Meta-analysis and Meta-regression of Cognitive Behavioral Therapy for Psychosis (CBTp) Across Time: The Effectiveness of CBTp has Improved for Delusions

Published research shows small-to-medium effects of Cognitive Behavioral Therapy for Psychosis (CBTp) on reducing psychotic symptoms. Given the on-going development of CBTp interventions, the aim of this systematic review is to examine whether the effectiveness of CBTp has changed across time. MEDLINE, EMBASE, PsycINFO, and CENTRAL were searched for randomized controlled trials examining CBTp interventions targeting positive and/or negative symptoms vs treatment as usual. Four meta-analyses were carried out to examine the effectiveness of CBTp for: positive symptoms; delusions; hallucinations; and negative symptoms. Four meta-regressions examined whether the effectiveness of CBTp changed across time for these groups of symptoms. A total of 28 studies (n = 2698) yielded a pooled g of −0.24 (95% confidence interval [CI] −0.32, −0.16, P < .001) favoring CBTp for positive symptoms, with nonsignificant heterogeneity (Q = 26.87, P = .47; I2 =0%); 13 studies (n = 890) yielded a pooled g of −0.36 (95% CI −0.59, −0.13, P = .002) for delusions, with substantial heterogeneity (Q = 31.99, P = .001; I2 =62%); 16 studies (n = 849) yielded a pooled g of −0.26 (95% CI −0.42, −0.11, P < .001) for hallucinations, with nonsignificant heterogeneity (Q = 18.10, P = .26; I2 =17%); 19 studies (n = 1761) yielded a pooled g of −0.22 (95% CI −0.33, −0.12, P < .001) for negative symptoms, with nonsignificant heterogeneity (Q = 20.32, P = .32, I2 =11%). Meta-regressions indicated a significant effect of year on the effectiveness of CBTp only for delusions (F[1, 11] = 5.99, P = .032; R2 = 0.594); methodological quality did not effect this finding. Findings indicate small-to-medium effects of CBTp for psychotic symptoms, with increasing effectiveness across time for delusions

Factors Affecting Patients’ Use of Electronic Personal Health Records in England: Cross-Sectional Study

Background: Electronic personal health records (ePHRs) are secure Web-based tools that enable individuals to access, manage, and share their medical records. England recently introduced a nationwide ePHR called Patient Online. As with ePHRs in other countries, adoption rates of Patient Online remain low. Understanding factors affecting patients’ ePHR use is important to increase adoption rates and improve the implementation success of ePHRs. Objective: This study aimed to examine factors associated with patients’ use of ePHRs in England. Methods: The unified theory of acceptance and use of technology was adapted to the use of ePHRs. To empirically examine the adapted model, a cross-sectional survey of a convenience sample was carried out in 4 general practices in West Yorkshire, England. Factors associated with the use of ePHRs were explored using structural equation modeling. Results: Of 800 eligible patients invited to take part in the survey, 624 (78.0%) returned a valid questionnaire. Behavioral intention (BI) was significantly influenced by performance expectancy (PE; beta=.57, P<.001), effort expectancy (EE; beta=.16, P<.001), and perceived privacy and security (PPS; beta=.24, P<.001). The path from social influence to BI was not significant (beta=.03, P=.18). Facilitating conditions (FC) and BI significantly influenced use behavior (UB; beta=.25, P<.001 and beta=.53, P<.001, respectively). PE significantly mediated the effect of EE and PPS on BI (beta=.19, P<.001 and beta=.28, P=.001, respectively). Age significantly moderated 3 paths: PE→BI, EE→BI, and FC→UB. Sex significantly moderated only the relationship between PE and BI. A total of 2 paths were significantly moderated by education and internet access: EE→BI and FC→UB. Income moderated the relationship between FC and UB. The adapted model accounted for 51% of the variance in PE, 76% of the variance in BI, and 48% of the variance in UB. Conclusions: This study identified the main factors that affect patients’ use of ePHRs in England, which should be taken into account for the successful implementation of these systems. For example, developers of ePHRs should involve patients in the process of designing the system to consider functions and features that fit patients’ preferences and skills to ensure systems are useful and easy to use. The proposed model accounted for 48% of the variance in UB, indicating the existence of other, as yet unidentified, factors that influence the adoption of ePHRs. Future studies should confirm the effect of the factors included in this model and identify additional factors

Factors that affect the use of electronic personal health records among patients: A systematic review

