 2 of these status updates per day throughout the intervention. Anxiety was measured using the Overall Anxiety Severity and Impairment Scale (OASIS). Time spent engaging in physical activity was assessed using the International Physical Activity Questionnaire (IPAQ). Results: The OASIS change score for the dynamic Facebook group was statistically significant (P=.003), whereas the change score for the static group was not (P=.48). A statistically significant group-by-time interaction was observed (P=.03). The total IPAQ group-by-time interaction was not statistically significant (P=.06). Conclusions: We observed a decrease in anxiety and increase in total physical activity for the dynamic group only. Dynamic social networking sites, featuring regularly updated content, may be more advantageous than websites that retain static content over time. Trial Registration: ClinicalTrials.gov NCT03363737; https://clinicaltrials.gov/ct2/show/NCT03363737 (Archived by WebCite at http://www.webcitation.org/6vXzNbOWJ) UR - http://mental.jmir.org/2017/4/e50/ UR - http://dx.doi.org/10.2196/mental.8086 UR - http://www.ncbi.nlm.nih.gov/pubmed/29222077 ID - info:doi/10.2196/mental.8086 ER - TY - JOUR AU - Pirolli, Peter AU - Mohan, Shiwali AU - Venkatakrishnan, Anusha AU - Nelson, Les AU - Silva, Michael AU - Springer, Aaron PY - 2017/11/30 TI - Implementation Intention and Reminder Effects on Behavior Change in a Mobile Health System: A Predictive Cognitive Model JO - J Med Internet Res SP - e397 VL - 19 IS - 11 KW - mobile applications KW - models, theoretical KW - habits N2 - Background: Implementation intentions are mental representations of simple plans to translate goal intentions into behavior under specific conditions. Studies show implementation intentions can produce moderate to large improvements in behavioral goal achievement. Human associative memory mechanisms have been implicated in the processes by which implementation intentions produce effects. On the basis of the adaptive control of thought-rational (ACT-R) theory of cognition, we hypothesized that the strength of implementation intention effect could be manipulated in predictable ways using reminders delivered by a mobile health (mHealth) app. Objective: The aim of this experiment was to manipulate the effects of implementation intentions on daily behavioral goal success in ways predicted by the ACT-R theory concerning mHealth reminder scheduling. Methods: An incomplete factorial design was used in this mHealth study. All participants were asked to choose a healthy behavior goal associated with eat slowly, walking, or eating more vegetables and were asked to set implementation intentions. N=64 adult participants were in the study for 28 days. Participants were stratified by self-efficacy and assigned to one of two reminder conditions: reminders-presented versus reminders-absent. Self-efficacy and reminder conditions were crossed. Nested within the reminders-presented condition was a crossing of frequency of reminders sent (high, low) by distribution of reminders sent (distributed, massed). Participants in the low frequency condition got 7 reminders over 28 days; those in the high frequency condition were sent 14. Participants in the distributed conditions were sent reminders at uniform intervals. Participants in the massed distribution conditions were sent reminders in clusters. Results: There was a significant overall effect of reminders on achieving a daily behavioral goal (coefficient=2.018, standard error [SE]=0.572, odds ratio [OR]=7.52, 95% CI 0.9037-3.2594, P<.001). As predicted by ACT-R, using default theoretical parameters, there was an interaction of reminder frequency by distribution on daily goal success (coefficient=0.7994, SE=0.2215, OR=2.2242, 95% CI 0.3656-1.2341, P<.001). The total number of times a reminder was acknowledged as received by a participant had a marginal effect on daily goal success (coefficient=0.0694, SE=0.0410, OR=1.0717, 95% CI ?0.01116 to 0.1505, P=.09), and the time since acknowledging receipt of a reminder was highly significant (coefficient=?0.0490, SE=0.0104, OR=0.9522, 95% CI ?0.0700 to ?0.2852], P<.001). A dual system ACT-R mathematical model was fit to individuals? daily goal successes and reminder acknowledgments: a goal-striving system dependent on declarative memory plus a habit-forming system that acquires automatic procedures for performance of behavioral goals. Conclusions: Computational cognitive theory such as ACT-R can be used to make precise quantitative predictions concerning daily health behavior goal success in response to implementation intentions and the dosing schedules of reminders. UR - http://www.jmir.org/2017/11/e397/ UR - http://dx.doi.org/10.2196/jmir.8217 UR - http://www.ncbi.nlm.nih.gov/pubmed/29191800 ID - info:doi/10.2196/jmir.8217 ER - TY - JOUR AU - Rathbone, Leigh Amy AU - Clarry, Laura AU - Prescott, Julie PY - 2017/11/28 TI - Assessing the Efficacy of Mobile Health Apps Using the Basic Principles of Cognitive Behavioral Therapy: Systematic Review JO - J Med Internet Res SP - e399 VL - 19 IS - 11 KW - cognitive therapy KW - behavior KW - mHealth KW - mobile KW - phone KW - health KW - treatment efficacy KW - intervention study KW - randomized controlled trial KW - review KW - systematic N2 - Background: Cognitive behavioral therapy (CBT) in its basic principle has developed itself as a stand-alone, substantial method of therapy. With effective application in therapy for a range of mental health issues, the spread of CBT methods to Web-based therapy sources is evident. The development of mobile phone apps using CBT principles is increasing within the research area. Despite the move to Web-based methods of therapy, it is argued that these methods lack the same efficacy of face-to-face therapy sessions. Objective: The aim of this review was to assess extent research findings with regard to the effectiveness of CBT-related mobile health (mHealth) apps. By assessing only studies employing a randomized controlled trial design, the review aimed to determine app efficacy within the highly regarded method of investigation. Methods: A comprehensive literature search was conducted across several databases. Search results were filtered, and results were subject to strict inclusion and exclusion criteria because of the nature of the review. Where possible, analysis of effect size was calculated and results reported. Results: A total of 8 studies investigating the effectiveness of mHealth CBT-related apps across a range of mental health issues were reviewed. Three studies used the app against a control group, and 5 studies used the app intervention against another form of treatment or intervention. A range of effect sizes were seen across all included studies (d=?0.13 to 1.83; 0.03-1.44), with the largest effects often being seen when comparing the data from pre- to posttest for the app engaged group. Conclusions: The studies reviewed support the use of mHealth apps containing CBT principles for a range of mental health issues. However, the effectiveness over longer time periods should be assessed. Researchers and professionals should seek to collaborate effectively when creating new apps to enhance their effectiveness as a treatment for the general public. UR - http://www.jmir.org/2017/11/e399/ UR - http://dx.doi.org/10.2196/jmir.8598 UR - http://www.ncbi.nlm.nih.gov/pubmed/29187342 ID - info:doi/10.2196/jmir.8598 ER - TY - JOUR AU - Whelan, E. Maxine AU - Morgan, S. Paul AU - Sherar, B. Lauren AU - Kingsnorth, P. Andrew AU - Magistro, Daniele AU - Esliger, W. Dale PY - 2017/11/08 TI - Brain Activation in Response to Personalized Behavioral and Physiological Feedback From Self-Monitoring Technology: Pilot Study JO - J Med Internet Res SP - e384 VL - 19 IS - 11 KW - functional magnetic resonance imaging KW - neuroimaging KW - physical activity KW - sedentary behavior KW - interstitial glucose N2 - Background: The recent surge in commercially available wearable technology has allowed real-time self-monitoring of behavior (eg, physical activity) and physiology (eg, glucose levels). However, there is limited neuroimaging work (ie, functional magnetic resonance imaging [fMRI]) to identify how people?s brains respond to receiving this personalized health feedback and how this impacts subsequent behavior. Objective: Identify regions of the brain activated and examine associations between activation and behavior. Methods: This was a pilot study to assess physical activity, sedentary time, and glucose levels over 14 days in 33 adults (aged 30 to 60 years). Extracted accelerometry, inclinometry, and interstitial glucose data informed the construction of personalized feedback messages (eg, average number of steps per day). These messages were subsequently presented visually to participants during fMRI. Participant physical activity levels and sedentary time were assessed again for 8 days following exposure to this personalized feedback. Results: Independent tests identified significant activations within the prefrontal cortex in response to glucose feedback compared with behavioral feedback (P<.001). Reductions in mean sedentary time (589.0 vs 560.0 minutes per day, P=.014) were observed. Activation in the subgyral area had a moderate correlation with minutes of moderate-to-vigorous physical activity (r=0.392, P=.043). Conclusion: Presenting personalized glucose feedback resulted in significantly more brain activation when compared with behavior. Participants reduced time spent sedentary at follow-up. Research on deploying behavioral and physiological feedback warrants further investigation. UR - http://www.jmir.org/2017/11/e384/ UR - http://dx.doi.org/10.2196/jmir.8890 UR - http://www.ncbi.nlm.nih.gov/pubmed/29117928 ID - info:doi/10.2196/jmir.8890 ER - TY - JOUR AU - Kinsey, W. Amber AU - Whipple, Matthew AU - Reid, Lauren AU - Affuso, Olivia PY - 2017/10/20 TI - Formative Assessment: Design of a Web-Connected Sedentary Behavior Intervention for Females JO - JMIR Hum Factors SP - e28 VL - 4 IS - 4 KW - health promotion KW - qualitative research KW - sedentary lifestyle KW - motivation N2 - Background: Sedentary behavior (SB) is a significant risk factor for heart disease, diabetes, obesity, and early mortality, particularly among women, and the health consequences associated with SB are independent of physical activity status. Interventions utilizing wearable technologies can improve SB, but their effectiveness is influenced by individual preferences, device engagement strategies, and technological features, which may affect user compliance. Gathering a priori insight from target populations on their preferences for program tools and strategies may assist researchers in identifying effective methods to improve the efficacy of SB interventions. Objective: The objective of this study was to (1) explore the likeability (likes and dislikes) and usability (engagement intentions and navigation) of a wearable device (Movband) and its accompanying website (dashboard), (2) examine social incentive preferences (teammates), and (3) assess the feasibility (participants? experiences during an activity-monitoring period) of these tools for use in an intervention to reduce SB in girls and women. Methods: A total of 9 girls (mean age: 8.9 years, standard deviation [SD] 1.1 years) and 11 college-aged women (mean age: 22.6 years, SD 3.2 years) participated in this study. Separate focus groups were held for girls and women, and all participants attended one before and the other following a 7-day activity-monitoring period. During the focus groups, participants were prompted with questions to address the study aims, and the nominal group technique was used to compile lists of group-specific preferences for the activity-monitoring system. The top three ranking likes and dislikes were reverse coded to determine likeability. Results: The top-ranking responses for the girls and women were the following: visual display of movements and ease of navigation (dashboard like), boring to look at and no calorie-tracking function (dashboard dislike), backlight and long battery life (Movband like), and color and not waterproof (tied for girls) and vertical time display (Movband dislike). Additionally, participants identified several aesthetic preferences and functional limitations. At the second focus group visit, the majority of the participants self-reported less SB during the previous week. Objective data from the activity-monitoring period revealed that the average steps per day for girls and women were 12,373.4 (SD 2617.6) and 8515.8 (SD 3076.7), respectively. Conclusions: These results suggest that the girls and women liked many features of the Movband and dashboard. However, several dislikes were mentioned, which may negatively influence compliance and the effectiveness of the activity-monitoring system and require improvements before using in an SB intervention. UR - http://humanfactors.jmir.org/2017/4/e28/ UR - http://dx.doi.org/10.2196/humanfactors.7670 UR - http://www.ncbi.nlm.nih.gov/pubmed/29054836 ID - info:doi/10.2196/humanfactors.7670 ER - TY - JOUR AU - Crookston, T. Benjamin AU - West, H. Joshua AU - Hall, Cougar P. AU - Dahle, Martinez Kaitana AU - Heaton, L. Thomas AU - Beck, N. Robin AU - Muralidharan, Chandni PY - 2017/10/17 TI - Mental and Emotional Self-Help Technology Apps: Cross-Sectional Study of Theory, Technology, and Mental Health Behaviors JO - JMIR Ment Health SP - e45 VL - 4 IS - 4 KW - mental health KW - decision theory KW - mobile applications N2 - Background: Mental and emotional self-help apps have emerged as potential mental illness prevention and treatment tools. The health behavior theory mechanisms by which these apps influence mental health?related behavior change have not been thoroughly examined. Objective: The objective of this study was to examine the association between theoretical behavior change mechanisms and use of mental and emotional self-help apps and whether the use of such apps is associated with mental health behaviors. Methods: This study utilized a cross-sectional survey of 150 users of mental or emotional health apps in the past 6 months. Survey questions included theory-based items, app engagement and likeability items, and behavior change items. Stata version 14 was used to calculate all statistics. Descriptive statistics were calculated for each of the demographic, theory, engagement, and behavior variables. Multiple regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior after controlling for potentially confounding variables. Results: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. Engagement (P<.001) was positively associated with the reported changes in theory items, whereas perceived behavior change was positively associated with theory (P<.001), engagement (P=.004), frequency of use of apps (P=.01), and income (P=.049). Conclusions: Participants reported that app use increased their motivation, desire to set goals, confidence, control, and intentions to be mentally and emotionally healthy. This increase in perceptions, beliefs, and attitudes surrounding their mental and emotional health was considerably associated with perceived change in behavior. There was a positive association between the level of engagement with the app and the impact on theory items. Future efforts should consider the value of impacting key theoretical constructs when designing mental and emotional health apps. As apps are evaluated and additional theory-based apps are created, cost-effective self-help apps may become common preventative and treatment tools in the mental health field. UR - http://mental.jmir.org/2017/4/e45/ UR - http://dx.doi.org/10.2196/mental.7262 UR - http://www.ncbi.nlm.nih.gov/pubmed/29042340 ID - info:doi/10.2196/mental.7262 ER - TY - JOUR AU - Kebede, M. Mihiretu AU - Liedtke, P. Tatjana AU - Möllers, Tobias AU - Pischke, R. Claudia PY - 2017/10/12 TI - Characterizing Active