Current state of scientific evidence on Internet-based interventions for the treatment of depression, anxiety, eating disorders and substance abuse: An overview of systematic reviews and meta-analyses

BACKGROUND: ICare represents a consortium of European Investigators examining the effects of online mental health care for a variety of common mental health disorders provided in a variety of settings. This article provides an overview of the evidence of effectiveness for Internet-based treatment for four common mental health disorders that are the focus of much of this work: depression, anxiety, substance abuse and eating disorders. METHODS: The overview focused primarily on systematic reviews and meta-analyses identified through PubMed (Ovid) and other databases and published in English. Given the large number of reviews specific to depression, anxiety, substance abuse and/or eating disorders, we did not focus on reviews that examined the effects of Internet-based interventions on mental health disorders in general. Each article was reviewed and summarized by one of the senior authors, and this review was then reviewed by the other senior authors. We did not address issues of prevention, cost-effectiveness, implementation or dissemination, as these are addressed in other reviews in this supplement. RESULTS: Across Internet-based intervention studies addressing depression, anxiety, substance abuse and eating disorders primarily among adults, almost all reviews and meta-analyses found that these interventions successfully reduce symptoms and are efficacious treatments. Generally, effect sizes for Internet-based interventions treating eating disorders and substance abuse are lower compared with interventions for depression and anxiety. CONCLUSIONS: Given the effectiveness of Internet-based interventions to reduce symptoms of these common mental health disorders, efforts are needed to examine issues of how they can be best disseminated and implemented in a variety of health care and other settings

Measuring Comprehensive, General Health Literacy in the General Adult Population: The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries

Background: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS19-Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region. Methods: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out. Results: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS19-Q12 score with social determinants and selected consequences of HL. The HLS19-Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS19-Q47 long form. Conclusions: The HLS19-Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument

Measuring Comprehensive, General Health Literacy in the General Adult Population:The Development and Validation of the HLS19-Q12 Instrument in Seventeen Countries

Background: For improving health literacy (HL) by national and international public health policy, measuring population HL by a comprehensive instrument is needed. A short instrument, the HLS(19)-Q12 based on the HLS-EU-Q47, was developed, translated, applied, and validated in 17 countries in the WHO European Region. Methods: For factorial validity/dimensionality, Cronbach alphas, confirmatory factor analysis (CFA), Rasch model (RM), and Partial Credit Model (PCM) were used. For discriminant validity, correlation analysis, and for concurrent predictive validity, linear regression analysis were carried out. Results: The Cronbach alpha coefficients are above 0.7. The fit indices for the single-factor CFAs indicate a good model fit. Some items show differential item functioning in certain country data sets. The regression analyses demonstrate an association of the HLS(19)-Q12 score with social determinants and selected consequences of HL. The HLS(19)-Q12 score correlates sufficiently highly (r ≥ 0.897) with the equivalent score for the HLS(19)-Q47 long form. Conclusions: The HLS(19)-Q12, based on a comprehensive understanding of HL, shows acceptable psychometric and validity characteristics for different languages, country contexts, and methods of data collection, and is suitable for measuring HL in general, national, adult populations. There are also indications for further improvement of the instrument

Interrelations between participant and intervention characteristics, process variables and outcomes in online interventions: A protocol for overarching analyses within and across seven clinical trials in ICare

Background: It is well known that web-based interventions can be effective treatments for various conditions. Less is known about predictors, moderators, and mediators of outcome and especially interrelations between participant and interventions characteristics, process variables and outcomes in online interventions. Clinical trials often lack statistical power to detect variables that affect intervention effects and their interrelations. Within ICare, we can investigate the interrelation of potential predictor and process variables in a large sample. Method: The ICare consortium postulated a model of interrelations between participant and intervention characteristics, process variables and outcomes in online interventions. We will assess general and disorderspecific interrelations between characteristics of the intervention, characteristics of the participants, adherence, working alliance, early response, and intervention outcomes in a sample of over 7500 participants from seven clinical trials evaluating 15 online interventions addressing a range of mental health conditions and disorders, using an individual participant data meta-analyses approach. Discussion/conclusion: Existing research tends to support the efficacy of online mental health interventions, but the knowledge base regarding factors that affect intervention effects needs to be expanded. The overarching analyses using data from the ICare intervention trials will add considerably to the evidence

Healthy Teens @ School: Evaluating and disseminating transdiagnostic preventive interventions for eating disorders and obesity for adolescents in school settings

