Design and formative evaluation of a virtual voice-based coach for problem-solving treatment: Observational study

BACKGROUND: Artificial intelligence has provided new opportunities for human interactions with technology for the practice of medicine. Among the recent artificial intelligence innovations, personal voice assistants have been broadly adopted. This highlights their potential for health care-related applications such as behavioral counseling to promote healthy lifestyle habits and emotional well-being. However, the use of voice-based applications for behavioral therapy has not been previously evaluated. OBJECTIVE: This study aimed to conduct a formative user evaluation of Lumen, a virtual voice-based coach developed as an Alexa skill that delivers evidence-based, problem-solving treatment for patients with mild to moderate depression and/or anxiety. METHODS: A total of 26 participants completed 2 therapy sessions-an introductory (session 1) and a problem-solving (session 2)-with Lumen. Following each session with Lumen, participants completed user experience, task-related workload, and work alliance surveys. They also participated in semistructured interviews addressing the benefits, challenges and barriers to Lumen use, and design recommendations. We evaluated the differences in user experience, task load, and work alliance between sessions using 2-tailed paired t tests. Interview transcripts were coded using an inductive thematic analysis to characterize the participants\u27 perspectives regarding Lumen use. RESULTS: Participants found Lumen to provide high pragmatic usability and favorable user experience, with marginal task load during interactions for both Lumen sessions. However, participants experienced a higher temporal workload during the problem-solving session, suggesting a feeling of being rushed during their communicative interactions. On the basis of the qualitative analysis, the following themes were identified: Lumen\u27s on-demand accessibility and the delivery of a complex problem-solving treatment task with a simplistic structure for achieving therapy goals; themes related to Lumen improvements included streamlining and improved personalization of conversations, slower pacing of conversations, and providing additional context during therapy sessions. CONCLUSIONS: On the basis of an in-depth formative evaluation, we found that Lumen supported the ability to conduct cognitively plausible interactions for the delivery of behavioral therapy. Several design suggestions identified from the study including reducing temporal and cognitive load during conversational interactions, developing more natural conversations, and expanding privacy and security features were incorporated in the revised version of Lumen. Although further research is needed, the promising findings from this study highlight the potential for using Lumen to deliver personalized and accessible mental health care, filling a gap in traditional mental health services

Effect of physical activity, social support, and skills training on late-life emotional health: a systematic literature review and implications for public health research

Purpose: Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults’ emotional health. Methods: A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions – physical activity, social support, and skills training – given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness). Results: In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention–outcome pairings yielded insufficient evidence. Conclusion: Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area

The global, health care, and social value of community-based late-life depression care

Thesis (Ph.D.)--University of Washington, 2023Despite its impact on health, health care, and costs of care, depression remains under-recognized and treated among older adults, in particular those underserved due to poverty, racism, and other social disadvantages. Traditional clinic-based mental health care is inadequate for addressing social determinants of mental health (e.g. economic deprivation, discrimination). One model for improving equity in access to late-life depression care is the Program to Encourage Active, Rewarding Lives (PEARLS). PEARLS aligns with global mental health recommendations to integrate quality care into accessible community-based organizations via trusted providers that reach underserved populations. Though PEARLS was developed with and by such organizations and has shown clinical effectiveness, it has not been widely adopted. The field of implementation science aims to close research-to-practice gaps so that evidence-based programs (EBPs) like PEARLS have the greatest public health impact. Research is needed to move beyond effectiveness in reducing depression to evaluate what matters to multiple partners - older persons, providers, organizations, and policymakers. What we know about barriers to EBP uptake offers clues for closing this research-to-practice gap. First, EBPs need to be adapted to local resource-constrained contexts in and outside the U.S. to reduce rather than exacerbate health inequities. For PEARLS, this means adapting the model for resource-constrained older persons and the community-based organizations that serve them. Second, EBPs need to show potential cost savings (e.g., through lower health care utilization), as improvement in health alone is often insufficient for PEARLS adoption or sustainability. Third, EBPs must address what matters now for both EBP participants and providers; for PEARLS and in COVID-19 context, what matter now is social isolation and loneliness (“social connectedness”). This dissertation brings together three studies to better understand PEARLS’ value by evaluating its global, health care, and social impact to promote older-adult health equity. Aim 1 uses a concurrent mixed-methods design to evaluate whether and how PEARLS improves social connectedness among older social service recipients living with depression and in poverty in five U.S. areas. Aim 2 applies quasi-experimental methods to existing administrative data on older social service recipients to assess PEARLS potential cost savings from reduced health care utilization (hospitalizations and nursing home stays). Aim 3 uses a multiple-case study design to evaluate PEARLS implementation with two resource-constrained cultural contexts: community health workers to support older U.S. Latinos, and newly trained social workers to support Cambodians living with diabetes. This dissertation integrates health services research, implementation science, global mental health, and health equity frameworks and methods to demonstrate the value of evidence-based depression care to improve the lives of underserved older populations

Treating Depression in Older Adults: Challenges to Implementing the Recommendations of an Expert Panel

Depression is increasingly recognized as a significant public health problem among older adults. Because the condition is highly treatable and currently undertreated among community-based older adults, late-life depression is an appropriate focus for disease prevention programs. We report findings from a recent project to review the scientific literature for published reports about treatment for depression among community-dwelling older adults and to recommend the interventions with proven effectiveness. We also summarize the research findings related to each recommended intervention and describe the elements of each. To show the difficulties involved in translating research into practice, we describe real-world experiences in implementing these evidence-based interventions in various community settings. Because depression among older people is viewed more and more as a public health problem, we suggest that partnerships of providers, patients, and policy makers be forged to overcome challenges related to funding, training, and implementing treatments for this condition

Utilization of diabetes management health care services and its association with glycemic control among patients participating in a peer educator-based program in Cambodia.

BackgroundSubstantial evidence supports the effectiveness of peer educator programs for diabetes management in low- and middle-income countries. However, little is known about peer educators' impact relative to other treatment components such as medication and physician consultation. In Cambodia, the non-governmental organization MoPoTsyo organizes four services for people with diabetes: self-management training through peer educator visits, lab tests, physician consultations, and low-cost medicines. Our aims were to 1) quantify MoPoTsyo participant utilization of each program service and 2) define the relationship between each program service and glycemic control.MethodsWe conducted a retrospective cohort study among 4,210 MoPoTsyo participants, using data collected by MoPoTsyo from 2006-2016. Independent variables assessed were medication adherence, number of peer educator visits, number of physician consultations, and number of lab tests. A multiple logistic regression model was used to evaluate the association between these disease management services and glycemic control-fasting plasma glucose ≤130 mg/dl or post-prandial glucose ≤180 mg/dl-based on most recent glucose level. The model was adjusted for baseline demographic and disease characteristics.FindingsParticipants with 12 or more peer educator visits per year had a 35% higher odds of glycemic control relative to participants with 4 or fewer visits (odds ratio 1.35, 95% CI: 1.08-1.69; p = 0.009), after adjustment for utilization of other treatment components (medication adherence, number of physician visits, number of lab tests), follow-up time, and demographic and disease characteristics. Better adherence to medications and a greater number of lab tests per year were also associated with a higher odds of glycemic control after adjustment. Number of physician consultations was not associated with glycemic control after adjustment.ConclusionsThis study demonstrates a positive association between peer educator utilization and glycemic control incremental to other elements of diabetes management. These results suggest that peer educators may be a valuable addition to comprehensive diabetes management programs in low- and middle-income countries even when other health care services are accessible. The associations identified in this research warrant further prospective studies to explore the causal impact of peer educators on glycemic control relative to other disease management components