Ingredients of eHealth Interventions Targeting Persons With Poorly Controlled Type 2 Diabetes Mellitus Using the Behavior Change Techniques Taxonomy: Scoping Review JO - J Med Internet Res SP - e348 VL - 19 IS - 10 KW - type 2 diabetes KW - telemedicine KW - mobile health KW - telehealth KW - eHealth KW - mHealth N2 - Background: The behavior change technique taxonomy v1 (BCTTv1; Michie and colleagues, 2013) is a comprehensive tool to characterize active ingredients of interventions and includes 93 labels that are hierarchically clustered into 16 hierarchical clusters. Objective: The aim of this study was to identify the active ingredients in electronic health (eHealth) interventions targeting patients with poorly controlled type 2 diabetes mellitus (T2DM) and relevant outcomes. Methods: We conducted a scoping review using the BCTTv1. Randomized controlled trials (RCTs), studies with or pre-post-test designs, and quasi-experimental studies examining efficacy and effectiveness of eHealth interventions for disease management or the promotion of relevant health behaviors were identified by searching PubMed, Web of Science, and PsycINFO. Reviewers independently screened titles and abstracts for eligibility using predetermined eligibility criteria. Data were extracted following a data extraction sheet. The BCTTv1 was used to characterize active ingredients of the interventions reported in the included studies. Results: Of the 1404 unique records screened, 32 studies fulfilled the inclusion criteria and reported results on the efficacy and or or effectiveness of interventions. Of the included 32 studies, 18 (56%) were Web-based interventions delivered via personal digital assistant (PDA), tablet, computer, and/or mobile phones; 7 (22%) were telehealth interventions delivered via landline; 6 (19%) made use of text messaging (short service message, SMS); and 1 employed videoconferencing (3%). Of the 16 hierarchical clusters of the BCTTv1, 11 were identified in interventions included in this review. Of the 93 individual behavior change techniques (BCTs), 31 were identified as active ingredients of the interventions. The most common BCTs identified were instruction on how to perform behavior, adding objects to the environment, information about health consequences, self-monitoring of the outcomes and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided of a certain behavior Author: Please note that the journal discourages the use of parenthesis to denote either and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided ?and/or? and prefers to be explicit to avoid ambiguity. Response: Checked and avoided, and feedback on outcomes of behavior. Conclusions: Our results suggest that the majority of BCTs employed in interventions targeting persons with T2DM revolve around the promotion of self-regulatory behavior to manage the disease or to assist patients in performing health behaviors necessary to prevent further complications of the disease. Detailed reporting of the BCTs included in interventions targeting this population may facilitate the replication and further investigation of such interventions. UR - http://www.jmir.org/2017/10/e348/ UR - http://dx.doi.org/10.2196/jmir.7135 UR - http://www.ncbi.nlm.nih.gov/pubmed/29025693 ID - info:doi/10.2196/jmir.7135 ER - TY - JOUR AU - Duncan, Mitch AU - Murawski, Beatrice AU - Short, E. Camille AU - Rebar, L. Amanda AU - Schoeppe, Stephanie AU - Alley, Stephanie AU - Vandelanotte, Corneel AU - Kirwan, Morwenna PY - 2017/08/14 TI - Activity Trackers Implement Different Behavior Change Techniques for Activity, Sleep, and Sedentary Behaviors JO - Interact J Med Res SP - e13 VL - 6 IS - 2 KW - health behavior KW - public health KW - exercise KW - sleep KW - behavior change KW - fitness trackers KW - adult, mobile applications N2 - Background: Several studies have examined how the implementation of behavior change techniques (BCTs) varies between different activity trackers. However, activity trackers frequently allow tracking of activity, sleep, and sedentary behaviors; yet, it is unknown how the implementation of BCTs differs between these behaviors. Objective: The aim of this study was to assess the number and type of BCTs that are implemented by wearable activity trackers (self-monitoring systems) in relation to activity, sleep, and sedentary behaviors and to determine whether the number and type of BCTs differ between behaviors. Methods: Three self-monitoring systems (Fitbit [Charge HR], Garmin [Vivosmart], and Jawbone [UP3]) were each used for a 1-week period in August 2015. Each self-monitoring system was used by two of the authors (MJD and BM) concurrently. The Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy was used to assess the implementation of 40 BCTs in relation to activity, sleep, and sedentary behaviors. Discrepancies in ratings were resolved by discussion, and interrater agreement in the number of BCTs implemented was assessed using kappa statistics. Results: Interrater agreement ranged from 0.64 to 1.00. From a possible range of 40 BCTs, the number of BCTs present for activity ranged from 19 (Garmin) to 33 (Jawbone), from 4 (Garmin) to 29 (Jawbone) for sleep, and 0 (Fitbit) to 10 (Garmin) for sedentary behavior. The average number of BCTs implemented was greatest for activity (n=26) and smaller for sleep (n=14) and sedentary behavior (n=6). Conclusions: The number and type of BCTs implemented varied between each of the systems and between activity, sleep, and sedentary behaviors. This provides an indication of the potential of these systems to change these behaviors, but the long-term effectiveness of these systems to change activity, sleep, and sedentary behaviors remains unknown. UR - http://www.i-jmr.org/2017/2/e13/ UR - http://dx.doi.org/10.2196/ijmr.6685 UR - http://www.ncbi.nlm.nih.gov/pubmed/28807889 ID - info:doi/10.2196/ijmr.6685 ER - TY - JOUR AU - Lalouni, Maria AU - Ljótsson, Brjánn AU - Bonnert, Marianne AU - Hedman-Lagerlöf, Erik AU - Högström, Jens AU - Serlachius, Eva AU - Olén, Ola PY - 2017/08/10 TI - Internet-Delivered Cognitive Behavioral Therapy for Children With Pain-Related Functional Gastrointestinal Disorders: Feasibility Study JO - JMIR Ment Health SP - e32 VL - 4 IS - 3 KW - cognitive therapy KW - behavior therapy KW - functional gastrointestinal disorders KW - abdominal pain KW - irritable bowel syndrome N2 - Background: Pain-related functional gastrointestinal disorders (P-FGIDs; eg, irritable bowel syndrome) are highly prevalent in children and associated with low quality of life, anxiety, and school absence. Treatment options are scarce, and there is a need for effective and accessible treatments. Internet-delivered cognitive behavior therapy (Internet-CBT) based on exposure exercises is effective for adult and adolescent irritable bowel syndrome, but it has not been evaluated for younger children. Objective: The objective of this study was to assess acceptability, feasibility, and potential clinical efficacy of Internet-CBT for children with P-FGIDs. Methods: This was a feasibility study with a within-group design. We included 31 children aged 8-12 years and diagnosed with P-FGID, according to the ROME III criteria. Mean duration of abdominal symptoms at baseline was 3.8 years (standard deviation [SD] 2.6). The treatment was therapist-guided and consisted of 10 weekly modules of exposure-based Internet-CBT. The children were instructed to provoke abdominal symptoms in a graded manner and to engage in previously avoided activities. The parents were taught to decrease their attention to their children?s pain behaviors and to reinforce and support their work with the exposures. Assessments included treatment satisfaction, subjective treatment effect, gastrointestinal symptoms, quality of life, pain intensity, anxiety, depression, and school absence. Data were collected at pretreatment, posttreatment, and 6-month follow-up. Means, standard errors (SEs), and Cohen d effect sizes were estimated based on multi-level linear mixed models. Results: Most children 25/31 (81%) completed 9 or 10 of the 10 treatment modules. Almost all children, 28/31 (90%), reported that the treatment had helped them to deal more effectively with their symptoms, and 27/31 (87%) children declared that their symptoms had improved during the treatment. Assessments from the parents were in accordance with the children?s reports. No child or parent reported that the symptoms had worsened. We observed a large within-group effect size on the primary outcome measure, child-rated gastrointestinal symptoms from pretreatment to posttreatment (Cohen d=1.14, P<.001, 95% CI 0.69-1.61), and this effect size was maintained at 6-month follow-up (Cohen d=1.40, P<.001, 95% CI 1.04-1.81). We also observed significant improvements from pretreatment to posttreatment on a wide range of child- and parent-rated measures including quality of life, pain intensity, anxiety, depression, and school absence. All results remained stable or were further improved at 6-month follow-up. Conclusions: This study shows that children with longstanding P-FGIDs, and their parents, perceive exposure-based Internet-CBT as a helpful and feasible treatment. The included children improved significantly despite a long duration of abdominal symptoms before the intervention. The treatment shows potential to be highly effective for P-FGIDs. The results need to be confirmed in a randomized controlled trial (RCT). UR - http://mental.jmir.org/2017/3/e32/ UR - http://dx.doi.org/10.2196/mental.7985 UR - http://www.ncbi.nlm.nih.gov/pubmed/28798012 ID - info:doi/10.2196/mental.7985 ER - TY - JOUR AU - Hoj, H. Taylor AU - Covey, L. Emarie AU - Jones, C. Allyn AU - Haines, C. Amanda AU - Hall, Cougar P. AU - Crookston, T. Benjamin AU - West, H. Joshua PY - 2017/08/03 TI - How Do Apps Work? An Analysis of Physical Activity App Users? Perceptions of Behavior Change Mechanisms JO - JMIR Mhealth Uhealth SP - e114 VL - 5 IS - 8 KW - mHealth KW - mobile apps KW - health behavior KW - smartphone N2 - Background: Physical activity apps are commonly used to increase levels of activity and health status. To date, the focus of research has been to determine the potential of apps to influence behavior, to ascertain the efficacy of a limited number of apps to change behavior, and to identify the characteristics of apps that users prefer. Objective: The purpose of this study was to identify the mechanisms by which the use of physical activity apps may influence the users? physical activity behavior. Methods: This study used a cross-sectional survey of users of health-related physical activity apps during the past 6 months. An electronic survey was created in Qualtrics? Web-based survey software and deployed on Amazon Mechanical Turk. Individuals who had used at least one physical activity app in the past 6 months were eligible to respond. The final sample comprised 207 adults living in the United States. 86.0% (178/207) of respondents were between the ages of 26 and 54 years, with 51.2% (106/207) of respondents being female. Behavior change theory informed the creation of 20 survey items relating to the mechanisms of behavior change. Respondents also reported about engagement with the apps, app likeability, and physical activity behavior. Results: Respondents reported that using a physical activity app in the past 6 months resulted in a change in their attitudes, beliefs, perceptions, and motivation. Engagement with the app (P<.001), frequency of app use (P=.03), and app price (P=.01) were related to the reported impact of the behavior change theory or mechanisms of change. The mechanisms of change were associated with self-reported physical activity behaviors (P<.001). Conclusions: The findings from this study provide an overview of the mechanisms by which apps may impact behavior. App developers may wish to incorporate these mechanisms in an effort to increase impact. Practitioners should consider the extent to which behavior change theory is integrated into a particular app when they consider making recommendations to others wishing to increase levels of physical activity. UR - http://mhealth.jmir.org/2017/8/e114/ UR - http://dx.doi.org/10.2196/mhealth.7206 UR - http://www.ncbi.nlm.nih.gov/pubmed/28778846 ID - info:doi/10.2196/mhealth.7206 ER - TY - JOUR AU - Duff, Mairead Orlaith AU - Walsh, MJ Deirdre AU - Furlong, A. Bróna AU - O'Connor, E. Noel AU - Moran, A. Kieran AU - Woods, B. Catherine PY - 2017/08/02 TI - Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review JO - J Med Internet Res SP - e281 VL - 19 IS - 8 KW - systematic review KW - exercise KW - behavior KW - telemedicine KW - cardiovascular disease N2 - Background: Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost ?196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. Objective: The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. Methods: A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration?s tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. Results: Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each. Conclusions: This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area. UR - http://www.jmir.org/2017/8/e281/ UR - http://dx.doi.org/10.2196/jmir.7782 UR - http://www.ncbi.nlm.nih.gov/pubmed/28768610 ID - info:doi/10.2196/jmir.7782 ER - TY - JOUR AU - West, H. Joshua AU - Belvedere, M. Lindsay AU - Andreasen, Rebecca AU - Frandsen, Christine AU - Hall, Cougar P. AU - Crookston, T. Benjamin PY - 2017/07/10 TI - Controlling Your ?App?etite: How Diet and Nutrition-Related Mobile Apps Lead to Behavior Change JO - JMIR Mhealth Uhealth SP - e95 VL - 5 IS - 7 KW - diet KW - nutritional status KW - mobile apps KW - behavior and behavior mechanisms N2 - Background: In recent years, obesity has become a serious public health crisis in the United States. Although the problem of obesity is being addressed through a variety of strategies, the use of mobile apps is a relatively new development that could prove useful in helping people to develop healthy dietary habits. Though such apps might lead to health behavior change, especially when relevant behavior change theory constructs are integrated into them, the mechanisms by which these apps facilitate behavior change are largely unknown. Objective: The purpose of this study was to identify which behavior change mechanisms are associated with the use of diet- and nutrition-related health apps and whether the use of diet- and nutrition-related apps is associated with health behavior change. Methods: A cross-sectional survey was administered to a total of 217 participants. Participants responded to questions on demographics, use of diet and nutrition apps in the past 6 months, engagement and likability of apps, and changes in the participant?s dietary behaviors. Regression analysis was used to identify factors associated with reported changes in theory and separately for reported changes in actual behavior, after controlling for potential confounding variables. Results: The majority of study participants agreed or strongly agreed with statements regarding app use increasing their motivation to eat a healthy diet, improving their self-efficacy, and increasing their desire to set and achieve health diet goals. Additionally, majority of participants strongly agreed that using diet/nutrition apps led to changes in their behavior, namely increases in actual goal setting to eat a healthy diet (58.5%, 127/217), increases in their frequency of eating healthy foods (57.6%, 125/217), and increases in their consistency of eating healthy foods (54.4%, 118/217). Participants also responded favorably to questions related to engagement and likability of diet/nutrition apps. A number of predictors were also positively associated with diet-related behavior change. Theory (P<.001), app engagement (P<.001), app use (P<.003), and education (P<.010) were all positively associated with behavior change. Conclusions: