Comparing Email Versus Text Messaging as Delivery Platforms for Supporting Patients With Major Depressive Disorder: Noninferiority Randomized Controlled Trial.

BACKGROUND: The prevalence of major depressive disorder (MDD) poses significant global health challenges, with available treatments often insufficient in achieving remission for many patients. Digital health technologies, such as SMS text messaging-based cognitive behavioral therapy, offer accessible alternatives but may not reach all individuals. Email communication presents a secure avenue for health communication, yet its effectiveness compared to SMS text messaging in providing mental health support for patients with MDD remains uncertain. OBJECTIVE: This study aims to compare the efficacy of email versus SMS text messaging as delivery platforms for supporting patients with MDD, addressing a critical gap in understanding optimal digital interventions for mental health care. METHODS: A randomized noninferiority pilot trial was conducted, comparing outcomes for patients receiving 6-week daily supportive messages via email with those receiving messages via SMS text message. This duration corresponds to a minimum of 180 days of message delivery. The supportive messages maintained consistent length and structure across both delivery methods. Participants (N=66) were recruited from the Access 24/7 clinic in Edmonton, Alberta, among those who were diagnosed with MDD. The outcomes were measured at baseline and 6 months after enrollment using the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and the World Health Organization Well-Being Index (WHO-5). RESULTS: Most of the participants were females (n=43, 65%), aged between 26 and 40 years (n=34, 55%), had high school education (n=35, 58%), employed (n=33, 50%), and single (n=24, 36%). Again, most participants had had no history of any major physical illness (n=56, 85%) and (n=61, 92%) responded "No" to having a history of admission for treatment of mood disorders. There was no statistically significant difference in the mean changes in PHQ-9, GAD-7, and WHO-5 scores between the email and SMS text messaging groups (mean difference, 95% CI: -1.90, 95% CI -6.53 to 2.74; 5.78, 95% CI -1.94 to 13.50; and 11.85, 95% CI -3.81 to 27.51), respectively. Both supportive modalities showed potential in reducing depressive symptoms and improving quality of life. CONCLUSIONS: The study's findings suggest that both email and SMS text messaging interventions have equivalent effectiveness in reducing depression symptoms among individuals with MDD. As digital technology continues to evolve, harnessing the power of multiple digital platforms for mental health interventions can significantly contribute to bridging the existing treatment gaps and improving the overall well-being of individuals with depressive conditions. Further research is needed with a larger sample size to confirm and expand upon these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT04638231; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8552095/.

Primary healthcare planning, bottleneck analysis and performance improvement: An evaluation of processes and outcomes in a Nigerian context.

Operational planning of interventions defines roadmaps, timelines and resources necessary for translating policies into expected health outcomes along the evidence-policy-implementation continuum. However, bottlenecks often hinder the attainment of objectives and the timely delivery of intervention packages leading to sub-optimal performance of health systems. Bottleneck identification, analysis and removal approaches to planning, which requires key stakeholders' participation, have been recommended to improve health system outcomes in LMICs. This study demonstrates how integration of participatory action research (PAR) within a quality improvement model can help navigate the complexities of health system bottleneck analyses, planning and performance improvement in a Nigerian sub-national context. The study is based on data collected between June 2016 and June 2017, from Chikun LGA in Kaduna State Nigeria. PAR was integrated into a quality improvement model called DIVA (Diagnose-Intervene-Verify-Adjust) applied across selected interventions (eMTCT, Antenatal care, skilled birth attendance, immunization and Integrated Management of Childhood Illnesses). PAR was used to identify and analyse health system bottlenecks, as well as develop, monitor implementation and follow-up on action plans to address them. Evaluations were conducted involving 2 cycles of DIVA. The outputs (bottleneck analysis charts, driver diagrams, operational plans, M/E reports, etc.) from each cycle of the DIVA process were collated and analysed. Bottlenecks identified include availability of human resources for health, availability of health commodities as well as geographical accessibility. These had implications on acceptability and quality of services. Mean Improvements recorded were 20.4%, 14.0% and 10.8% and 11.2%, 7.5%; 5.5% (across eMTCT, maternal health and child health interventions) in the 1 st and 2nd DIVA cycles respectively. This study highlights processes and outcomes of integrating PAR in quality improvement design and operations in health intervention programmes with a focus on health systems strengthening in a Nigerian context. Implementing the DIVA model using a PAR approach may be considered an effective strategy for planning and implementing health interventions in comparable settings.

Implementation process and quality of a primary health care system improvement initiative in a decentralized context: A retrospective appraisal using the quality implementation framework.

BACKGROUND: Effective implementation processes are essential in achieving desired outcomes of health initiatives. Whereas many approaches to implementation may seem straightforward, careful advanced planning, multiple stakeholder involvements, and addressing other contextual constraints needed for quality implementation are complex. Consequently, there have been recent calls for more theory-informed implementation science in health systems strengthening. This study applies the quality implementation framework (QIF) developed by Meyers, Durlak, and Wandersman to identify and explain observed implementation gaps in a primary health care system improvement intervention in Nigeria. METHODS: We conducted a retrospective process appraisal by analyzing contents of 39 policy document and 15 key informant interviews. Using the QIF, we assessed challenges in the implementation processes and quality of an improvement model across the tiers of Nigeria's decentralized health system. RESULTS: Significant process gaps were identified that may have affected subnational implementation quality. Key challenges observed include inadequate stakeholder engagements and poor fidelity to planned implementation processes. Although needs and fit assessments, organizational capacity building, and development of implementation plans at national level were relatively well carried out, these were not effective in ensuring quality and sustainability at the subnational level. CONCLUSIONS: Implementing initiatives between levels of governance is more complex than within a tier. Adequate preintervention planning, understanding, and engaging the various interests across the governance spectrum are key to improving quality.