Comparing usage of a web and app stress management intervention : an observational study

Choices in the design and delivery of digital health behaviour interventions may have a direct influence on subsequent usage and engagement. Few studies have been able to make direct, detailed comparisons of differences in usage between interventions that are delivered via web or app. This study compared the usage of two versions of a digital stress management intervention, one delivered via a website (Healthy Paths) and the other delivered via an app (Healthy Mind). Design modifications were introduced within Healthy Mind to take account of reported differences in how individuals engage with websites compared to apps and mobile phones. Data were collected as part of an observational study nested within a broader exploratory trial of Healthy Mind. Objective usage of Healthy Paths and Healthy Mind were automatically recorded, including frequency and duration of logins, access to specific components within the intervention and order of page/screen visits. Usage was compared for a two week period following initial registration. In total, 381 participants completed the registration process for Healthy Paths (web) and 162 participants completed the registration process for Healthy Mind (app). App users logged in twice as often (Mdn = 2.00) as web users (Mdn = 1.00), U = 13,059.50, p ≤ 0.001, but spent half as much time (Mdn = 5.23 min) on the intervention compared to web users (Mdn = 10.52 min), U = 19,740.00, p ≤ 0.001. Visual exploration of usage patterns over time revealed that a significantly higher proportion of app users (n = 126, 82.35%) accessed both types of support available within the intervention (i.e. awareness and change-focused tools) compared to web users (n = 92, 40.17%), χ2(1, n = 382) = 66.60, p < 0.001. This study suggests that the digital platform used to deliver an intervention (i.e. web versus app) and specific design choices (e.g. navigation, length and volume of content) may be associated with differences in how the intervention content is used. Broad summative usage data (e.g. total time spent on the intervention) may mask important differences in how an intervention is used by different user groups if it is not complemented by more fine-grained analyses of usage patterns over time. Trial registration number: ISRCTN67177737

‘That’s just how I am’: a qualitative interview study to identify factors influencing engagement with a digital intervention for tinnitus self-management

© 2020 The Authors. British Journal of Health Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society Objectives: To explore users’ reactions to and expectations of the Tinnitus E-Programme 2.0, a digital cognitive behavioural intervention for tinnitus, and to identify contextual factors and mechanisms of action that may influence user engagement with the intervention. Design: Qualitative interview study. Methods: Think-aloud and semi-structured interviews were carried out with 19 people with tinnitus. Interviews explored participants’ views of the intervention’s information and advice, its wider intervention goals (e.g. behaviour change, self-management), and factors that may strengthen or impede users’ engagement. Data were analysed using inductive thematic analysis, and findings were used to develop a conceptual model of user engagement with the intervention. Results: Generally, participants expressed positive views of the intervention, its intervention components, and its design features. Identified contextual factors included pre-existing attitudes, beliefs, skills, and knowledge (e.g. perceptions of tinnitus symptom severity, openness to tinnitus management, and psychological techniques); previous experience of tinnitus management; and characteristics of the condition (e.g. heterogeneous nature of tinnitus, stage in healthcare journey). These contextual factors were hypothesized to influence engagement through four mechanisms of action: motivation to change tinnitus-related attitudes and behaviour; perceived personal relevance of the intervention; expectations of benefit; and appeal of the intervention techniques. Conclusions: This study demonstrated the acceptability of the Tinnitus E-Programme 2.0 amongst its target group, while highlighting potential areas for improvement in future intervention modifications. Our findings identified contextual factors that others developing interventions for tinnitus or cognitive behavioural interventions may wish to consider

Distinguishing emotional distress from mental disorder: A qualitative exploration of the Four-Dimensional Symptom Questionnaire (4DSQ).

BACKGROUND: Primary care clinicians see people experiencing the full range of mental health problems. Determining when symptoms reflect disorder is complex. The Four-Dimensional Symptom Questionnaire (4DSQ) uniquely distinguishes general distress from depressive and anxiety disorders. It may support diagnostic conversations and targeting of treatment. AIM: We aimed to explore peoples' experiences of completing the 4DSQ and their perceptions of their resulting score profile across distress, depression, anxiety and physical symptoms. DESIGN AND SETTING: A qualitative study conducted in the UK with people recruited from primary care and community settings. METHOD: Participants completed the 4DSQ then took part in semi-structured telephone interviews. They were interviewed about their experience of completing the 4DSQ, their perceptions of their scores across four dimensions, and the perceived utility if used with a clinician. Interviews were transcribed verbatim and data were analysed thematically. RESULTS: Twenty-four interviews were conducted. Most participants found the 4DSQ easy to complete and reported that scores across the four dimensions aligned well with their symptom experience. Distinct scores for distress, depression and anxiety appeared to support improved self-understanding. Some valued the opportunity to discuss their scores and provide relevant context. Many felt the use of the 4DSQ with clinicians would be helpful and likely to support treatment decisions, although some were concerned about time-limited consultations. CONCLUSION: Distinguishing general distress from depressive and anxiety disorders aligned well with people's experience of symptoms. Use of the 4DSQ as part of mental health consultations may support targeting of treatment and personalisation of care