Study findings indicate that the use of diet/nutrition apps is associated with diet-related behavior change. Hence, diet- and nutrition-related apps that focus on improving motivation, desire, self-efficacy, attitudes, knowledge, and goal setting may be particularly useful. As the number of diet- and nutrition-related apps continues to grow, developers should consider integrating appropriate theoretical constructs for health behavior change into the newly developed mobile apps. UR - http://mhealth.jmir.org/2017/7/e95/ UR - http://dx.doi.org/10.2196/mhealth.7410 UR - http://www.ncbi.nlm.nih.gov/pubmed/28694241 ID - info:doi/10.2196/mhealth.7410 ER - TY - JOUR AU - Michie, Susan AU - Yardley, Lucy AU - West, Robert AU - Patrick, Kevin AU - Greaves, Felix PY - 2017/06/29 TI - Developing and Evaluating Digital Interventions to Promote Behavior Change in Health and Health Care: Recommendations Resulting From an International Workshop JO - J Med Internet Res SP - e232 VL - 19 IS - 6 KW - health behavior KW - psychological theory KW - mobile applications KW - behavioral medicine KW - mHealth KW - eHealth UR - http://www.jmir.org/2017/6/e232/ UR - http://dx.doi.org/10.2196/jmir.7126 UR - http://www.ncbi.nlm.nih.gov/pubmed/28663162 ID - info:doi/10.2196/jmir.7126 ER - TY - JOUR AU - Wright, C. Cassandra J. AU - Dietze, M. Paul AU - Lim, C. Megan S. PY - 2017/06/20 TI - Beyond Basic Feedback in Mobile Brief Interventions: Designing SMS Message Content for Delivery to Young Adults During Risky Drinking Events JO - JMIR Mhealth Uhealth SP - e79 VL - 5 IS - 6 KW - alcohol drinking KW - young adult KW - mHealth KW - text messaging KW - motivational interviewing KW - community-based participatory research N2 - Background: Brief interventions can reduce alcohol consumption in young people through screening and delivery of personally relevant feedback. Recently, Web and mobile platforms have been harnessed to increase the reach of brief interventions. Existing literature on mobile-based alcohol brief interventions indicates mixed use of theory in developing interventions. There is no research available to guide the development of SMS text messaging (short message service, SMS) interventions delivered during risky drinking events. Objective: The aim of this study was to develop and pilot an alcohol-related risk-reduction brief intervention delivered by SMS to Australian young adults during drinking events. This paper describes the development of intervention message content, with specific focus on the context of delivery during drinking events. Methods: A sample of 42 young adults attended 4 workshops; these comprised focus-group style discussion on drinking habits and motivations, discussion of intervention design, analysis of existing alcohol media campaigns, and participant development of message content. Data were analyzed thematically. Results: Participants described a focus on having fun and blocking out any incongruent negative influences during drinking episodes. For content to be acceptable, nonjudgmental and non-authoritative language was deemed essential. A preference for short, actionable messages was observed, including suggestions for reminders around drinking water, organizing transport home, checking on friends, and plans the next day. Participants were excited about the potential for messages to be tailored to individuals, as previous alcohol-related campaigns were deemed too generic and often irrelevant. Normative-based messages were also perceived as largely irrelevant as participants felt that they understood the drinking-related norms of their immediate peers already. Conclusions: Findings from this study offer insights into young adults? drinking events and practical advice for designing alcohol-related brief interventions. During our formative development process, we demonstrated a neat correspondence between young people?s preferences for alcohol harm reduction interventions and the theoretical principles of brief interventions, including acceptable topics and message style. UR - http://mhealth.jmir.org/2017/6/e79/ UR - http://dx.doi.org/10.2196/mhealth.6497 UR - http://www.ncbi.nlm.nih.gov/pubmed/28634153 ID - info:doi/10.2196/mhealth.6497 ER - TY - JOUR AU - Tang, Wei AU - Kreindler, David PY - 2017/06/08 TI - Supporting Homework Compliance in Cognitive Behavioural Therapy: Essential Features of Mobile Apps JO - JMIR Ment Health SP - e20 VL - 4 IS - 2 KW - cognitive behavioral therapy KW - homework compliance KW - mobile apps UR - http://mental.jmir.org/2017/2/e20/ UR - http://dx.doi.org/10.2196/mental.5283 UR - http://www.ncbi.nlm.nih.gov/pubmed/28596145 ID - info:doi/10.2196/mental.5283 ER - TY - JOUR AU - Hoffmann, Alexandra AU - Christmann, A. Corinna AU - Bleser, Gabriele PY - 2017/06/07 TI - Gamification in Stress Management Apps: A Critical App Review JO - JMIR Serious Games SP - e13 VL - 5 IS - 2 KW - game element KW - mHealth, motivation KW - app KW - behavior change KW - gamification N2 - Background: In today?s society, stress is more and more often a cause of disease. This makes stress management an important target of behavior change programs. Gamification has been suggested as one way to support health behavior change. However, it remains unclear to which extend available gamification techniques are integrated in stress management apps, and if their occurrence is linked to the use of elements from behavior change theory. Objective: The aim of this study was to investigate the use of gamification techniques in stress management apps and the cooccurrence of these techniques with evidence-based stress management methods and behavior change techniques. Methods: A total of 62 stress management apps from the Google Play Store were reviewed on their inclusion of 17 gamification techniques, 15 stress management methods, and 26 behavior change techniques. For this purpose, an extended taxonomy of gamification techniques was constructed and applied by 2 trained, independent raters. Results: Interrater-reliability was high, with agreement coefficient (AC)=.97. Results show an average of 0.5 gamification techniques for the tested apps and reveal no correlations between the use of gamification techniques and behavior change techniques (r=.17, P=.20), or stress management methods (r=.14, P=.26). Conclusions: This leads to the conclusion that designers of stress management apps do not use gamification techniques to influence the user?s behaviors and reactions. Moreover, app designers do not exploit the potential of combining gamification techniques with behavior change theory. UR - http://games.jmir.org/2017/2/e13/ UR - http://dx.doi.org/10.2196/games.7216 UR - http://www.ncbi.nlm.nih.gov/pubmed/28592397 ID - info:doi/10.2196/games.7216 ER - TY - JOUR AU - Kramer, Jan-Niklas AU - Kowatsch, Tobias PY - 2017/06/02 TI - Using Feedback to Promote Physical Activity: The Role of the Feedback Sign JO - J Med Internet Res SP - e192 VL - 19 IS - 6 KW - feedback KW - internet KW - physical activity KW - health behavior KW - activity trackers N2 - Background: Providing feedback is a technique to promote health behavior that is emphasized by behavior change theories. However, these theories make contradicting predictions regarding the effect of the feedback sign?that is, whether the feedback signals success or failure. Thus, it is unclear whether positive or negative feedback leads to more favorable behavior change in a health behavior intervention. Objective: The aim of this study was to examine the effect of the feedback sign in a health behavior change intervention. Methods: Data from participants (N=1623) of a 6-month physical activity intervention was used. Participants received a feedback email at the beginning of each month. Feedback was either positive or negative depending on the participants? physical activity in the previous month. In an exploratory analysis, change in monthly step count averages was used to evaluate the feedback effect. Results: The feedback sign did not predict the change in monthly step count averages over the course of the intervention (b=?84.28, P=.28). Descriptive differences between positive and negative feedback can be explained by regression to the mean. Conclusions: The feedback sign might not influence the effect of monthly feedback emails sent out to participants of a large-scale physical activity intervention. However, randomized studies are needed to further support this conclusion. Limitations as well as opportunities for future research are discussed. UR - http://www.jmir.org/2017/6/e192/ UR - http://dx.doi.org/10.2196/jmir.7012 UR - http://www.ncbi.nlm.nih.gov/pubmed/28576757 ID - info:doi/10.2196/jmir.7012 ER - TY - JOUR AU - Muench, Frederick AU - Baumel, Amit PY - 2017/05/26 TI - More Than a Text Message: Dismantling Digital Triggers to Curate Behavior Change in Patient-Centered Health Interventions JO - J Med Internet Res SP - e147 VL - 19 IS - 5 KW - alerts KW - digital triggers KW - text messaging KW - haptic triggers KW - reminder systems KW - push alerts KW - mHealth KW - mobile health KW - engagement KW - marketing KW - behavior change KW - behavioral medicine UR - http://www.jmir.org/2017/5/e147/ UR - http://dx.doi.org/10.2196/jmir.7463 UR - http://www.ncbi.nlm.nih.gov/pubmed/28550001 ID - info:doi/10.2196/jmir.7463 ER - TY - JOUR AU - Aguilera, Adrian AU - Bruehlman-Senecal, Emma AU - Demasi, Orianna AU - Avila, Patricia PY - 2017/05/08 TI - Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial JO - J Med Internet Res SP - e148 VL - 19 IS - 5 KW - depression KW - text messaging KW - cognitive behavioral therapy KW - mhealth KW - mental health KW - Latinos N2 - Background: Cognitive Behavioral Therapy (CBT) for depression is efficacious, but effectiveness is limited when implemented in low-income settings due to engagement difficulties including nonadherence with skill-building homework and early discontinuation of treatment. Automated messaging can be used in clinical settings to increase dosage of depression treatment and encourage sustained engagement with psychotherapy. Objectives: The aim of this study was to test whether a text messaging adjunct (mood monitoring text messages, treatment-related text messages, and a clinician dashboard to display patient data) increases engagement and improves clinical outcomes in a group CBT treatment for depression. Specifically, we aim to assess whether the text messaging adjunct led to an increase in group therapy sessions attended, an increase in duration of therapy attended, and reductions in Patient Health Questionnaire-9 item (PHQ-9) symptoms compared with the control condition of standard group CBT in a sample of low-income Spanish speaking Latino patients. Methods: Patients in an outpatient behavioral health clinic were assigned to standard group CBT for depression (control condition; n=40) or the same treatment with the addition of a text messaging adjunct (n=45). The adjunct consisted of a daily mood monitoring message, a daily message reiterating the theme of that week?s content, and medication and appointment reminders. Mood data and qualitative responses were sent to a Web-based platform (HealthySMS) for review by the therapist and displayed in session as a tool for teaching CBT skills. Results: Intent-to-treat analyses on therapy attendance during 16 sessions of weekly therapy found that patients assigned to the text messaging adjunct stayed in therapy significantly longer (median of 13.5 weeks before dropping out) than patients assigned to the control condition (median of 3 weeks before dropping out; Wilcoxon-Mann-Whitney z=?2.21, P=.03). Patients assigned to the text messaging adjunct also generally attended more sessions (median=6 sessions) during this period than patients assigned to the control condition (median =2.5 sessions), but the effect was not significant (Wilcoxon-Mann-Whitney z=?1.65, P=.10). Both patients assigned to the text messaging adjunct (B=?.29, 95% CI ?0.38 to ?0.19, z=?5.80, P<.001) and patients assigned to the control conditions (B=?.20, 95% CI ?0.32 to ?0.07, z=?3.12, P=.002) experienced significant decreases in depressive symptom severity over the course of treatment; however, the conditions did not significantly differ in their degree of symptom reduction. Conclusions: This study provides support for automated text messaging as a tool to sustain engagement in CBT for depression over time. There were no differences in depression outcomes between conditions, but this may be influenced by low follow-up rates of patients who dropped out of treatment. UR - http://www.jmir.org/2017/5/e148/ UR - http://dx.doi.org/10.2196/jmir.6914 UR - http://www.ncbi.nlm.nih.gov/pubmed/28483742 ID - info:doi/10.2196/jmir.6914 ER - TY - JOUR AU - Smit, Suzanne Eline AU - Dima, Lelia Alexandra AU - Immerzeel, Maria Stephanie Annette AU - van den Putte, Bas AU - Williams, Colin Geoffrey PY - 2017/05/08 TI - The Virtual Care Climate Questionnaire: Development and Validation of a Questionnaire Measuring Perceived Support for Autonomy in a Virtual Care Setting JO - J Med Internet Res SP - e155 VL - 19 IS - 5 KW - questionnaire design KW - validation studies KW - psychometrics KW - personal autonomy KW - Internet KW - health behavior KW - health promotion KW - self-determination theory N2 - Background: Web-based health behavior change interventions may be more effective if they offer autonomy-supportive communication facilitating the internalization of motivation for health behavior change. Yet, at this moment no validated tools exist to assess user-perceived autonomy-support of such interventions. Objective: The aim of this study was to develop and validate the virtual climate care questionnaire (VCCQ), a measure of perceived autonomy-support in a virtual care setting. Methods: Items were developed based on existing questionnaires and expert consultation and were pretested among experts and target populations. The virtual climate care questionnaire was administered in relation to Web-based interventions aimed at reducing consumption of alcohol (Study 1; N=230) or cannabis (Study 2; N=228). Item properties, structural validity, and reliability were examined with item-response and classical test theory methods, and convergent and divergent validity via correlations with relevant concepts. Results: In Study 1, 20 of 23 items formed a one-dimensional scale (alpha=.97; omega=.97; H=.66; mean 4.9 [SD 1.0]; range 1-7) that met the assumptions of monotonicity and invariant item ordering. In Study 2, 16 items fitted these criteria (alpha=.92; H=.45; omega=.93; mean 4.2 [SD 1.1]; range 1-7). Only 15 items remained in the questionnaire in both studies, thus we proceeded to the analyses of the questionnaire?s reliability and construct validity with a 15-item version of the virtual climate care questionnaire. Convergent validity of the resulting 15-item virtual climate care questionnaire was confirmed by positive associations with autonomous motivation (Study 1: r=.66, P<.001; Study 2: r=.37, P<.001) and perceived competence for reducing alcohol intake (Study 1: r=.52, P<.001). Divergent validity could only be confirmed by the nonsignificant association with perceived competence for learning (Study 2: r=.05, P=.48). Conclusions: The virtual climate care questionnaire accurately assessed participants? perceived autonomy-support offered by two Web-based health behavior change interventions. Overall, the scale showed the expected properties and relationships with relevant concepts, and the studies presented suggest this first version of the virtual climate care questionnaire to be reasonably valid and reliable. As a result, the current version may cautiously be used in future research and practice to measure perceived support for autonomy within a virtual care climate. Future research efforts are required that focus on further investigating the virtual climate care questionnaire's divergent validity, on determining the