Background: Electronic personal health records (ePHRs) are web-based tools that enable patients to access parts of their medical records and other services. In spite of the potential benefits of using ePHRs, their adoption rates remain very low. The lack of use of ePHRs among patients leads to implementation failures of these systems. Many studies have been conducted to examine the factors that influence patients’ use of ePHRs, and they need to be synthesised in a meaningful way.ObjectiveThe current study aimed to systematically review the evidence regarding factors that influence patients’ use of ePHRs. Methods: The search included: 42 bibliographic databases (e.g. Medline, Embase, CINHAL, and PsycINFO), hand searching, checking reference lists of the included studies and relevant reviews, contacting experts, and searching two general web engines. Study selection, data extraction, and study quality assessment were carried out by two reviewers independently. The quality of studies was appraised using the Mixed Methods Appraisal Tool. The extracted data were synthesised narratively according to the outcome: intention to use, subjective measures of use, and objective measures of use. The identified factors were categorised into groups based on Or and Karsh’s conceptual framework. Results: Of 5225 citations retrieved, 97 studies were relevant to this review. These studies examined more than 150 different factors: 59 related to intention to use, 52 regarding subjectively-measured use, and 105 related to objectively-measured use. The current review was able to draw definitive conclusions regarding the effect of only 18 factors. Of these, only three factors have been investigated in connection with every outcome, which are: perceived usefulness, privacy and security concerns, and internet access. Conclusion: Of the numerous factors examined by the included studies, this review concluded the effect of 18 factors: 13 personal factors (e.g. gender, ethnicity, and income), four human-technology factors (e.g. perceived usefulness and ease of use), and one organisational factor (facilitating conditions). These factors should be taken into account by stakeholders for the successful implementation of these systems. For example, patients should be assured that the system is secure and no one can access their records without their permission in order to decrease their concerns about the privacy and security. Further, advertising campaigns should be carried out to increase patients’ awareness of the system. More studies are needed to conclude the effect of other factors. In addition, researchers should conduct more theory-based longitudinal studies for assessing factors affecting initial use and continuing use of ePHRs among patients

An overview of the features of chatbots in mental health: A scoping review

Background: Chatbots are systems that are able to converse and interact with human users using spoken, written, and visual languages. Chatbots have the potential to be useful tools for individuals with mental disorders, especially those who are reluctant to seek mental health advice due to stigmatization. While numerous studies have been conducted about using chatbots for mental health, there is a need to systematically bring this evidence together in order to inform mental health providers and potential users about the main features of chatbots and their potential uses, and to inform future research about the main gaps of the previous literature. Objective: We aimed to provide an overview of the features of chatbots used by individuals for their mental health as reported in the empirical literature. Methods: Seven bibliographic databases (Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, IEEE Xplore, ACM Digital Library, and Google Scholar) were used in our search. In addition, backward and forward reference list checking of the included studies and relevant reviews was conducted. Study selection and data extraction were carried out by two reviewers independently. Extracted data were synthesised using a narrative approach. Chatbots were classified according to their purposes, platforms, response generation, dialogue initiative, input and output modalities, embodiment, and targeted disorders. Results: Of 1039 citations retrieved, 53 unique studies were included in this review. Those studies assessed 41 different chatbots. Common uses of chatbots were: therapy (n = 17), training (n = 12), and screening (n = 10). Chatbots in most studies were rule-based (n = 49) and implemented in stand-alone software (n = 37). In 46 studies, chatbots controlled and led the conversations. While the most frequently used input modality was writing language only (n = 26), the most frequently used output modality was a combination of written, spoken and visual languages (n = 28). In the majority of studies, chatbots included virtual representations (n = 44). The most common focus of chatbots was depression (n = 16) or autism (n = 10). Conclusion: Research regarding chatbots in mental health is nascent. There are numerous chatbots that are used for various mental disorders and purposes. Healthcare providers should compare chatbots found in this review to help guide potential users to the most appropriate chatbot to support their mental health needs. More reviews are needed to summarise the evidence regarding the effectiveness and acceptability of chatbots in mental health

The impact of a social norms approach onreducing levels of misperceptions aroundsmokefree hospital entrances amongstpatients, staff, and visitors of a NHShospital: a repeated cross-sectional surveystudy