Using an internet intervention to support self-management of low back pain in primary care:Findings from a randomised controlled feasibility trial (SupportBack)

Introduction Low back pain (LBP) is a prevalent and costly condition. The majority of patients experiencing LBP are managed in primary care, where first-line care recommendations consist of advice to self-manage and remain active. Internet interventions present a potential means of providing patients with tailored self-management advice and evidence-based support for increasing physical activity.Methods/analysis This protocol describes a single-blind, randomised controlled feasibility trial of an internet intervention developed to support the self-management of LBP in primary care. Patients are being randomised to 1 of 3 groups receiving either usual primary care, usual primary care with the addition of an internet intervention or an internet intervention with physiotherapist telephone support. Patients are followed up at 3 months. Primary outcomes are the feasibility of (1) the trial design/methods, (2) the delivery of the internet intervention and (3) the provision of telephone support by physiotherapists. Secondary outcomes will include exploratory analysis of estimates and variation in clinical outcomes of pain and disability, in order to inform a future main trial.Ethics/dissemination This feasibility trial has undergone ethical scrutiny and been approved by the National Health Service (NHS) Research Ethics Committee, REC Reference 13/SC/0202. The feasibility findings will be disseminated to the research community through presentations at conferences and publication in peer review journals. Broader dissemination will come following a definitive trial

Psychology Meets Biology in COVID-19: What We Know and Why It Matters for Public Health

Psychosocial factors are related to immune, viral, and vaccination outcomes. Yet, this knowledge has been poorly represented in public health initiatives during the COVID-19 pandemic. This review provides an overview of biopsychosocial links relevant to COVID-19 outcomes by describing seminal evidence about these associations known prepandemic as well as contemporary research conducted during the pandemic. This focuses on the negative impact of the pandemic on psychosocial health and how this in turn has likely consequences for critically relevant viral and vaccination outcomes. We end by looking forward, highlighting the potential of psychosocial interventions that could be leveraged to support all people in navigating a postpandemic world and how a biopsychosocial approach to health could be incorporated into public health responses to future pandemics

Nasal sprays and behavioural interventions compared with usual care for acute respiratory illness in primary care: a randomised, controlled, open-label, parallel-group trial