virtual climate care questionnaire?s validity and reliability when used in the context of Web-based interventions aimed at improving nonaddictive or other health behaviors, and on developing and validating a short form virtual climate care questionnaire. UR - http://www.jmir.org/2017/5/e155/ UR - http://dx.doi.org/10.2196/jmir.6714 UR - http://www.ncbi.nlm.nih.gov/pubmed/28483743 ID - info:doi/10.2196/jmir.6714 ER - TY - JOUR AU - Masteller, Brittany AU - Sirard, John AU - Freedson, Patty PY - 2017/4/28 TI - The Physical Activity Tracker Testing in Youth (P.A.T.T.Y.) Study: Content Analysis and Children?s Perceptions JO - JMIR Mhealth Uhealth SP - e55 VL - 5 IS - 4 KW - child KW - physical activity KW - qualitative research N2 - Background: Activity trackers are widely used by adults and several models are now marketed for children. Objective: The aims of this study were to (1) perform a content analysis of behavioral change techniques (BCTs) used by three commercially available youth-oriented activity trackers and (2) obtain feedback describing children?s perception of these devices and the associated websites. Methods: A content analysis recorded the presence of 36 possible BCTs for the MovBand (MB), Sqord (SQ), and Zamzee (ZZ) activity trackers. In addition, 16 participants (mean age 8.6 years [SD 1.6]; 50% female [8/16]) received all three trackers and were oriented to the devices and websites. Participants were instructed to wear the trackers on 4 consecutive days and spend ?10 min/day on each website. A cognitive interview and survey were administered when the participant returned the devices. Qualitative data analysis was used to analyze the content of the cognitive interviews. Chi-square analyses were used to determine differences in behavioral monitoring and social interaction features between websites. Results: The MB, SQ, and ZZ devices or websites included 8, 15, and 14 of the possible 36 BCTs, respectively. All of the websites had a behavioral monitoring feature (charts for tracking activity), but the percentage of participants indicating that they ?liked? those features varied by website (MB: 8/16, 50%; SQ: 6/16, 38%; ZZ: 11/16, 69%). Two websites (SQ and ZZ) included an ?avatar? that the user could create to represent themselves on the website. Participants reported that they ?liked? creating and changing their avatar (SQ: 12/16, 75%, ZZ: 15/16, 94%), which was supported by the qualitative analyses of the cognitive interviews. Most participants (75%) indicated that they would want to wear the devices more if their friends were wearing a tracker. No significant differences were observed between SQ and ZZ devices in regards to liking or use of social support interaction features (P=.21 to .37). Conclusions: The websites contained several BCTs consistent with previously identified strategies. Children ?liked? the social aspects of the websites more than the activity tracking features. Developers of commercial activity trackers for youth may benefit from considering a theoretical perspective during the website design process. UR - http://mhealth.jmir.org/2017/4/e55/ UR - http://dx.doi.org/10.2196/mhealth.6347 UR - http://www.ncbi.nlm.nih.gov/pubmed/28455278 ID - info:doi/10.2196/mhealth.6347 ER - TY - JOUR AU - Burke, E. Lora AU - Shiffman, Saul AU - Music, Edvin AU - Styn, A. Mindi AU - Kriska, Andrea AU - Smailagic, Asim AU - Siewiorek, Daniel AU - Ewing, J. Linda AU - Chasens, Eileen AU - French, Brian AU - Mancino, Juliet AU - Mendez, Dara AU - Strollo, Patrick AU - Rathbun, L. Stephen PY - 2017/03/15 TI - Ecological Momentary Assessment in Behavioral Research: Addressing Technological and Human Participant Challenges JO - J Med Internet Res SP - e77 VL - 19 IS - 3 KW - ecological momentary assessment KW - relapse KW - obesity KW - smartphone KW - eating behavior KW - adherence N2 - Background: Ecological momentary assessment (EMA) assesses individuals? current experiences, behaviors, and moods as they occur in real time and in their natural environment. EMA studies, particularly those of longer duration, are complex and require an infrastructure to support the data flow and monitoring of EMA completion. Objective: Our objective is to provide a practical guide to developing and implementing an EMA study, with a focus on the methods and logistics of conducting such a study. Methods: The EMPOWER study was a 12-month study that used EMA to examine the triggers of lapses and relapse following intentional weight loss. We report on several studies that informed the implementation of the EMPOWER study: (1) a series of pilot studies, (2) the EMPOWER study?s infrastructure, (3) training of study participants in use of smartphones and the EMA protocol and, (4) strategies used to enhance adherence to completing EMA surveys. Results: The study enrolled 151 adults and had 87.4% (132/151) retention rate at 12 months. Our learning experiences in the development of the infrastructure to support EMA assessments for the 12-month study spanned several topic areas. Included were the optimal frequency of EMA prompts to maximize data collection without overburdening participants; the timing and scheduling of EMA prompts; technological lessons to support a longitudinal study, such as proper communication between the Android smartphone, the Web server, and the database server; and use of a phone that provided access to the system?s functionality for EMA data collection to avoid loss of data and minimize the impact of loss of network connectivity. These were especially important in a 1-year study with participants who might travel. It also protected the data collection from any server-side failure. Regular monitoring of participants? response to EMA prompts was critical, so we built in incentives to enhance completion of EMA surveys. During the first 6 months of the 12-month study interval, adherence to completing EMA surveys was high, with 88.3% (66,978/75,888) completion of random assessments and around 90% (23,411/25,929 and 23,343/26,010) completion of time-contingent assessments, despite the duration of EMA data collection and challenges with implementation. Conclusions: This work informed us of the necessary preliminary steps to plan and prepare a longitudinal study using smartphone technology and the critical elements to ensure participant engagement in the potentially burdensome protocol, which spanned 12 months. While this was a technology-supported and -programmed study, it required close oversight to ensure all elements were functioning correctly, particularly once human participants became involved. UR - http://www.jmir.org/2017/3/e77/ UR - http://dx.doi.org/10.2196/jmir.7138 UR - http://www.ncbi.nlm.nih.gov/pubmed/28298264 ID - info:doi/10.2196/jmir.7138 ER - TY - JOUR AU - Meng, Jingbo AU - Peng, Wei AU - Shin, Yun Soo AU - Chung, Minwoong PY - 2017/03/06 TI - Online Self-Tracking Groups to Increase Fruit and Vegetable Intake: A Small-Scale Study on Mechanisms of Group Effect on Behavior Change JO - J Med Internet Res SP - e63 VL - 19 IS - 3 KW - online support group KW - quantified self KW - fruit and vegetable consumption KW - social comparison KW - similarity KW - social modeling N2 - Background: Web-based interventions with a self-tracking component have been found to be effective in promoting adults? fruit and vegetable consumption. However, these interventions primarily focus on individual- rather than group-based self-tracking. The rise of social media technologies enables sharing and comparing self-tracking records in a group context. Therefore, we developed an online group-based self-tracking program to promote fruit and vegetable consumption. Objective: This study aims to examine (1) the effectiveness of online group-based self-tracking on fruit and vegetable consumption and (2) characteristics of online self-tracking groups that make the group more effective in promoting fruit and vegetable consumption in early young adults. Methods: During a 4-week Web-based experiment, 111 college students self-tracked their fruit and vegetable consumption either individually (ie, the control group) or in an online group characterized by a 2 (demographic similarity: demographically similar vs demographically diverse) × 2 (social modeling: incremental change vs ideal change) experimental design. Each online group consisted of one focal participant and three confederates as group members or peers, who had their demographics and fruit and vegetable consumption manipulated to create the four intervention groups. Self-reported fruit and vegetable consumption were assessed using the Food Frequency Questionnaire at baseline and after the 4-week experiment. Results: Participants who self-tracked their fruit and vegetable consumption collectively with other group members consumed more fruits and vegetables than participants who self-tracked individually (P=.01). The results did not show significant main effects of demographic similarity (P=.32) or types of social modeling (P=.48) in making self-tracking groups more effective in promoting fruit and vegetable consumption. However, additional analyses revealed the main effect of performance discrepancy (ie, difference in fruit and vegetable consumption between a focal participant and his/her group members during the experiment), such that participants who had a low performance discrepancy from other group members had greater fruit and vegetable consumption than participants who had a high performance discrepancy from other group members (P=.002). A mediation test showed that low performance discrepancy led to greater downward contrast (b=?0.78, 95% CI ?2.44 to ?0.15), which in turn led to greater fruit and vegetable consumption. Conclusions: Online self-tracking groups were more effective than self-tracking alone in promoting fruit and vegetable consumption for early young adults. Low performance discrepancy from other group members lead to downward contrast, which in turn increased participants? fruit and vegetable consumption over time. The study highlighted social comparison processes in online groups that allow for sharing personal health information. Lastly, given the small scale of this study, nonsignificant results with small effect sizes might be subject to bias. UR - http://www.jmir.org/2017/3/e63/ UR - http://dx.doi.org/10.2196/jmir.6537 UR - http://www.ncbi.nlm.nih.gov/pubmed/28264793 ID - info:doi/10.2196/jmir.6537 ER - TY - JOUR AU - Brown, Menna AU - Glendenning, Alexander AU - Hoon, E. Alice AU - John, Ann PY - 2016/08/24 TI - Effectiveness of Web-Delivered Acceptance and Commitment Therapy in Relation to Mental Health and Well-Being: A Systematic Review and Meta-Analysis JO - J Med Internet Res SP - e221 VL - 18 IS - 8 KW - acceptance and commitment therapy KW - systematic review KW - meta-analysis KW - depression KW - anxiety KW - quality of life KW - Internet-based KW - mobile-based N2 - Background: The need for effective interventions to improve mental health and emotional well-being at a population level are gaining prominence both in the United Kingdom and globally. Advances in technology and widespread adoption of Internet capable devices have facilitated rapid development of Web-delivered psychological therapies. Interventions designed to manage a range of affective disorders by applying diverse therapeutic approaches are widely available. Objective: The main aim of this review was to evaluate the evidence base of acceptance and commitment therapy (ACT) in a Web-based delivery format. Method: A systematic review of the literature and meta-analysis was conducted. Two electronic databases were searched for Web-delivered interventions utilizing ACT for the management of affective disorders or well-being. Only Randomized Controlled Trials (RCTs) were included. Results: The search strategy identified 59 articles. Of these, 10 articles met the inclusion criteria specified. The range of conditions and outcome measures that were identified limited the ability to draw firm conclusions about the efficacy of Web-delivered ACT-based intervention for anxiety or well-being. Conclusions: ACT in a Web-based delivery format was found to be effective in the management of depression. Rates of adherence to study protocols and completion were high overall suggesting that this therapeutic approach is highly acceptable for patients and the general public. UR - http://www.jmir.org/2016/8/e221/ UR - http://dx.doi.org/10.2196/jmir.6200 UR - http://www.ncbi.nlm.nih.gov/pubmed/27558740 ID - info:doi/10.2196/jmir.6200 ER - TY - JOUR AU - Hartin, J. Phillip AU - Nugent, D. Chris AU - McClean, I. Sally AU - Cleland, Ian AU - Tschanz, T. JoAnn AU - Clark, J. Christine AU - Norton, C. Maria PY - 2016/08/02 TI - The Empowering Role of Mobile Apps in Behavior Change Interventions: The Gray Matters Randomized Controlled Trial JO - JMIR Mhealth Uhealth SP - e93 VL - 4 IS - 3 KW - behavior KW - health behavior KW - behavior change KW - motivation KW - Alzheimer disease KW - smartphone N2 - Background: Health education and behavior change programs targeting specific risk factors have demonstrated their effectiveness in reducing the development of future diseases. Alzheimer disease (AD) shares many of the same risk factors, most of which can be addressed via behavior change. It is therefore theorized that a behavior change intervention targeting these risk factors would likely result in favorable rates of AD prevention. Objective: The objective of this study was to reduce the future risk of developing AD, while in the short term promoting vascular health, through behavior change. Methods: The study was an interventional randomized controlled trial consisting of subjects who were randomly assigned into either treatment (n=102) or control group (n=42). Outcome measures included various blood-based biomarkers, anthropometric measures, and behaviors related to AD risk. The treatment group was provided with a bespoke ?Gray Matters? mobile phone app designed to encourage and facilitate behavior change. The app presented evidence-based educational material relating to AD risk and prevention strategies, facilitated self-reporting of behaviors across 6 behavioral domains, and presented feedback on the user?s performance, calculated from reported behaviors against recommended guidelines. Results: This paper explores the rationale for a mobile phone?led intervention and details the app?s effect on behavior change and subsequent clinical outcomes. Via the app, the average participant submitted 7.3 (SD 3.2) behavioral logs/day (n=122,719). Analysis of these logs against primary outcome measures revealed that participants who improved their high-density lipoprotein cholesterol levels during the study duration answered a statistically significant higher number of questions per day (mean 8.30, SD 2.29) than those with no improvement (mean 6.52, SD 3.612), t97.74=?3.051, P=.003. Participants who decreased their body mass index (BMI) performed significantly better in attaining their recommended daily goals (mean 56.21 SD 30.4%) than those who increased their BMI (mean 40.12 SD 29.1%), t80 = ?2.449, P=.017. In total, 69.2% (n=18) of those who achieved a mean performance percentage of 60% or higher, across all domains, reduced their BMI during the study, whereas 60.7% (n=34) who did not, increased their BMI. One-way analysis of variance of systolic blood pressure category changes showed a significant correlation between reported efforts to reduce stress and category change as a whole, P=.035. An exit survey highlighted that respondents (n=83) reported that the app motivated them to perform physical activity (85.4%) and make healthier food choices (87.5%). Conclusions: In this study, the ubiquitous nature of the mobile phone excelled as a delivery platform for the intervention, enabling the dissemination of educational intervention material while simultaneously monitoring and encouraging positive behavior