Profiles of Low-Income Help-Seeking Couples and Implications for Intervention Gains: A Couple-Centered Approach.

Using a couple-centered approach, the current study seeks to understand (a) the specific ways in which help-seeking couples vary in how their relationship satisfaction changes over time, (b) whether there are important differences in relationship characteristics at the beginning of the interventions, and (c) whether couples with distinct relationship characteristics benefit equally from effective online relationship programs. Mixed-gender low-income couples (Ncouple = 659) seeking help for their relationship were randomly assigned to one of two online relationship programs (n = 432) or the wait-list control group (n = 227). Latent profile analyses were conducted to identify (a) trajectory profiles with both partners' relationship satisfaction assessed at baseline, during, and postprogram, and at 2- and 4-month follow-ups; and (b) baseline couple profiles with indicators of baseline communication, commitment, emotional support, and sexual satisfaction reported by both partners. Four unique satisfaction trajectories were identified: women-small-men-medium improvement (39%), men-only decline (25%), large improvement (19%), and women-only improvement (17%). Five unique baseline couple profiles were identified: conflictual passionate (30%), companionate (22%), men-committed languishing (22%), satisfied (16%), and languishing (10%). Compared to control couples, intervention couples' odds of following the large improvement trajectory increased and their odds of following the men-only decline trajectory decreased; the odds of following the other two intermediate trajectories did not differ by intervention status. Moreover, couples with more distressed baseline profiles were more likely to follow trajectories characterized by greater satisfaction gains regardless of their intervention status. However, program effects did not differ based on baseline couple profiles, suggesting that a universal approach may be sufficient for delivering online relationship programs to improve relationship satisfaction in this population.

The Goldilocks Dilemma on Balancing User Response and Reflection in mHealth Interventions: Observational Study.

Background: Mobile health (mHealth) has the potential to radically improve health behaviors and quality of life; however, there are still key gaps in understanding how to optimize mHealth engagement. Most engagement research reports only on system use without consideration of whether the user is reflecting on the content cognitively. Although interactions with mHealth are critical, cognitive investment may also be important for meaningful behavior change. Notably, content that is designed to request too much reflection could result in users' disengagement. Understanding how to strike the balance between response burden and reflection burden has critical implications for achieving effective engagement to impact intended outcomes. Objective: In this observational study, we sought to understand the interplay between response burden and reflection burden and how they impact mHealth engagement. Specifically, we explored how varying the response and reflection burdens of mHealth content would impact users' text message response rates in an mHealth intervention. Methods: We recruited support persons of people with diabetes for a randomized controlled trial that evaluated an mHealth intervention for diabetes management. Support person participants assigned to the intervention (n=148) completed a survey and received text messages for 9 months. During the 2-year randomized controlled trial, we sent 4 versions of a weekly, two-way text message that varied in both reflection burden (level of cognitive reflection requested relative to that of other messages) and response burden (level of information requested for the response relative to that of other messages). We quantified engagement by using participant-level response rates. We compared the odds of responding to each text and used Poisson regression to estimate associations between participant characteristics and response rates. Results: The texts requesting the most reflection had the lowest response rates regardless of response burden (high reflection and low response burdens: median 10%, IQR 0%-40%; high reflection and high response burdens: median 23%, IQR 0%-51%). The response rate was highest for the text requesting the least reflection (low reflection and low response burdens: median 90%, IQR 61%-100%) yet still relatively high for the text requesting medium reflection (medium reflection and low response burdens: median 75%, IQR 38%-96%). Lower odds of responding were associated with higher reflection burden (P<.001). Younger participants and participants who had a lower socioeconomic status had lower response rates to texts with more reflection burden, relative to those of their counterparts (all P values were <.05). Conclusions: As reflection burden increased, engagement decreased, and we found more disparities in engagement across participants' characteristics. Content encouraging moderate levels of reflection may be ideal for achieving both cognitive investment and system use. Our findings provide insights into mHealth design and the optimization of both engagement and effectiveness.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT.

AIMS: Family/friend Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS' effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT. METHODS: Persons with diabetes (PWDs) were randomized to FAMS or control with their support person (family/friend, optional). FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period. RESULTS: PWDs (N = 329) were 52 % male, 39 % reported minoritized race or ethnicity, with mean HbA1c 8.6 ± 1.7 %. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64 %; 95 % CI [-1.22 %, -0.05 %]), but overall mean effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27 %; 95 % CI [-0.49 %, -0.09 %]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19 %; 95 % CI [-0.40 %, -0.01 %]). CONCLUSIONS: Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

A randomized controlled trial of the online OurRelationship program with varying levels of coach support.