Background: Smoking is a cause of avoidable morbidity and mortality. In the United Kingdom (UK) the national smoking ban inside hospital buildings is widely adhered to. There is a perception it has led to smokers congregating around hospital entrances (Selbie D. 2016, It’s time for a truly smokefree NHS. Public Health Matters Blog. Public Health England). Efforts to shift social norms and create positive smokefree environments might be strengthened by delivering social norms messages. This study explored the impact of a social norms approach campaign to reduce levels of misperceptions surrounding support for smokefree hospital entrances. Method: Repeated cross sectional study design. Staff, patients, and hospital visitors at Pinderfields National Health Service (NHS) Hospital (Wakefield, United Kingdom (UK)) completed a survey before and after implementation of a public health social norms campaign (n = 481 surveyed before; n = 459 surveyed after). The main outcome measure was difference between perceived and reported levels of support for smokefree hospital entrances. Results: There were high levels of support for smokefree hospital entrances. The majority of participants agreed that patients (n = 849, 90% agreed), staff (n = 863, 92% agreed), and visitors (n = 850, 90% agreed) should not smoke in the hospital entrance. Participants underestimated the proportion of others who self-reported keeping the entrance smokefree. Over 90% of respondents reported not smoking in the hospital entrance, but the perception was that between 50 to 75% of hospital staff, patients, and visitors did not smoke in the hospital entrance. The mean percentage of hospital staff, patients, and visitors who respondents thought did not smoke in entrances was higher for respondents responding after, compared to those responding before, the campaign. There was an overall significant effect of time on attitudes towards smoking in the entrances; in all instances the mean percentage of hospital staff, patients, and visitors the participants believed agreed that hospital entrances should be smokefree was higher for those responding after, compared with before, the campaign. Conclusions: People hold misperceptions of the proportion of people who choose to smoke in the hospital entrance. The social norms approach campaign was associated with a strengthening of positive social norms. Such campaigns should be considered by Trusts as one evidence-based based tactic to denormalise smoking, increase support for smokefree policies

Student and staff perceptions of alcohol as part of student life in Denmark: A Q methodology study

Introduction: Intervening effectively to prevent students’ harmful use of alcohol remains a challenge. Harmful alcohol use has been noted as the most dominant public health problem facing universities today. This study sought to investigate the diversity in staff and student perceptions of the contribution alcohol makes to student life in a Danish university setting. Increasing understanding of staff and students’ perceptions of how alcohol fits into student life is required to amend future public health intervention for this population. Materials and methods: This Q methodology study included 38 staff members and 105 students from Aarhus University, Denmark. Participants used online Q sorting software, to rank 40 statements about the contribution alcohol makes to the university student experience from strongly agree to disagree. To support the interpretation of the factors, self-reported alcohol consumption and demographic data were collected. In addition qualitative data was collected on the participant’s reasons for the ranking of the items they most strongly agreed or disagreed with. Results and discussion: Using principal components analysis, five statistically independent viewpoints for students and four for staff were identified. The findings provide evidence to inform approaches to prevent harmful alcohol use. Some viewpoints suggest a need for tailored secondary and tertiary prevention and intervention that focusses on individuals and/or sub-groups who are at risk of consuming alcohol at harmful levels. Other viewpoints suggest the need for primary universal prevention to support the maintenance of healthy norms which can prevent harmful alcohol behaviour. Public health campaigns need to ensure that interventions targeting harmful alcohol use at universities challenge problematic perceptions and attitudes while also bolstering exposure to positive norms

When Does a Lot Become Too Much? A Q Methodological Investigation of UK Student Perceptions of Digital Addiction

Despite the benefits of the internet and other digital technology, the online world has been associated with a negative impact on university student wellbeing. Many university students report symptoms of pathological internet use. Internationally, further research is needed to understand what student users of technology perceive to be problematic internet and/or digital use. The current study explores the range of perceptions that university students hold about ‘digital addiction’. We recruited 33 participants from a UK university into a Q-methodology study. Participants sorted, ranked, and commented on fifty-two statements representing the concourse of ‘things written or said about digital addiction’. The statements were identified from a comprehensive search of a wide variety of sources (e.g., newspapers, academic articles, blogs, and YouTube). Principal Component Analysis was used to identify four distinct viewpoints of ‘digital addiction’: (I) digital addiction is differentiated by the negative consequences experienced by addicted individuals; (II) digital addiction comes from our fascination with the online world; (III) digital addiction is an attempt to escape real world problems and impacts on mental health and relationships; (IV) digital addiction is defined by the amount of time we spend online. All four viewpoints share the perception that people do not realize they are digitally addicted because using and having digital devices on you at all times has become the social norm. There was also overall agreement that that those with ‘addictive personalities’ were more likely to be ‘digitally addicted’. Despite these similarities, complexity and contradictions within the viewpoints surrounding what digital addiction is and how it might be defined are apparent. The information found in this study provides important suggestions of how we might frame prevention and early intervention messages to engage students and ensure they develop the skills necessary to successfully manage their digital lives

A feasibility trial to examine the social norms approach for the prevention and reduction of licit and illicit drug use in European University and college students.