change, resulting in desirable clinical effects. Sustained effort to maintain the achieved behaviors is expected to mitigate future AD risk. Trial Registration: ClinicalTrails.gov NCT02290912; https://clinicaltrials.gov/ct2/show/NCT02290912 (Archived by WebCite at http://www.webcitation.org/6ictUEwnm) UR - http://mhealth.jmir.org/2016/3/e93/ UR - http://dx.doi.org/10.2196/mhealth.4878 UR - http://www.ncbi.nlm.nih.gov/pubmed/27485822 ID - info:doi/10.2196/mhealth.4878 ER - TY - JOUR AU - Chang, Cherng-Shiow Rebecca AU - Lu, Hsi-Peng AU - Yang, Peishan AU - Luarn, Pin PY - 2016/07/05 TI - Reciprocal Reinforcement Between Wearable Activity Trackers and Social Network Services in Influencing Physical Activity Behaviors JO - JMIR Mhealth Uhealth SP - e84 VL - 4 IS - 3 KW - Wearable activity trackers KW - wearables KW - physical activity KW - social support KW - social network services KW - behavior change techniques N2 - Background: Wearable activity trackers (WATs) are emerging consumer electronic devices designed to support physical activities (PAs), which are based on successful behavior change techniques focusing on goal-setting and frequent behavioral feedbacks. Despite their utility, data from both recent academic and market research have indicated high attrition rates of WAT users. Concurrently, evidence shows that social support (SS), delivered/obtained via social network services or sites (SNS), could increase adherence and engagement of PA intervention programs. To date, relatively few studies have looked at how WATs and SS may interact and affect PAs. Objective: The purpose of this study was to explore how these two Internet and mobile technologies, WATs and SNS, could work together to foster sustainable PA behavior changes and habits among middle-aged adults (40-60 years old) in Taiwan. Methods: We used purposive sampling of Executive MBA Students from National Taiwan University of Science and Technology to participate in our qualitative research. In-depth interviews and focus groups were conducted with a total of 15 participants, including 9 WAT users and 6 nonusers. Analysis of the collected materials was done inductively using the thematic approach with no preset categories. Two authors from different professional backgrounds independently annotated and coded the transcripts, and then discussed and debated until consensus was reached on the final themes. Results: The thematic analysis revealed six themes: (1) WATs provided more awareness than motivation in PA with goal-setting and progress monitoring, (2) SS, delivered/obtained via SNS, increased users? adherence and engagement with WATs and vice versa, (3) a broad spectrum of configurations would be needed to deliver WATs with appropriately integrated SS functions, (4) WAT design, style, and appearance mattered even more than those of smartphones, as they are body-worn devices, (5) the user interfaces of WATs left a great deal to be desired, and (6) privacy concerns must be addressed before more mainstream consumers would consider adopting WATs. Conclusions: Participants perceived WATs as an awareness tool to understand one?s PA level. It is evident from our study that SS, derived from SNS and other pertinent vehicles such as the LINE social messaging application (similar to WhatsApp and WeChat), will increase the engagement and adherence of WAT usage. Combining WATs and SNS enables cost-effective, scalable PA intervention programs with end-to-end services and data analytics capabilities, to elevate WATs from one-size-fits-all consumer electronics to personalized PA assistants. UR - http://mhealth.jmir.org/2016/3/e84/ UR - http://dx.doi.org/10.2196/mhealth.5637 UR - http://www.ncbi.nlm.nih.gov/pubmed/27380798 ID - info:doi/10.2196/mhealth.5637 ER - TY - JOUR AU - Rees, Samantha Clare AU - Anderson, Anne Rebecca AU - Kane, Thomas Robert AU - Finlay-Jones, Louise Amy PY - 2016/07/05 TI - Online Obsessive-Compulsive Disorder Treatment: Preliminary Results of the ?OCD? Not Me!? Self-Guided Internet-Based Cognitive Behavioral Therapy Program for Young People JO - JMIR Ment Health SP - e29 VL - 3 IS - 3 KW - adolescent KW - anxiety disorders/therapy KW - Australia KW - Internet KW - obsessive-compulsive disorder KW - self-care KW - therapy KW - computer-assisted/statistics and numerical data KW - treatment outcome KW - young adult KW - iCBT KW - adolescents N2 - Background: The development and evaluation of Internet-delivered cognitive behavioral therapy (iCBT) interventions provides a potential solution for current limitations in the acceptability, availability, and accessibility of mental health care for young people with obsessive-compulsive disorder (OCD). Preliminary results support the effectiveness of therapist-assisted iCBT for young people with OCD; however, no previous studies have examined the effectiveness of completely self-guided iCBT for OCD in young people. Objective: We aimed to conduct a preliminary evaluation of the effectiveness of the OCD? Not Me! program for reducing OCD-related psychopathology in young people (12-18 years). This program is an eight-stage, completely self-guided iCBT treatment for OCD, which is based on exposure and response prevention. Methods: These data were early and preliminary results of a longer study in which an open trial design is being used to evaluate the effectiveness of the OCD? Not Me! program. Participants were required to have at least subclinical levels of OCD to be offered the online program. Participants with moderate-high suicide/self-harm risk or symptoms of eating disorder or psychosis were not offered the program. OCD symptoms and severity were measured at pre- and posttest, and at the beginning of each stage of the program. Data was analyzed using generalized linear mixed models. Results: A total of 334 people were screened for inclusion in the study, with 132 participants aged 12 to 18 years providing data for the final analysis. Participants showed significant reductions in OCD symptoms (P<.001) and severity (P<.001) between pre- and posttest. Conclusions: These preliminary results suggest that fully automated iCBT holds promise as a way of increasing access to treatment for young people with OCD; however, further research needs to be conducted to replicate the results and to determine the feasibility of the program. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000152729; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363654 (Archived by WebCite at http://www.webcitation.org/ 6iD7EDFqH) UR - http://mental.jmir.org/2016/3/e29/ UR - http://dx.doi.org/10.2196/mental.5363 UR - http://www.ncbi.nlm.nih.gov/pubmed/27381977 ID - info:doi/10.2196/mental.5363 ER - TY - JOUR AU - Glasner-Edwards, Suzette AU - Patrick, Kevin AU - Ybarra, L. Michele AU - Reback, J. Cathy AU - Rawson, A. Richard AU - Chokron Garneau, Helene AU - Chavez, Kathryn AU - Venegas, Alexandra PY - 2016/06/24 TI - A Cognitive Behavioral Therapy?Based Text Messaging Intervention Versus Medical Management for HIV-Infected Substance Users: Study Protocol for a Pilot Randomized Trial JO - JMIR Res Protoc SP - e131 VL - 5 IS - 2 KW - SMS KW - medication adherence KW - HIV KW - relapse prevention KW - text messaging KW - CBT KW - ART N2 - Background: Evidence-based psychosocial interventions for addictions and related conditions such as cognitive behavioral therapy (CBT) are underutilized. Obstacles to implementation of CBT in clinical settings include limited availability of quality training, supervision, and certification in CBT for clinicians; high rates of clinician turnover and high caseloads; and limited qualifications of the workforce to facilitate CBT expertise. Objective: Mobile phone?based delivery of CBT, if demonstrated to be feasible and effective, could be transformative in broadening its application and improving the quality of addiction treatment. No experimental interventions that deliver CBT targeting both drug use and medication adherence using text messaging have been previously reported; as such, the objective of this study is to develop and test an SMS-based treatment program for HIV-positive adults with comorbid substance use disorders. Methods: With user input, we developed a 12-week CBT-based text messaging intervention (TXT-CBT) targeting antiretroviral (ART) adherence, risk behaviors, and drug use in a population of HIV-infected substance users. Results: The intervention has been developed and is presently being tested in a pilot randomized clinical trial. Results will be reported later this year. Conclusions: This investigation will yield valuable knowledge about the utility of a cost-effective, readily deployable text messaging behavioral intervention for HIV-infected drug users. UR - http://www.researchprotocols.org/2016/2/e131/ UR - http://dx.doi.org/10.2196/resprot.5407 UR - http://www.ncbi.nlm.nih.gov/pubmed/27341852 ID - info:doi/10.2196/resprot.5407 ER - TY - JOUR AU - van Genugten, Lenneke AU - Dusseldorp, Elise AU - Webb, Llewelyn Thomas AU - van Empelen, Pepijn PY - 2016/06/07 TI - Which Combinations of Techniques and Modes of Delivery in Internet-Based Interventions Effectively Change Health Behavior? A Meta-Analysis JO - J Med Internet Res SP - e155 VL - 18 IS - 6 KW - meta-analysis KW - prevention KW - health behavior KW - behavior change KW - online N2 - Background: Many online interventions designed to promote health behaviors combine multiple behavior change techniques (BCTs), adopt different modes of delivery (MoD) (eg, text messages), and range in how usable they are. Research is therefore needed to examine the impact of these features on the effectiveness of online interventions. Objective: This study applies Classification and Regression Trees (CART) analysis to meta-analytic data, in order to identify synergistic effects of BCTs, MoDs, and usability factors. Methods: We analyzed data from Webb et al. This review included effect sizes from 52 online interventions targeting a variety of health behaviors and coded the use of 40 BCTs and 11 MoDs. Our research also developed a taxonomy for coding the usability of interventions. Meta-CART analyses were performed using the BCTs and MoDs as predictors and using treatment success (ie, effect size) as the outcome. Results: Factors related to usability of the interventions influenced their efficacy. Specifically, subgroup analyses indicated that more efficient interventions (interventions that take little time to understand and use) are more likely to be effective than less efficient interventions. Meta-CART identified one synergistic effect: Interventions that included barrier identification/ problem solving and provided rewards for behavior change reported an average effect size that was smaller (?=0.23, 95% CI 0.08-0.44) than interventions that used other combinations of techniques (?=0.43, 95% CI 0.27-0.59). No synergistic effects were found for MoDs or for MoDs combined with BCTs. Conclusions: Interventions that take little time to understand and use were more effective than those that require more time. Few specific combinations of BCTs that contribute to the effectiveness of online interventions were found. Furthermore, no synergistic effects between BCTs and MoDs were found, even though MoDs had strong effects when analyzed univariately in the original study. UR - http://www.jmir.org/2016/6/e155/ UR - http://dx.doi.org/10.2196/jmir.4218 UR - http://www.ncbi.nlm.nih.gov/pubmed/27268104 ID - info:doi/10.2196/jmir.4218 ER - TY - JOUR AU - Coughlin, Steven AU - Thind, Herpreet AU - Liu, Benyuan AU - Champagne, Nicole AU - Jacobs, Molly AU - Massey, I. Rachael PY - 2016/05/30 TI - Mobile Phone Apps for Preventing Cancer Through Educational and Behavioral Interventions: State of the Art and Remaining Challenges JO - JMIR Mhealth Uhealth SP - e69 VL - 4 IS - 2 KW - mobile phone apps KW - cancer KW - early detection of cancer KW - diet KW - environmental carcinogens KW - health literacy KW - nutrition KW - obesity KW - prevention KW - randomized controlled trials KW - screening KW - smoking KW - sun safety KW - weight loss N2 - Background: Rapid developments in technology have encouraged the use of mobile phones in smoking cessation, promoting healthy diet, nutrition, and physical activity, sun safety, and cancer screening. Although many apps relating to the prevention of cancer and other chronic diseases are available from major mobile phone platforms, relatively few have been tested in research studies to determine their efficacy. Objective: In this paper, we discuss issues related to the development and testing of new apps for preventing cancer through smoking cessation, sun safety, and other healthy behaviors, including key methodologic issues and outstanding challenges. Methods: An exploratory literature review was conducted using bibliographic searches in PubMed and CINAHL with relevant search terms (eg, smartphones, smoking cessation, cancer prevention, cancer screening, and carcinogens) to identify papers published in English through October 2015. Results: Only 4 randomized controlled trials of the use of mobile phone apps for smoking cessation and 2 trials of apps for sun safety were identified, indicating that it is premature to conduct a systematic search and meta-analysis of the published literature on this topic. Conclusions: Future studies should utilize randomized controlled trial research designs, larger sample sizes, and longer study periods to better establish the cancer prevention and control capabilities of mobile phone apps. In developing new and refined apps for cancer prevention and control, both health literacy and eHealth literacy should be taken into account. There is a need for culturally appropriate, tailored health messages to increase knowledge and awareness of health behaviors such as smoking cessation, cancer screening, and sun safety. Mobile phone apps are likely to be a useful and low-cost intervention for preventing cancer through behavioral changes. UR - http://mhealth.jmir.org/2016/2/e69/ UR - http://dx.doi.org/10.2196/mhealth.5361 UR - http://www.ncbi.nlm.nih.gov/pubmed/27242162 ID - info:doi/10.2196/mhealth.5361 ER - TY - JOUR AU - Mercer, Kathryn AU - Li, Melissa AU - Giangregorio, Lora AU - Burns, Catherine AU - Grindrod, Kelly PY - 2016/04/27 TI - Behavior Change Techniques Present in Wearable Activity Trackers: A Critical Analysis JO - JMIR mHealth uHealth SP - e40 VL - 4 IS - 2 KW - older adults KW - physical activity KW - wearables KW - mobile health KW - chronic disease management N2 - Background: Wearable activity trackers are promising as interventions that offer guidance and support for increasing physical activity and health-focused tracking. Most adults do not meet their recommended daily activity guidelines, and wearable fitness trackers are increasingly cited as having great potential to improve the physical activity levels of adults. Objective: The objective of this study was to use the Coventry, Aberdeen, and London-Refined (CALO-RE) taxonomy to examine if the design of wearable activity trackers incorporates behavior change techniques (BCTs). A secondary objective was to critically analyze whether the BCTs present relate to known drivers of behavior change, such as self-efficacy, with the intention of extending applicability to older adults in addition to the overall population. Methods: Wearing each device for a period of 1 week, two independent raters used CALO-RE taxonomy to code the BCTs of the seven wearable activity trackers available in Canada as of March 2014. These included Fitbit Flex, Misfit Shine, Withings Pulse, Jawbone UP24, Spark Activity Tracker by SparkPeople, Nike+ FuelBand SE, and Polar Loop. We calculated interrater reliability using Cohen's kappa. Results: The average number of BCTs identified was 16.3/40. Withings Pulse had the highest number of BCTs and Misfit Shine had the lowest. Most techniques centered around self-monitoring and self-regulation, all of which have