Online programs that reduce relationship distress fill a critical need; however, their scalability is limited by their reliance on coach calls. To determine the effectiveness of the online OurRelationship program with varying levels of coach support, we conducted a comparative effectiveness trial with 740 low-income couples in the United States. Couples were randomly assigned to full-coach (ncouples = 226; program as originally designed), automated-coach (ncouples = 145; as a stand-alone program with tailored automated emails only), contingent-coach (ncouples = 145; as an adaptive program where tailored automated emails are followed by more coaching if couples did not meet progress milestones), or a waitlist control condition (ncouples = 224). All analyses were conducted within a Bayesian framework. Completion rates were comparable across conditions (full-coach: 65 %, automated-coach: 59 %, contingent-coach: 54 %). All intervention couples reported reliable pre-post gains in relationship satisfaction compared to waitlist control couples (dfull = 0.46, dcontingent = 0.47, and dautomated = 0.40) with no reliable differences across intervention conditions. Over four-month follow-up, couples in full- and contingent-coach conditions maintained gains in relationship satisfaction and couples in the automated-coach condition continued to improve. Given the comparable completion rates and minimal differences in effect sizes across intervention conditions, all three coaching models appear viable; therefore, the choice of model can vary depending on available resources as well as couple or stakeholder preferences. This study was preregistered (ClinicalTrials.govNCT03568565).

Family Typology for Adults With Type 2 Diabetes: Longitudinal Stability and Validity for Diabetes Management and Well-being.

OBJECTIVE: We validated longitudinally a typology of diabetes-specific family functioning (named Collaborative and Helpful, Satisfied with Low Involvement, Want More Involvement, and Critically Involved) in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted k-means cluster analyses with nine dimensions to determine if the typology replicated in a diverse sample and if type assignment was robust to variations in sampling and included dimensions. In a subsample with repeated assessments over 9 months, we examined the stability and validity of the typology. We also applied a multinomial logistic regression approach to make the typology usable at the individual level, like a diagnostic tool. RESULTS: Participants (N = 717) were 51% male, more than one-third reported minority race or ethnicity, mean age was 57 years, and mean hemoglobin A1c (HbA1c) was 7.9% (63 mmol/mol; 8.7% [72 mmol/mol] for the longitudinal subsample). The typology was replicated with respect to the number of types and dimension patterns. Type assignment was robust to sampling variations (97% consistent across simulations). Type had an average 52% stability over time within participants; instability was not explained by measurement error. Over 9 months, type was independently associated with HbA1c, diabetes self-efficacy, diabetes medication adherence, diabetes distress, and depressive symptoms (all P < 0.05). CONCLUSIONS: The typology of diabetes-specific family functioning was replicated, and longitudinal analyses suggest type is more of a dynamic state than a stable trait. However, type varies with diabetes self-management and well-being over time as a consistent independent indicator of outcomes. The typology is ready to be applied to further precision medicine approaches to behavioral and psychosocial diabetes research and care.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT.

AIMS: Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friend Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons. METHODS: PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9 months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons. RESULTS: PWDs (N = 329) were 52% male and 39% reported minoritized race or ethnicity ; 50% enrolled with elevated diabetes distress. Support persons (N = 294) were 26% male and 33% reported minoritized race or ethnicity. FAMS improved PWDs' diabetes distress (d = -0.19) and global well-being (d = 0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention (9-month) and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement. CONCLUSIONS: FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT.

Aims: Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friends Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons. Methods: PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9-months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons. Results: PWDs (N=329) were 52% male and 39% from minoritized racial or ethnic groups; 50% enrolled with elevated diabetes distress. Support persons (N=294) were 26% male and 33% minoritized racial or ethnic groups. FAMS improved PWDs' diabetes distress ( d =-0.19) and global well-being ( d =0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement. Conclusions: FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT.

Aims: Family/friends Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT. Methods: Persons with diabetes (PWDs) and their support persons (family/friend, optional) were randomized to FAMS or control. FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period. Results: PWDs (N=329) were 52% male, 39% from minoritized racial or ethnic groups, with mean HbA1c 8.6±1.7%. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64%; 95% CI [-1.22%, -0.05%]), but overall effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27%; 95% CI [-0.49%, -0.09%]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19%; 95% CI [-0.40%, -0.01%]). Conclusions: Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Optimizing adaptive stepped-care interventions to change adults' health behaviors: A systematic review.

Chronic diseases are ubiquitous and costly in American populations. Interventions targeting health behavior change to manage chronic diseases are needed, but previous efforts have fallen short of producing meaningful change on average. Adaptive stepped-care interventions, that tailor treatment based on the needs of the individual over time, are a promising new area in health behavior change. We therefore conducted a systematic review of tests of adaptive stepped-care interventions targeting health behavior changes for adults with chronic diseases. We identified 9 completed studies and 13 research protocols testing adaptive stepped-care interventions for health behavior change. The most common health behaviors targeted were substance use, weight management, and smoking cessation. All identified studies test intermediary tailoring for treatment non-responders via sequential multiple assignment randomized trials (SMARTs) or singly randomized trials (SRTs); none test baseline tailoring. From completed studies, there were few differences between embedded adaptive interventions and minimal differences between those classified as treatment responders and non-responders. In conclusion, updates to this work will be needed as protocols identified here publish results. Future research could explore baseline tailoring variables, apply methods to additional health behaviors and target populations, test tapering interventions for treatment responders, and consider adults' context when adapting interventions.

Prerandomization withdrawals from a Type 2 diabetes self-care support intervention trial are associated with lack of available support person coparticipant.