Background: Incorrect perceptions of high rates of peer alcohol and tobacco use are predictive of increased personal use in student populations. Correcting misperceptions by providing feedback has been shown to be an effective intervention for reducing licit drug use. It is currently unknown if social norms interventions are effective in preventing and reducing illicit drug use in European students. The purpose of this paper is to describe the design of a multi-site cluster controlled trial of a web-based social norms intervention aimed at reducing licit and preventing illicit drug use in European university students. Methods/Design: An online questionnaire to assess rates of drug use will be developed and translated based on existing social norms surveys. Students from sixteen universities in seven participating European countries will be invited to complete the questionnaire. Both intervention and control sites will be chosen by convenience. In each country, the intervention site will be the university that the local principal investigator is affiliated with. We aim to recruit 1000 students per site (baseline assessment). All participants will complete the online questionnaire at baseline. Baseline data will be used to develop social norms messages that will be included in a web-based intervention. The intervention group will receive individualized social norms feedback. The website will remain online during the following 5 months. After five months, a second survey will be conducted and effects of the intervention on social norms and drug use will be measured in comparison to the control site. Discussion: This project is the first cross-national European collaboration to investigate the feasibility of a social norms intervention to reduce licit and prevent illicit drug use among European university students. Final trial registration number DRKS00004375 on the ‘German Clinical Trials Register’.This study is funded by the European Commission, Directorate General Justice, Freedom and Security (JLS/2009-2010/DPIP/AG

Student estimations of peer alcohol consumption: links between the Social Norms Approach and the Health Promoting University concept.

The Social Norms Approach, with its focus on positive behaviour and its consensus orientation, is a health promotion intervention of relevance to the context of a Health Promoting University. In particular, the approach could assist with addressing excessive alcohol consumption

Patients’ Adoption of Electronic Personal Health Records in England: Secondary data analysis

Background: In England, almost all general practices (GPs) have implemented GP online services such as electronic personal health records (ePHRs) that allow people to schedule appointments, request repeat prescriptions, and access parts of their medical records. The overall adoption rate of GP online services has been low, reaching just 28% in October 2019. In a previous study, Abd-Alrazaq et al adopted a model to assess the factors that influence patients’ use of GP online services in England. According to the previous literature, the predictive power of the Abd-Alrazaq model could be improved by proposing new associations between the existing variables in the model. Objective: This study aims to improve the predictive power of the Abd-Alrazaq model by proposing new relationships between the existing variables in the model. Methods: The Abd-Alrazaq model was amended by proposing new direct, mediating, moderating, and moderated mediating effects. The amended model was examined using data from a previous study, which were collected by a cross-sectional survey of a convenience sample of 4 GPs in West Yorkshire, England. Structural equation modeling was used to examine the theoretical model and hypotheses. Results: The new model accounted for 53% of the variance in performance expectancy (PE), 76% of the variance in behavioral intention (BI), and 49% of the variance in use behavior (UB). In addition to the significant associations found in the previous study, this study found that social influence (SI) and facilitating conditions (FCs) are associated with PE directly and BI indirectly through PE. The association between BI and UB was stronger for younger women with higher levels of education, income, and internet access. The indirect effects of effort expectancy (EE), perceived privacy and security (PPS), and SI on BI were statistically stronger for women without internet access, patients with internet access, and patients without internet access, respectively. The indirect effect of PPS on BI was stronger for patients with college education or diploma than for those with secondary school education and lower, whereas the indirect effect of EE on BI was stronger for patients with secondary school education or lower than for those with college education or a diploma. Conclusions: The predictive power of the Abd-Alrazaq model improved by virtue of new significant associations that were not examined before in the context of ePHRs. Further studies are required to validate the new model in different contexts and to improve its predictive power by proposing new variables. The influential factors found in this study should be considered to improve patients’ use of ePHRs