been associated with improved physical activity in older adults. Techniques related to planning and providing instructions were scarce. Conclusions: Overall, wearable activity trackers contain several BCTs that have been shown to increase physical activity in older adults. Although more research and development must be done to fully understand the potential of wearables as health interventions, the current wearable trackers offer significant potential with regard to BCTs relevant to uptake by all populations, including older adults. UR - http://mhealth.jmir.org/2016/2/e40/ UR - http://dx.doi.org/10.2196/mhealth.4461 UR - http://www.ncbi.nlm.nih.gov/pubmed/27122452 ID - info:doi/10.2196/mhealth.4461 ER - TY - JOUR AU - Coulson, S. Neil AU - Smedley, Richard AU - Bostock, Sophie AU - Kyle, D. Simon AU - Gollancz, Rosie AU - Luik, I. Annemarie AU - Hames, Peter AU - Espie, A. Colin PY - 2016/04/25 TI - The Pros and Cons of Getting Engaged in an Online Social Community Embedded Within Digital Cognitive Behavioral Therapy for Insomnia: Survey Among Users JO - J Med Internet Res SP - e88 VL - 18 IS - 4 KW - engagement KW - sleep KW - online community KW - discussion forum KW - insomnia KW - cognitive behavioral therapy N2 - Background: Sleepio is a proven digital sleep improvement program based on cognitive behavioral therapy techniques. Users have the option to join an online community that includes weekly expert discussions, peer-to-peer discussion forums, and personal message walls. Objective: The aim of this study was to conduct an online survey to (1) explore the reasons for deciding to engage with the Sleepio online community, (2) explore the potential benefits arising from engagement with the online community, and (3) identify and describe any problematic issues related to use of the online community. Methods: We developed an online survey and posted an invitation to the community discussion forum inviting users to participate. In addition, we sent an email invitation to 970 individuals who had previously or were currently working through the Sleepio program to participate in this study. Results: In total, 100 respondents (70/100, 70% female; mean age 51 years, range 26?82 years) completed the online survey. Most respondents had started Sleepio with chronic sleep problems (59/100, 59% up to 10 years; 35/100, 35% >10 years) and had actively engaged with the online community (85/100, 85%) had made a discussion or wall post). At the time of the survey, respondents had used Sleepio for a median of 12 weeks (range from 3 weeks to 2 years). We analyzed responses to the open-ended questions using thematic analysis. This analysis revealed 5 initial drivers for engagement: (1) the desire to connect with people facing similar issues, (2) seeking personalized advice, (3) curiosity, (4) being invited by other members, and (5) wanting to use all available sleep improvement tools. Advantages of engagement included access to continuous support, a reduced sense of isolation, being part of a nonjudgmental community, personalized advice, positive comparisons with others, encouragement to keep going, and altruism. We found 5 potential disadvantages: design and navigation issues, uncertain quality of user-generated content, negative comparisons with others, excessive time commitments, and data privacy concerns. Participants related their community experiences to engagement with the Sleepio program, with many stating it had supported their efforts to improve their sleep, as well as helping with adherence and commitment to the program. Despite some concerns, members regarded the Sleepio community as a valuable resource. Conclusions: Online communities may be a useful means through which to support long-term engagement with Web-based therapy for insomnia. UR - http://www.jmir.org/2016/4/e88/ UR - http://dx.doi.org/10.2196/jmir.5654 UR - http://www.ncbi.nlm.nih.gov/pubmed/27113540 ID - info:doi/10.2196/jmir.5654 ER - TY - JOUR AU - Sadasivam, Shankar Rajani AU - Cutrona, L. Sarah AU - Kinney, L. Rebecca AU - Marlin, M. Benjamin AU - Mazor, M. Kathleen AU - Lemon, C. Stephenie AU - Houston, K. Thomas PY - 2016/03/07 TI - Collective-Intelligence Recommender Systems: Advancing Computer Tailoring for Health Behavior Change Into the 21st Century JO - J Med Internet Res SP - e42 VL - 18 IS - 3 KW - computer-tailored health communication KW - machine learning KW - recommender systems N2 - Background: What is the next frontier for computer-tailored health communication (CTHC) research? In current CTHC systems, study designers who have expertise in behavioral theory and mapping theory into CTHC systems select the variables and develop the rules that specify how the content should be tailored, based on their knowledge of the targeted population, the literature, and health behavior theories. In collective-intelligence recommender systems (hereafter recommender systems) used by Web 2.0 companies (eg, Netflix and Amazon), machine learning algorithms combine user profiles and continuous feedback ratings of content (from themselves and other users) to empirically tailor content. Augmenting current theory-based CTHC with empirical recommender systems could be evaluated as the next frontier for CTHC. Objective: The objective of our study was to uncover barriers and challenges to using recommender systems in health promotion. Methods: We conducted a focused literature review, interviewed subject experts (n=8), and synthesized the results. Results: We describe (1) limitations of current CTHC systems, (2) advantages of incorporating recommender systems to move CTHC forward, and (3) challenges to incorporating recommender systems into CTHC. Based on the evidence presented, we propose a future research agenda for CTHC systems. Conclusions: We promote discussion of ways to move CTHC into the 21st century by incorporation of recommender systems. UR - http://www.jmir.org/2016/3/e42/ UR - http://dx.doi.org/10.2196/jmir.4448 UR - http://www.ncbi.nlm.nih.gov/pubmed/26952574 ID - info:doi/10.2196/jmir.4448 ER - TY - JOUR AU - Lygidakis, Charilaos AU - Wallace, Paul AU - Tersar, Costanza AU - Marcatto, Francesco AU - Ferrante, Donatella AU - Della Vedova, Roberto AU - Scafuri, Francesca AU - Scafato, Emanuele AU - Struzzo, Pierluigi PY - 2016/03/04 TI - Download Your Doctor: Implementation of a Digitally Mediated Personal Physician Presence to Enhance Patient Engagement With a Health-Promoting Internet Application JO - JMIR Res Protoc SP - e36 VL - 5 IS - 1 KW - alcohol drinking KW - physician-patient relations KW - behavior and behavior mechanisms KW - research design KW - Internet KW - multimedia KW - primary health care KW - family physicians N2 - Background: Brief interventions delivered in primary health care are effective in reducing excessive drinking; online behavior-changing technique interventions may be helpful. Physicians may actively encourage the use of such interventions by helping patients access selected websites (a process known as ?facilitated access?). Although the therapeutic working alliance plays a significant role in the achievement of positive outcomes in face-to-face psychotherapy and its development has been shown to be feasible online, little research has been done on its impact on brief interventions. Strengthening patients? perception of their physician?s endorsement of a website could facilitate the development of an effective alliance between the patient and the app. Objective: We describe the implementation of a digitally mediated personal physician presence to enhance patient engagement with an alcohol-reduction website as part of the experimental online intervention in a noninferiority randomized controlled trial. We also report the feedback of the users on the module. Methods: The Download Your Doctor module was created to simulate the personal physician presence for an alcohol-reduction website that was developed for the EFAR-FVG trial conducted in the Italian region of Friuli-Venezia-Giulia. The module was designed to enhance therapeutic alliance and thus improve outcomes in the intervention group (facilitated access to the website). Participating general and family practitioners could customize messages and visual elements and upload a personal photo, signature, and video recordings. To assess the perceptions and attitudes of the physicians, a semistructured interview was carried out 3 months after the start of the trial. Participating patients were invited to respond to a short online questionnaire 12 months following recruitment to investigate their evaluation of their online experiences. Results: Nearly three-quarters (23/32, 72%) of the physicians interviewed chose to customize the contents of the interaction with their patients using the provided features and acknowledged the ease of use of the online tools. The majority of physicians (21/32, 57%) customized at least the introductory photo and video. Barriers to usage among those who did not customize the contents were time restrictions, privacy concerns, difficulties in using the tools, and considering the approach not useful. Over half (341/620, 55.0%) of participating patients completed the optional questionnaire. Many of them (240/341, 70.4%) recalled having noticed the personalized elements of their physicians, and the majority of those (208/240, 86.7%) reacted positively, considering the personalization to be of either high or the highest importance. Conclusions: The use of a digitally mediated personal physician presence online was both feasible and welcomed by both patients and physicians. Training of the physicians seems to be a key factor in addressing perceived barriers to usage. Further research is recommended to study the mechanisms behind this approach and its impact. Trial Registration: Clinicaltrials.gov NCT 01638338; https://clinicaltrials.gov/ct2/show/NCT01638338 (Archived by WebCite at http://www.webcitation.org/6f0JLZMtq) UR - http://www.researchprotocols.org/2016/1/e36/ UR - http://dx.doi.org/10.2196/resprot.5232 UR - http://www.ncbi.nlm.nih.gov/pubmed/26944482 ID - info:doi/10.2196/resprot.5232 ER - TY - JOUR AU - Davis, F. Siena AU - Ellsworth, A. Marisa AU - Payne, E. Hannah AU - Hall, M. Shelby AU - West, H. Joshua AU - Nordhagen, L. Amber PY - 2016/03/02 TI - Health Behavior Theory in Popular Calorie Counting Apps: A Content Analysis JO - JMIR mHealth uHealth SP - e19 VL - 4 IS - 1 KW - cell phones KW - mobile applications KW - telemedicine KW - weight loss KW - caloric restriction N2 - Background: Although the Health & Fitness category of the Apple App Store features hundreds of calorie counting apps, the extent to which popular calorie counting apps include health behavior theory is unknown. Objective: This study evaluates the presence of health behavior theory in calorie counting apps. Methods: Data for this study came from an extensive content analysis of the 10 most popular calorie counting apps in the Health & Fitness category of the Apple App Store. Results: Each app was given a theory score to reflect the extent to which health behavior theory was integrated into the app. The highest possible score was 60. Out of the 10 apps evaluated, My Diet Coach obtained the highest theory score of 15. MapMyFitness and Yumget received the lowest scores of 0. The average theory score among the apps was 5.6. Conclusions: Most of the calorie counting apps in the sample contained minimal health behavior theory. UR - http://mhealth.jmir.org/2016/1/e19/ UR - http://dx.doi.org/10.2196/mhealth.4177 UR - http://www.ncbi.nlm.nih.gov/pubmed/26935898 ID - info:doi/10.2196/mhealth.4177 ER - TY - JOUR AU - Hales, Sarah AU - Turner-McGrievy, Gabrielle AU - Fahim, Arjang AU - Freix, Andrew AU - Wilcox, Sara AU - Davis, E. Rachel AU - Huhns, Michael AU - Valafar, Homayoun PY - 2016/02/12 TI - A Mixed-Methods Approach to the Development, Refinement, and Pilot Testing of Social Networks for Improving Healthy Behaviors JO - JMIR Human Factors SP - e8 VL - 3 IS - 1 KW - mHealth KW - obesity KW - weight loss KW - social support KW - social cognitive theory N2 - Background: Mobile health (mHealth) has shown promise as a way to deliver weight loss interventions, including connecting users for social support. Objective: To develop, refine, and pilot test the Social Pounds Off Digitally (POD) Android app for personalized health monitoring and interaction. Methods: Adults who were overweight and obese with Android smartphones (BMI 25-49.9 kg/m2; N=9) were recruited for a 2-month weight loss pilot intervention and iterative usability testing of the Social POD app. The app prompted participants via notification to track daily weight, diet, and physical activity behaviors. Participants received the content of the behavioral weight loss intervention via podcast. In order to re-engage infrequent users (did not use the app within the previous 48 hours), the app prompted frequent users to select 1 of 3 messages to send to infrequent users targeting the behavioral theory constructs social support, self-efficacy, or negative outcome expectations. Body weight, dietary intake (2 24-hr recalls), and reported calories expended during physical activity were assessed at baseline and 2 months. All participants attended 1 of 2 focus groups to provide feedback on use of the app. Results: Participants lost a mean of 0.94 kg (SD 2.22, P=.24) and consumed significantly fewer kcals postintervention (1570 kcal/day, SD 508) as compared to baseline (2384 kcal/day, SD 993, P=.01). Participants reported expending a mean of 171 kcal/day (SD 153) during intentional physical activity following the intervention as compared to 138 kcal/day (SD 139) at baseline, yet this was not a statistically significant difference (P=.57). There was not a statistically significant correlation found between total app entries and percent weight loss over the course of the intervention (r=.49, P=.19). Mean number of app entries was 77.2 (SD 73.8) per person with a range of 0 to 219. Messages targeting social support were selected most often (32/68, 47%), followed by self-efficacy (28/68, 41%), and negative outcome expectations (8/68, 12%). Themes from the focus groups included functionality issues, revisions to the messaging system, and the addition of a point system with rewards for achieving goals. Conclusions: The Social POD app provides an innovative way to re-engage infrequent users by encouraging frequent users to provide social support. Although more time is needed for development, this mHealth intervention can be disseminated broadly for many years and to many individuals without the need for additional intensive in-person hours. UR - http://humanfactors.jmir.org/2016/1/e8/ UR - http://dx.doi.org/10.2196/humanfactors.4512 UR - http://www.ncbi.nlm.nih.gov/pubmed/27026535 ID - info:doi/10.2196/humanfactors.4512 ER - TY - JOUR AU - Pagoto, Sherry AU - Waring, E. Molly AU - May, N. Christine AU - Ding, Y. Eric AU - Kunz, H. Werner AU - Hayes, Rashelle AU - Oleski, L. Jessica PY - 2016/01/29 TI - Adapting Behavioral Interventions for Social Media Delivery JO - J Med Internet Res SP - e24 VL - 18 IS - 1 KW - social media KW - behavioral interventions KW - health behavior KW - online social networks UR - http://www.jmir.org/2016/1/e24/ UR - http://dx.doi.org/10.2196/jmir.5086 UR - http://www.ncbi.nlm.nih.gov/pubmed/26825969 ID - info:doi/10.2196/jmir.5086 ER - TY - JOUR AU - Sawesi, Suhila AU - Rashrash, Mohamed AU - Phalakornkule, Kanitha AU - Carpenter, S. Janet AU - Jones, F. Josette PY - 2016/01/21 TI - The Impact of Information Technology on Patient Engagement and Health Behavior Change: A Systematic Review of the Literature JO - JMIR Med Inform SP - e1 VL - 4 IS - 1 KW - patient engagement KW - patient behavior KW - technology KW - Internet KW - web-based KW - cell phone KW - social media N2 - Background: Advancements in information technology (IT) and its increasingly ubiquitous nature expand the ability to engage patients