Background The worldwide prevalence of overweight and obesity is at alarming levels. Nearly one in three children in Europe is overweight or obese. Disordered eating and body image concerns are equally widespread and increase risk for more chronic and severe weight-related problems. Research has shown that online interventions that address both healthy weight regulation and body image can reduce risk for eating disorders and obesity simultaneously and are feasible to implement in school settings. To date, evaluation and dissemination of such programs in Europe is scant. Methods The Healthy Teens @ School study is a multi-country cluster-randomized controlled trial (RCT) comparing the effectiveness of an unguided, online, multi-level intervention for promoting a healthy lifestyle and reducing problematic eating behavior, eating disorder and obesity risk among students aged 14 to 19 years with control condition. As part of the Horizon 2020 funded project ICare (GA No. 634757) the trial is conducted in Austria and Spain. Cluster randomization by school is used. The intervention is an adapted version of an evidence-based program developed in the USA (StayingFit). Participants of the intervention group are assigned to one of two possible program tracks based on the results of the initial online-assessment: Overweight adolescents are assigned to the “Weight Management” track emphasizing balanced eating and exercise for weight maintenance, and all other individuals are assigned to the “Healthy Habits” track which aims at promoting healthy habits related to e.g., nutrition, physical activity, sleep. The participants of both tracks work on ten modules (one 20–30 min module per week) during school hours and/or at home. Assessments are conducted at pre- and post-intervention, and at 6- and 12-months after baseline assessment. The primary outcome is intuitive eating, secondary outcomes are eating disorder symptomatology, body image concerns, body mass index, food intake, physical activity, self-esteem, stress coping, depression, and anxiety. Following the initial assessment, individuals in the control group do not have access to the prevention program but continue as normal and are only prompted to the assessments at all time points. At the end of the 12-month study they will get access to the program. Discussion The results from this study will add to the understanding of how to address eating and weight related problems in adolescents and will shed light on the feasibility of implementing online prevention programs in school routine in Austria and Spain. As part of the larger ICare project this RCT will determine how an adapted version of StayingFit is disseminated within Europe

Assessing the costs and cost-effectiveness of ICare internet-based interventions (protocol)

Background: Mental health problems are common and place a burden on the individual as well as on societal resources. Despite the existence of evidence-based treatments, access to treatment is often prevented or delayed due to insufficient health care resources. Effective internet-based self-help interventions have the potential to reduce the risk for mental health problems, to successfully bridge waiting time for face-to-face treatment and to address inequities in access. However, little is known about the cost-effectiveness of such interventions. This paper describes the study protocol for the economic evaluation of the studies that form the ICare programme of internet-based interventions for the prevention and treatment of a range of mental health problems. Methods: An overarching work package within the ICare programme was developed to assess the cost-effectiveness of the internet-based interventions alongside the clinical trials. There are two underlying tasks in the ICare economic evaluation. First, to develop schedules that generate equivalent and comparable information on use of services and supports across seven countries taking part in clinical trials of different interventions and second, to estimate unit costs for each service and support used. From these data the cost per person will be estimated by multiplying each participant's use of each service by the unit cost for that service, taking both a public sector and a societal perspective. This individual level of cost data matches the level of outcome data used in the clinical trials. Following the analyses of service use and costs data, joint analysis of costs and outcomes will be undertaken to provide findings on the relative cost-effectiveness of the interventions. These analyses use a well-established framework, the Production of Welfare approach, and standard methods and techniques underpinned by economic theory. Discussion/conclusion: Existing research tends to support the effectiveness of internet-based interventions, but there is little information on their cost-effectiveness compared to ‘treatment as usual’. The economic evaluation of ICare interventions will add considerably to this evidence base

Usability and Engagement Evaluation of an Unguided Online Program for Promoting a Healthy Lifestyle and Reducing the Risk for Eating Disorders and Obesity in the School Setting

Implementing integrated online prevention to reduce the risk of both obesity and eating disorders, in the school setting, is a promising approach. The challenge is to develop highly user-friendly and motivating programs, to foster adherence and effectiveness. The purpose of this study was to evaluate the usability of such a universal prevention program for students aged 14–19 years, and to address engagement issues. A mixed-methods approach was chosen, consisting of a think-aloud task, a semi-structured interview, and a questionnaire including items on sociodemographic characteristics and the System Usability Scale (SUS). Usability tests were conducted in two rounds, with five adolescents participating per round. Mean score in the SUS was 92.5 of 100 points (range 85–100), in the second round, after some adaptations from the participants’ feedback. In the course of the think-aloud tasks and interviews, five major themes emerged—visual design, navigation, mode of transfer, content, and engagement conditions. Interesting headlines, gamification, and monitoring tools are crucial for engagement. Apart from the importance of using the program during school hours, the study showed that problems currently perceived as important by the target group, need to be considered and addressed, prior to offering them prevention programs, which highlights the importance of a user-centered design