Background: A small amount of evidence suggests that nasal sprays, or physical activity and stress management, could shorten the duration of respiratory infections. This study aimed to assess the effect of nasal sprays or a behavioural intervention promoting physical activity and stress management on respiratory illnesses, compared with usual care. Methods: This randomised, controlled, open-label, parallel-group trial was done at 332 general practitioner practices in the UK. Eligible adults (aged ≥18 years) had at least one comorbidity or risk factor increasing their risk of adverse outcomes due to respiratory illness (eg, immune compromise due to serious illness or medication; heart disease; asthma or lung disease; diabetes; mild hepatic impairment; stroke or severe neurological problem; obesity [BMI ≥30 kg/m2]; or age ≥65 years) or at least three self-reported respiratory tract infections in a normal year (ie, any year before the COVID-19 pandemic). Participants were randomly assigned (1:1:1:1) using a computerised system to: usual care (brief advice about managing illness); gel-based spray (two sprays per nostril at the first sign of an infection or after potential exposure to infection, up to 6 times per day); saline spray (two sprays per nostril at the first sign of an infection or after potential exposure to infection, up to 6 times per day); or a brief behavioural intervention in which participants were given access to a website promoting physical activity and stress management. The study was partially masked: neither investigators nor medical staff were aware of treatment allocation, and investigators who did the statistical analysis were unaware of treatment allocation. The sprays were relabelled to maintain participant masking. Outcomes were assessed using data from participants' completed monthly surveys and a survey at 6 months. The primary outcome was total number of days of illness due to self-reported respiratory tract illnesses (coughs, colds, sore throat, sinus or ear infections, influenza, or COVID-19) in the previous 6 months, assessed in the modified intention-to-treat population, which included all randomly assigned participants who had primary outcome data available. Key secondary outcomes were possible harms, including headache or facial pain, and antibiotic use, assessed in all randomly assigned participants. This trial was registered with ISRCTN, 17936080, and is closed to recruitment. Findings: Between Dec 12, 2020, and April 7, 2023, of 19 475 individuals screened for eligibility, 13 799 participants were randomly assigned to usual care (n=3451), gel-based nasal spray (n=3448), saline nasal spray (n=3450), or the digital intervention promoting physical activity and stress management (n=3450). 11 612 participants had complete data for the primary outcome and were included in the primary outcome analysis (usual care group, n=2983; gel-based spray group, n=2935; saline spray group, n=2967; behavioural website group, n=2727). Compared with participants in the usual care group, who had a mean of 8·2 (SD 16·1) days of illness, the number of days of illness was significantly lower in the gel-based spray group (mean 6·5 days [SD 12·8]; adjusted incidence rate ratio [IRR] 0·82 [99% CI 0·76–0·90]; p<0·0001) and the saline spray group (6·4 days [12·4]; 0·81 [0·74–0·88]; p<0·0001), but not in the group allocated to the behavioural website (7·4 days [14·7]; 0·97 [0·89–1·06]; p=0·46). The most common adverse event was headache or sinus pain in the gel-based group: 123 (4·8%) of 2556 participants in the usual care group; 199 (7·8%) of 2498 participants in the gel-based group (risk ratio 1·61 [95% CI 1·30–1·99]; p<0·0001); 101 (4·5%) of 2377 participants in the saline group (0·81 [0·63–1·05]; p=0·11); and 101 (4·5%) of 2091 participants in the behavioural intervention group (0·95 [0·74–1·22]; p=0·69). Compared with usual care, antibiotic use was lower for all interventions: IRR 0·65 (95% CI 0·50–0·84; p=0·001) for the gel-based spray group; 0·69 (0·45–0·88; p=0·003) for the saline spray group; and 0·74 (0·57–0·94; p=0·02) for the behavioural website group. Interpretation: Advice to use either nasal spray reduced illness duration and both sprays and the behavioural website reduced antibiotic use. Future research should aim to address the impact of the widespread implementation of these simple interventions. Funding: National Institute for Health and Care Research

Internet and Telephone Support for Discontinuing Long-Term Antidepressants: The REDUCE Cluster Randomized Trial

Importance: There is significant concern regarding increasing long-term antidepressant treatment for depression beyond an evidence-based duration. Objective: To determine whether adding internet and telephone support to a family practitioner review to consider discontinuing long-term antidepressant treatment is safe and more effective than a practitioner review alone. Design, Setting, and Participants: In this cluster randomized clinical trial, 131 UK family practices were randomized between December 1, 2018, and March 31, 2022, with remote computerized allocation and 12 months of follow-up. Participants and researchers were aware of allocation, but analysis was blind. Participants were adults who were receiving antidepressants for more than 1 year for a first episode of depression or more than 2 years for recurrent depression who were currently well enough to consider discontinuation and wished to do so and who were at low risk of relapse. Of 6725 patients mailed invitations, 330 (4.9%) were eligible and consented. Interventions: Internet and telephone self-management support, codesigned and coproduced with patients and practitioners. Main Outcomes and Measures: The primary (safety) outcome was depression at 6 months (prespecified complete-case analysis), testing for noninferiority of the intervention to under 2 points on the 9-item Patient Health Questionnaire (PHQ-9). Secondary outcomes (testing for superiority) were antidepressant discontinuation, anxiety, quality of life, antidepressant withdrawal symptoms, mental well-being, enablement, satisfaction, use of health care services, and adverse events. Analyses for the main outcomes were performed on a complete-case basis, and multiple imputation sensitivity analysis was performed on an intention-to-treat basis. Results: Of 330 participants recruited (325 eligible for inclusion; 178 in intervention practices and 147 in control practices; mean [SD] age at baseline, 54.0 [14.9] years; 223 women [68.6%]), 276 (83.6%) were followed up at 6 months, and 240 (72.7%) at 12 months. The intervention proved noninferior; mean (SD) PHQ-9 scores at 6 months were slightly lower in the intervention arm than in the control arm in the complete-case analysis (4.0 [4.3] vs 5.0 [4.7]; adjusted difference, -1.1; 95% CI, -2.1 to -0.1; P = .03) but not significantly different in an intention-to-treat multiple imputation sensitivity analysis (adjusted difference, -0.9 (95% CI, -1.9 to 0.1; P = .08). By 6 months, antidepressants had been discontinued by 66 of 145 intervention arm participants (45.5%) who provided discontinuation data and 54 of 129 control arm participants (41.9%) (adjusted odds ratio, 1.02; 95% CI, 0.52-1.99; P = .96). In the intervention arm, antidepressant withdrawal symptoms were less severe, and mental well-being was better compared with the control arm; differences were small but significant. There were no significant differences in the other outcomes; 28 of 179 intervention arm participants (15.6%) and 22 of 151 control arm participants (14.6%) experienced adverse events. Conclusions and Relevance: In this cluster randomized clinical trial of adding internet and telephone support to a practitioner review for possible antidepressant discontinuation, depression was slightly better with support, but the rate of discontinuation of antidepressants did not significantly increase. Improvements in antidepressant withdrawal symptoms and mental well-being were also small. There were no significant harms. Family practitioner review for possible discontinuation of antidepressants appeared safe and effective for more than 40% of patients willing and well enough to discontinue. Trial Registration: ISRCTN registry Identifiers: ISRCTN15036829 (internal pilot trial) and ISRCTN12417565 (main trial)