in the health care process and motivate health behavior change. Objective: Our aim was to systematically review the (1) impact of IT platforms used to promote patients? engagement and to effect change in health behaviors and health outcomes, (2) behavior theories or models applied as bases for developing these interventions and their impact on health outcomes, (3) different ways of measuring health outcomes, (4) usability, feasibility, and acceptability of these technologies among patients, and (5) challenges and research directions for implementing IT platforms to meaningfully impact patient engagement and health outcomes. Methods: PubMed, Web of Science, PsycINFO, and Google Scholar were searched for studies published from 2000 to December 2014. Two reviewers assessed the quality of the included papers, and potentially relevant studies were retrieved and assessed for eligibility based on predetermined inclusion criteria. Results: A total of 170 articles met the inclusion criteria and were reviewed in detail. Overall, 88.8% (151/170) of studies showed positive impact on patient behavior and 82.9% (141/170) reported high levels of improvement in patient engagement. Only 47.1% (80/170) referenced specific behavior theories and only 33.5% (57/170) assessed the usability of IT platforms. The majority of studies used indirect ways to measure health outcomes (65.9%, 112/170). Conclusions: In general, the review has shown that IT platforms can enhance patient engagement and improve health outcomes. Few studies addressed usability of these interventions, and the reason for not using specific behavior theories remains unclear. Further research is needed to clarify these important questions. In addition, an assessment of these types of interventions should be conducted based on a common framework using a large variety of measurements; these measurements should include those related to motivation for health behavior change, long-standing adherence, expenditure, satisfaction, and health outcomes. UR - http://medinform.jmir.org/2016/1/e1/ UR - http://dx.doi.org/10.2196/medinform.4514 UR - http://www.ncbi.nlm.nih.gov/pubmed/26795082 ID - info:doi/10.2196/medinform.4514 ER - TY - JOUR AU - Sze, Yan Yan AU - Daniel, Oluyomi Tinuke AU - Kilanowski, K. Colleen AU - Collins, Lorraine R. AU - Epstein, H. Leonard PY - 2015/12/16 TI - Web-Based and Mobile Delivery of an Episodic Future Thinking Intervention for Overweight and Obese Families: A Feasibility Study JO - JMIR mHealth uHealth SP - e97 VL - 3 IS - 4 KW - obesity KW - ecological momentary intervention KW - episodic future thinking KW - Web-based KW - health behavior N2 - Background: The bias toward immediate gratification is associated with maladaptive eating behaviors and has been cross-sectionally and prospectively related to obesity. Engaging in episodic future thinking, which involves mental self-projection to pre-experience future events, reduces this bias and energy intake in overweight/obese adults and children. To examine how episodic future thinking can be incorporated into clinical interventions, a Web-based system was created to provide training for adults and children in their everyday lives. Objective: Our study examined the technical feasibility, usability, and acceptability of a Web-based system that is accessible by mobile devices and adapts episodic future thinking for delivery in family-based obesity interventions. Methods: We recruited 20 parent-child dyads (N=40) from the surrounding community and randomized to episodic future thinking versus a nutritional information thinking control to test the feasibility of a 4-week Web-based intervention. Parents were 44.1 (SD 7.8) years of age with BMI of 34.2 (SD 6.8) kg/m2. Children were 11.0 (SD 1.3) years of age with BMI percentile of 96.0 (SD 1.8). Families met weekly with a case manager for 4 weeks and used the system daily. Adherence was collected through the Web-based system, and perceived acceptance of the Web-based system was assessed postintervention. Measurements of body composition and dietary intake were collected at baseline and after the 4 weeks of intervention. Results: All 20 families completed the intervention and attended all sessions. Results showed parents and children had high adherence to the Web-based system and perceived it to be easy to use, useful, and helpful. No differences between conditions were found in adherence for parents (P=.65) or children (P=.27). In addition, results suggest that basic nutrition information along with episodic future thinking delivered through our Web-based system may reduce energy intake and weight. Conclusions: We showed that our Web-based system is an accepted technology and a feasible utility. Furthermore, results provide initial evidence that our system can be incorporated into family-based treatments targeting behaviors related to weight control. These results show promising utility in using our Web-based system in interventions. UR - http://mhealth.jmir.org/2015/4/e97/ UR - http://dx.doi.org/10.2196/mhealth.4603 UR - http://www.ncbi.nlm.nih.gov/pubmed/26678959 ID - info:doi/10.2196/mhealth.4603 ER - TY - JOUR AU - Spark, C. Lauren AU - Fjeldsoe, S. Brianna AU - Eakin, G. Elizabeth AU - Reeves, M. Marina PY - 2015/09/15 TI - Efficacy of a Text Message-Delivered Extended Contact Intervention on Maintenance of Weight Loss, Physical Activity, and Dietary Behavior Change JO - JMIR mHealth uHealth SP - e88 VL - 3 IS - 3 KW - weight KW - physical activity KW - diet KW - mobile telephone KW - intervention KW - behavior change KW - maintenance KW - SMS KW - mhealth KW - textmessaging N2 - Background: Extending contact with participants after the end of an initial intervention is associated with successful maintenance of weight loss and behavior change. However, cost-effective methods of extending intervention contact are needed. Objective: This study investigated whether extended contact via text message was efficacious in supporting long-term weight loss and physical activity and dietary behavior change in breast cancer survivors. Methods: Following the end of an initial 6-month randomized controlled trial of a telephone-delivered weight loss intervention versus usual care, eligible and consenting intervention participants received a 6-month extended contact intervention via tailored text messages targeting a range of factors proposed to influence the maintenance of behavior change. In this single-group, pre-post designed study, within group changes in weight, moderate-to-vigorous physical activity (Actigraph GT3X+ accelerometers), and total energy intake (2x24 hour dietary recalls) were evaluated from baseline to end of initial intervention (6 months), end of extended contact intervention (12 months), and after a no-contact follow-up (18 months) via linear mixed models. Feasibility of implementation was assessed through systematic tracking of text message delivery process outcomes, and participant satisfaction was assessed through semistructured interviews. Results: Participants at baseline (n=29) had a mean age of 54.9 years (SD 8.8), body mass index of 30.0 kg/m2 (SD 4.2), and were recruited a mean 16.6 months (SD 3.2) post diagnosis. From baseline to 18 months, participants showed statistically significantly lower mean weight (-4.2 kg [95% CI -6.0 to -2.4]; P<.001) and higher physical activity (mean 10.4 mins/day [95% CI 3.6-17.2]; P=.003), but no significant differences in energy intake (P=.200). Participants received a mean of 8 text messages every 2 weeks (range 2-11) and reported a high rate of satisfaction. Conclusions: In comparison to interventions without extended contact, results suggest text message?delivered extended contact may support the attenuation of weight regain and promote the maintenance of physical activity. UR - http://mhealth.jmir.org/2015/3/e88/ UR - http://dx.doi.org/10.2196/mhealth.4114 UR - http://www.ncbi.nlm.nih.gov/pubmed/26373696 ID - info:doi/10.2196/mhealth.4114 ER - TY - JOUR AU - Almeida, A. Fabio AU - Smith-Ray, L. Renae AU - Dzewaltowski, A. David AU - Glasgow, E. Russell AU - Lee, E. Rebecca AU - Thomas, SK Deborah AU - Xu, Stanley AU - Estabrooks, A. Paul PY - 2015/08/24 TI - An Interactive Computer Session to Initiate Physical Activity in Sedentary Cardiac Patients: Randomized Controlled Trial JO - J Med Internet Res SP - e206 VL - 17 IS - 8 KW - exercise, physical KW - treadmill test KW - human computer interaction KW - behavioral research KW - cardiovascular diseases KW - interactive media N2 - Background: Physical activity (PA) improves many facets of health. Despite this, the majority of American adults are insufficiently active. Adults who visit a physician complaining of chest pain and related cardiovascular symptoms are often referred for further testing. However, when this testing does not reveal an underlying disease or pathology, patients typically receive no additional standard care services. A PA intervention delivered within the clinic setting may be an effective strategy for improving the health of this population at a time when they may be motivated to take preventive action. Objective: Our aim was to determine the effectiveness of a tailored, computer-based, interactive personal action planning session to initiate PA among a group of sedentary cardiac patients following exercise treadmill testing (ETT). Methods: This study was part of a larger 2x2 randomized controlled trial to determine the impact of environmental and social-cognitive intervention approaches on the initiation and maintenance of weekly PA for patients post ETT. Participants who were referred to an ETT center but had a negative-test (ie, stress tests results indicated no apparent cardiac issues) were randomized to one of four treatment arms: (1) increased environmental accessibility to PA resources via the provision of a free voucher to a fitness facility in close proximity to their home or workplace (ENV), (2) a tailored social cognitive intervention (SC) using a ?5 As?-based (ask, advise, assess, assist, and arrange) personal action planning tool, (3) combined intervention of both ENV and SC approaches (COMBO), or (4) a matched contact nutrition control (CON). Each intervention was delivered using a computer-based interactive session. A general linear model for repeated measures was conducted with change in PA behavior from baseline to 1-month post interactive computer session as the primary outcome. Results: Sedentary participants (n=452; 34.7% participation rate) without a gym membership (mean age 58.57 years; 59% female, 78% white, 12% black, 11% Hispanic) completed a baseline assessment and an interactive computer session. PA increased across the study sample (F1,441=30.03, P<.001). However, a time by condition interaction (F3,441=8.33, P<.001) followed by post hoc analyses indicated that SC participants exhibited a significant increase in weekly PA participation (mean 45.1, SD 10.2) compared to CON (mean -2.5, SD 10.8, P=.004) and ENV (mean 8.3, SD 8.1, P<.05). Additionally, COMBO participants exhibited a significant increase in weekly PA participation (mean 53.4, SD 8.9) compared to CON (P<.001) and ENV (P=.003) participants. There were no significant differences between ENV and CON or between SC and COMBO. Conclusions: A brief, computer-based, interactive personal action planning session may be an effective tool to initiate PA within a health care setting, in particular as part of the ETT system. Trial Registration: Clinicaltrials.gov NCT00432133, http://clinicaltrials.gov/ct2/show/NCT00432133 (Archived by WebCite at http://www.webcitation.org/6aa8X3mw1). UR - http://www.jmir.org/2015/8/e206/ UR - http://dx.doi.org/10.2196/jmir.3759 UR - http://www.ncbi.nlm.nih.gov/pubmed/26303347 ID - info:doi/10.2196/jmir.3759 ER - TY - JOUR AU - Litman, Leib AU - Rosen, Zohn AU - Spierer, David AU - Weinberger-Litman, Sarah AU - Goldschein, Akiva AU - Robinson, Jonathan PY - 2015/8/14 TI - Mobile Exercise Apps and Increased Leisure Time Exercise Activity: A Moderated Mediation Analysis of the Role of Self-Efficacy and Barriers JO - J Med Internet Res SP - e195 VL - 17 IS - 8 KW - mobile health KW - apps KW - exercise KW - barriers to exercise KW - self-efficacy KW - BMI N2 - Background: There are currently over 1000 exercise apps for mobile devices on the market. These apps employ a range of features, from tracking exercise activity to providing motivational messages. However, virtually nothing is known about whether exercise apps improve exercise levels and health outcomes and, if so, the mechanisms of these effects. Objective: Our aim was to examine whether the use of exercise apps is associated with increased levels of exercise and improved health outcomes. We also develop a framework within which to understand how exercise apps may affect health and test multiple models of possible mechanisms of action and boundary conditions of these relationships. Within this framework, app use may increase physical activity by influencing variables such as self-efficacy and may help to overcome exercise barriers, leading to improved health outcomes such as lower body mass index (BMI). Methods: In this study, 726 participants with one of three backgrounds were surveyed about their use of exercise apps and health: (1) those who never used exercise apps, (2) those who used exercise apps but discontinued use, and (3) those who are currently using exercise apps. Participants were asked about their long-term levels of exercise and about their levels of exercise during the previous week with the International Physical Activity Questionnaire (IPAQ). Results: Nearly three-quarters of current app users reported being more active compared to under half of non-users and past users. The IPAQ showed that current users had higher total leisure time metabolic equivalent of task (MET) expenditures (1169 METs), including walking and vigorous exercise, compared to those who stopped using their apps (612 METs) or who never used apps (577 METs). Importantly, physical activity levels in domains other than leisure time activity were similar across the groups. The results also showed that current users had lower BMI (25.16) than past users (26.8) and non-users (26.9) and that this association was mediated by exercise levels and self-efficacy. That relationship was also moderated by perceived barriers to exercise. Multiple serial mediation models were tested, which revealed that the association between app use and BMI is mediated by increased self-efficacy and increased exercise. Conclusions: Exercise app users are more likely to exercise during their leisure time, compared to those who do not use exercise apps, essentially fulfilling the role that many of these apps were designed to accomplish. Data also suggest that one way that exercise apps may increase exercise levels and health outcomes such as BMI is by making it easier for users to overcome barriers to exercise, leading to increased self-efficacy. We discuss ways of improving the effectiveness of apps by incorporating theory-driven approaches. We conclude that exercise apps can be viewed as intervention delivery systems consisting of features that help users overcome specific barriers. UR - http://www.jmir.org/2015/8/e195/ UR - http://dx.doi.org/10.2196/jmir.4142 UR - http://www.ncbi.nlm.nih.gov/pubmed/26276227 ID - info:doi/10.2196/jmir.4142 ER - TY - JOUR AU - Payne, E. Hannah AU - Moxley, BA Victor AU - MacDonald, Elizabeth PY - 2015/07/13 TI - Health Behavior Theory in Physical Activity Game Apps: A Content Analysis JO - JMIR Serious Games SP - e4 VL - 3 IS - 2 KW - health and fitness apps KW - mobile phone KW - behavioral health KW - theory KW - content analysis KW - physical activity N2 - Background: Physical activity games developed for a mobile phone platform are becoming increasingly popular, yet little is known about their content or inclusion of health behavior theory (HBT). Objective: The objective of our