Dispositional predictors of placebo responding: a motivational interpretation of flower essence and gratitude therapy

ObjectivesThe aim of this study was to test a motivational interpretation of placebo responding using two different types of placebo therapy, one using flower essences and the other a nonspecific psychological therapy. The motivational concordance interpretation is that therapeutic rituals that are consistent with self-defining or self-actualizing goals have a nonspecific therapeutic benefit independently of expectancy.MethodsStudy 1 was a replication of an earlier flower essence outcome study but with additional outcome and predictor variables: 167 people completed questionnaires in return for free flower essence treatment. Predictor variables consisted of two measures of spirituality, optimism, expectancy, and attitudes and beliefs to complementary medicine. Outcome was assessed after 3 weeks. In Study 2, 90 people took part in “gratitude therapy” for improved sleep quality over one night in return for questionnaire completion (trait gratitude, spirituality, and expectancy).ResultsStudy 1 confirmed previous research: Trait spirituality predicted perceived improvement. This improvement was independent of optimism (P&lt;.001), cannot be explained by acquiescence or social desirability, and was independent of a highly conservative test of expectancy (P=.02). In Study 2, trait gratitude predicted perceived sleep improvement independently of expectancy (P=.01): Spirituality did not correlate with improvement.ConclusionsThese data suggest that in addition to expectations, degree of engagement in a positive, therapeutic ritual determines the extent of the placebo response. The placebo response depends in part on the interaction (i.e., the degree of concordance) between the type of therapy and the participant's personality: Dispositional predictors vary with the type of placebo therapy.<br/

Gratitude and well-being: a review and theoretical integration

This paper presents a new model of gratitude as a "life orientation towards noticing and appreciating the positive in life", incorporating not only the gratitude that arises following help from others, but also a habitual focusing on and appreciating the positive aspects of life. Research into individual differences in gratitude and well-being is reviewed, including gratitude and psychopathology, personality, relationships, health, subjective and eudemonic well-being, and humanistically orientated functioning. Gratitude is strongly related to well-being, however defined, and this link may be unique and causal. Interventions to clinically increase gratitude are critically reviewed, and concluded to be promising, although the positive psychology literature may have neglected current limitations, and a distinct research strategy is suggested. Finally, mechanisms whereby gratitude may relate to well-being are discussed, including schematic biases, coping, positive affect, and broaden-and-build principles. Gratitude is relevant to clinical psychology due to (a) strong explanatory power in understanding well-being, and (b) the potential of improving well-being through fostering gratitude with simple exercise

Dissociating the facets of hope: agency and pathways predict dropout from unguided self-help therapy in opposite directions

Hope comprises two components: agency (“goal directed determination”) and pathways (“planning of ways to meet goals”). We tested whether these two components can be dissociated and therefore differentially predict dropout from two unguided self-help interventions to reduce worry (gratitude vs. thought monitoring and cognitive restructuring interventions, N = 247 entered, 136 completed). The two hope components significantly predicted attrition in opposite directions; agency predicted completion (OR = 2.15, CI = 1.27–3.64, p = .004), whereas pathways predicted dropout (OR = .47, CI = .29–.77, p = .003). Gratitude and thought monitoring reduced worry compared a wait list control, and for completers there was no difference in outcome. Conclusion: hope facets can be dissociated; gratitude techniques are as effective and have better retention than a technique commonly used in cognitive behavior therapy