study was to quantify elements of HBT in physical activity games developed for mobile phones and to assess the relationship between theoretical constructs and various app features. Methods: We conducted an analysis of exercise and physical activity game apps in the Apple App Store in the fall of 2014. A total of 52 apps were identified and rated for inclusion of health behavior theoretical constructs using an established theory-based rubric. Each app was coded for 100 theoretical items, containing 5 questions for 20 different constructs. Possible total theory scores ranged from 0 to 100. Descriptive statistics and Spearman correlations were used to describe the HBT score and association with selected app features, respectively. Results: The average HBT score in the sample was 14.98 out of 100. One outlier, SuperBetter, scored higher than the other apps with a score of 76. Goal setting, self-monitoring, and self-reward were the most-reported constructs found in the sample. There was no association between either app price and theory score (P=.5074), or number of gamification elements and theory score (P=.5010). However, Superbetter, with the highest HBT score, was also the most expensive app. Conclusions: There are few content analyses of serious games for health, but a comparison between these findings and previous content analyses of non-game health apps indicates that physical activity mobile phone games demonstrate higher levels of behavior theory. The most common theoretical constructs found in this sample are known to be efficacious elements in physical activity interventions. It is unclear, however, whether app designers consciously design physical activity mobile phone games with specific constructs in mind; it may be that games lend themselves well to inclusion of theory and any constructs found in significant levels are coincidental. Health games developed for mobile phones could be potentially used in health interventions, but collaboration between app designers and behavioral specialists is crucial. Additionally, further research is needed to better characterize mobile phone health games and the relative importance of educational elements versus gamification elements in long-term behavior change. UR - http://games.jmir.org/2015/2/e4/ UR - http://dx.doi.org/10.2196/games.4187 UR - http://www.ncbi.nlm.nih.gov/pubmed/26168926 ID - info:doi/10.2196/games.4187 ER - TY - JOUR AU - ter Huurne, D. Elke AU - de Haan, A. Hein AU - Postel, G. Marloes AU - van der Palen, Job AU - VanDerNagel, EL Joanne AU - DeJong, AJ Cornelis PY - 2015/06/18 TI - Web-Based Cognitive Behavioral Therapy for Female Patients With Eating Disorders: Randomized Controlled Trial JO - J Med Internet Res SP - e152 VL - 17 IS - 6 KW - eating disorders KW - bulimia nervosa KW - binge-eating disorder KW - eating disorders not otherwise specified KW - randomized controlled trial KW - eHealth KW - Web-based treatment KW - asynchronous therapeutic support KW - treatment effectiveness KW - cognitive behavioral therapy N2 - Background: Many patients with eating disorders do not receive help for their symptoms, even though these disorders have severe morbidity. The Internet may offer alternative low-threshold treatment interventions. Objective: This study evaluated the effects of a Web-based cognitive behavioral therapy (CBT) intervention using intensive asynchronous therapeutic support to improve eating disorder psychopathology, and to reduce body dissatisfaction and related health problems among patients with eating disorders. Methods: A two-arm open randomized controlled trial comparing a Web-based CBT intervention to a waiting list control condition (WL) was carried out among female patients with bulimia nervosa (BN), binge eating disorder (BED), and eating disorders not otherwise specified (EDNOS). The eating disorder diagnosis was in accordance with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and was established based on participants? self-report. Participants were recruited from an open-access website, and the intervention consisted of a structured two-part program within a secure Web-based application. The aim of the first part was to analyze participant?s eating attitudes and behaviors, while the second part focused on behavioral change. Participants had asynchronous contact with a personal therapist twice a week, solely via the Internet. Self-report measures of eating disorder psychopathology (primary outcome), body dissatisfaction, physical health, mental health, self-esteem, quality of life, and social functioning were completed at baseline and posttest. Results: A total of 214 participants were randomized to either the Web-based CBT group (n=108) or to the WL group (n=106) stratified by type of eating disorder (BN: n=44; BED: n=85; EDNOS: n=85). Study attrition was low with 94% of the participants completing the posttest assignment. Overall, Web-based CBT showed a significant improvement over time for eating disorder psychopathology (F97=63.07, P<.001, d=.82) and all secondary outcome measures (effect sizes between d=.34 to d=.49), except for Body Mass Index. WL participants also improved on most outcomes; however, effects were smaller in this group with significant between-group effects for eating disorder psychopathology (F201=9.42, P=.002, d=.44), body dissatisfaction (F201=13.16, P<.001, d=.42), physical health (F200=12.55, P<.001, d=.28), mental health (F203=4.88, P=.028, d=.24), self-esteem (F202=5.06, P=.026, d=.20), and social functioning (F205=7.93, P=.005, d=.29). Analyses for the individual subgroups BN, BED, and EDNOS showed that eating disorder psychopathology improved significantly over time among Web-based CBT participants in all three subgroups; however, the between-group effect was significant only for participants with BED (F78=4.25, P=.043, d=.61). Conclusions: Web-based CBT proved to be effective in improving eating disorder psychopathology and related health among female patients with eating disorders. Trial Registration: Nederlands Trial Register (NTR): NTR2415; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2415 (Archived by WebCite at http://www.webcitation.org/6T2io3DnJ). UR - http://www.jmir.org/2015/6/e152/ UR - http://dx.doi.org/10.2196/jmir.3946 UR - http://www.ncbi.nlm.nih.gov/pubmed/26088580 ID - info:doi/10.2196/jmir.3946 ER - TY - JOUR AU - Crane, David AU - Garnett, Claire AU - Brown, James AU - West, Robert AU - Michie, Susan PY - 2015/05/14 TI - Behavior Change Techniques in Popular Alcohol Reduction Apps: Content Analysis JO - J Med Internet Res SP - e118 VL - 17 IS - 5 KW - alcohol KW - behaviour change KW - mHealth KW - smartphone KW - iPhone KW - android KW - apps KW - digital KW - intervention N2 - Background: Mobile phone apps have the potential to reduce excessive alcohol consumption cost-effectively. Although hundreds of alcohol-related apps are available, there is little information about the behavior change techniques (BCTs) they contain, or the extent to which they are based on evidence or theory and how this relates to their popularity and user ratings. Objective: Our aim was to assess the proportion of popular alcohol-related apps available in the United Kingdom that focus on alcohol reduction, identify the BCTs they contain, and explore whether BCTs or the mention of theory or evidence is associated with app popularity and user ratings. Methods: We searched the iTunes and Google Play stores with the terms ?alcohol? and ?drink?, and the first 800 results were classified into alcohol reduction, entertainment, or blood alcohol content measurement. Of those classified as alcohol reduction, all free apps and the top 10 paid apps were coded for BCTs and for reference to evidence or theory. Measures of popularity and user ratings were extracted. Results: Of the 800 apps identified, 662 were unique. Of these, 13.7% (91/662) were classified as alcohol reduction (95% CI 11.3-16.6), 53.9% (357/662) entertainment (95% CI 50.1-57.7), 18.9% (125/662) blood alcohol content measurement (95% CI 16.1-22.0) and 13.4% (89/662) other (95% CI 11.1-16.3). The 51 free alcohol reduction apps and the top 10 paid apps contained a mean of 3.6 BCTs (SD 3.4), with approximately 12% (7/61) not including any BCTs. The BCTs used most often were ?facilitate self-recording? (54%, 33/61), ?provide information on consequences of excessive alcohol use and drinking cessation? (43%, 26/61), ?provide feedback on performance? (41%, 25/61), ?give options for additional and later support? (25%, 15/61) and ?offer/direct towards appropriate written materials? (23%, 14/61). These apps also rarely included any of the 22 BCTs frequently used in other health behavior change interventions (mean 2.46, SD 2.06). Evidence was mentioned by 16.4% of apps, and theory was not mentioned by any app. Multivariable regression showed that apps including advice on environmental restructuring were associated with lower user ratings (?=-46.61, P=.04, 95% CI -91.77 to -1.45) and that both the techniques of ?advise on/facilitate the use of social support? (?=2549.21, P=.04, 95% CI 96.75-5001.67) and the mention of evidence (?=1376.74, P=.02, 95%, CI 208.62-2544.86) were associated with the popularity of the app. Conclusions: Only a minority of alcohol-related apps promoted health while the majority implicitly or explicitly promoted the use of alcohol. Alcohol-related apps that promoted health contained few BCTs and none referred to theory. The mention of evidence was associated with more popular apps, but popularity and user ratings were only weakly associated with the BCT content. UR - http://www.jmir.org/2015/5/e118/ UR - http://dx.doi.org/10.2196/jmir.4060 UR - http://www.ncbi.nlm.nih.gov/pubmed/25977135 ID - info:doi/10.2196/jmir.4060 ER - TY - JOUR AU - Cheek, Colleen AU - Fleming, Theresa AU - Lucassen, FG Mathijs AU - Bridgman, Heather AU - Stasiak, Karolina AU - Shepherd, Matthew AU - Orpin, Peter PY - 2015/04/21 TI - Integrating Health Behavior Theory and Design Elements in Serious Games JO - JMIR Mental Health SP - e11 VL - 2 IS - 2 KW - depression KW - adolescent KW - cognitive behavior therapy KW - online intervention KW - user-centered KW - self-efficacy KW - motivation KW - adherence KW - SPARX N2 - Background: Internet interventions for improving health and well-being have the potential to reach many people and fill gaps in service provision. Serious gaming interfaces provide opportunities to optimize user adherence and impact. Health interventions based in theory and evidence and tailored to psychological constructs have been found to be more effective to promote behavior change. Defining the design elements which engage users and help them to meet their goals can contribute to better informed serious games. Objective: To elucidate design elements important in SPARX, a serious game for adolescents with depression, from a user-centered perspective. Methods: We proposed a model based on an established theory of health behavior change and practical features of serious game design to organize ideas and rationale. We analyzed data from 5 studies comprising a total of 22 focus groups and 66 semistructured interviews conducted with youth and families in New Zealand and Australia who had viewed or used SPARX. User perceptions of the game were applied to this framework. Results: A coherent framework was established using the three constructs of self-determination theory (SDT), autonomy, competence, and relatedness, to organize user perceptions and design elements within four areas important in design: computer game, accessibility, working alliance, and learning in immersion. User perceptions mapped well to the framework, which may assist developers in understanding the context of user needs. By mapping these elements against the constructs of SDT, we were able to propose a sound theoretical base for the model. Conclusions: This study?s method allowed for the articulation of design elements in a serious game from a user-centered perspective within a coherent overarching framework. The framework can be used to deliberately incorporate serious game design elements that support a user?s sense of autonomy, competence, and relatedness, key constructs which have been found to mediate motivation at all stages of the change process. The resulting model introduces promising avenues for future exploration. Involving users in program design remains an imperative if serious games are to be fit for purpose. UR - http://mental.jmir.org/2015/2/e11/ UR - http://dx.doi.org/10.2196/mental.4133 UR - http://www.ncbi.nlm.nih.gov/pubmed/26543916 ID - info:doi/10.2196/mental.4133 ER - TY - JOUR AU - Yardley, Lucy AU - Morrison, Leanne AU - Bradbury, Katherine AU - Muller, Ingrid PY - 2015/01/30 TI - The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions JO - J Med Internet Res SP - e30 VL - 17 IS - 1 KW - person-based approach KW - Internet KW - qualitative research KW - evaluation studies KW - feasibility studies KW - health promotion KW - patient education KW - professional education KW - behavior change. UR - http://www.jmir.org/2015/1/e30/ UR - http://dx.doi.org/10.2196/jmir.4055 UR - http://www.ncbi.nlm.nih.gov/pubmed/25639757 ID - info:doi/10.2196/jmir.4055 ER - TY - JOUR AU - Lyons, J. Elizabeth AU - Lewis, H. Zakkoyya AU - Mayrsohn, G. Brian AU - Rowland, L. Jennifer PY - 2014/08/15 TI - Behavior Change Techniques Implemented in Electronic Lifestyle Activity Monitors: A Systematic Content Analysis JO - J Med Internet Res SP - e192 VL - 16 IS - 8 KW - electronic activity monitor KW - mobile KW - mhealth KW - physical activity KW - behavior change technique N2 - Background: Electronic activity monitors (such as those manufactured by Fitbit, Jawbone, and Nike) improve on standard pedometers by providing automated feedback and interactive behavior change tools via mobile device or personal computer. These monitors are commercially popular and show promise for use in public health interventions. However, little is known about the content of their feedback applications and how individual monitors may differ from one another. Objective: The purpose of this study was to describe the behavior change techniques implemented in commercially available electronic activity monitors. Methods: Electronic activity monitors (N=13) were systematically identified and tested by 3 trained coders for at least 1 week each. All monitors measured lifestyle physical activity and provided feedback via an app (computer or mobile). Coding was based on a hierarchical list of 93 behavior change techniques. Further coding of potentially effective techniques and adherence to theory-based recommendations were based on findings from meta-analyses and meta-regressions in the research literature. Results: All monitors provided tools for self-monitoring, feedback, and environmental change by definition. The next most prevalent techniques (13 out of 13 monitors) were goal-setting and emphasizing discrepancy between current and goal behavior. Review of behavioral goals, social support, social comparison, prompts/cues, rewards, and a focus on past success were found in more than half of the systems. The monitors included a range of 5-10 of 14 total techniques identified from the research literature as potentially effective. Most of the monitors included goal-setting, self-monitoring, and feedback content that closely matched recommendations from social cognitive theory. Conclusions: Electronic activity monitors contain a wide range of behavior change techniques typically used in clinical behavioral interventions. Thus, the monitors may represent a medium by which these interventions could be translated for widespread use. This technology has broad applications for use in clinical, public health, and rehabilitation settings. UR - http://www.jmir.org/2014/8/e192/ UR - http://dx.doi.org/10.2196/jmir.3469 UR - http://www.ncbi.nlm.nih.gov/pubmed/25131661 ID - info:doi/10.2196/jmir.3469 ER -