OBJECTIVES: Dyadic interventions, involving two persons with a preexisting close relationship, offer the opportunity to activate support persons (SPs) to improve health for adults with chronic conditions. Requiring SP coparticipation can challenge recruitment and bias samples; however, the associations between voluntary SP coparticipation and recruitment outcomes across patient characteristics are unknown. METHODS: The Family/Friend Activation to Motivate Self-care 2.0 randomized controlled trial (RCT) enrolled adults with Type 2 diabetes (T2D) from an academic health system. Participants were asked-but not required-to invite an SP to coenroll. Using data from the electronic health record we sought to describe RCT enrollment in the setting of voluntary SP coparticipation. RESULTS: In a diverse sample of adults with (T2D) (48% female, 44% minoritized race/ethnicity), most participants (91%) invited SPs and (89%) enrolled with SPs. However, prerandomization withdrawal was significantly higher among participants who did not have consenting SPs than those who did. Females were less likely to invite SPs than males and more Black PWD were prerandomization withdrawals than randomized. DISCUSSION: Voluntary SP coenrollment may benefit recruitment for dyadic sampling; however, more research is needed to understand if these methods systematically bias sampling and to prevent these unintended biases.

Coaching with Internet-Based Mental Health Program: Patient and Coach Experiences.

Introduction: The COVID-19 pandemic has laid bare the need for mental health treatment and the shortage of available providers. Internet-based, asynchronous mental health programs that incorporate coaching with a licensed provider address this widespread challenge. This study provides an in-depth exploration of both the patient and provider experience in webSTAIR, a coached, internet-based psychoeducational program, where coaching took place over video-telehealth. We focus on how patients and licensed mental health providers understood their coaching relationship in an internet-based mental health program. Materials and Methods: We interviewed a purposive sample of 60 patients who completed the coached, internet-based program and all 9 providers who provided coaching from 2017 to 2020. The project team and interviewers took notes during interviews. Patient interviews were studied using content and matrix analysis. Coach interviews were studied using thematic analysis. Results: Interviews across patients and coaches reveal the continued importance of relationship building and rapport and emphasized the central role of the coach in providing content clarification and application of skills. Discussion: For patients, coaches were critical for understanding and completing the internet-based program. As well, positive relationship with their coach further enhanced their experience in the program. Providers echoed the importance of relationship building and rapport for program success and saw their main role as helping patients to understand content and apply skills.

Family involvement and diabetes distress across dyads for adults with type 2 diabetes.

OBJECTIVE: Family/friend involvement and diabetes distress are associated with outcomes for persons with type 2 diabetes (PWDs), but little is known about how they relate to each other. We aim to (1) describe associations between PWD and support person (SP) distress; (2) describe associations between involvement and diabetes distress for PWDs, for SPs, and across the dyad; and (3) explore whether associations differ by PWD-SP cohabitation. METHODS: PWDs and SPs co-enrolled in a study evaluating the effects of a self-care support intervention and completed self-report measures at baseline. RESULTS: PWDs and SPs (N = 297 dyads) were, on average, in their mid-50s and around one-third identified as racial or ethnic minorities. The association between PWD and SP diabetes distress was small (Spearman's ρ = 0.25, p < 0.01). For PWDs, experienced harmful involvement from family/friends was associated with more diabetes distress (standardized ß = 0.23, p < 0.001) independent of helpful involvement in adjusted models. Separately, SPs' self-reported harmful involvement was associated with their own diabetes distress (standardized ß = 0.35, p < 0.001) and with PWDs' diabetes distress (standardized ß = 0.25, p = 0.002), independent of SPs' self-reported helpful involvement. CONCLUSION AND PRACTICE IMPLICATIONS: Findings suggest dyadic interventions may need to address both SP harmful involvement and SP diabetes distress, in addition to PWD distress.

Telemental health in emergency care settings: A qualitative analysis of considerations for sustainability and spread.

OBJECTIVES: Following rapid uptake of telehealth during the COVID-19 pandemic, we examined barriers and facilitators for sustainability and spread of telemental health video (TMH-V) as policies regarding precautions from the pandemic waned. METHODS: We conducted a qualitative study using semistructured interviews and observations guided by RE-AIM. We asked four groups, local clinicians, facility leadership, Veterans, and external partners, about barriers and facilitators impacting patient willingness to engage in TMH-V (reach), quality of care (effectiveness), barriers and facilitators impacting provider uptake (adoption), possible adaptations to TMH-V (implementation), and possibilities for long-term use of TMH-V (maintenance). Interviews were recorded, transcribed, and analyzed using framework analysis. We also observed TMH-V encounters in one emergency department (ED) and one urgent care (UC) to understand how clinicians and Veterans engaged with the technology. RESULTS: We conducted 35 interviews with ED/UC clinicians and staff (n = 10), clinical and facility leadership (n = 7), Veterans (n = 5), and external partners (n = 13), January-May 2022. We completed 10 observations. All interviewees were satisfied with the TMH-V program, and interviewees highlighted increased comfort discussing difficult topics for Veterans (reach). Clinicians identified that TMH-V allowed for cross-coverage across sites as well as increased safety and flexibility for clinicians (adoption). Opportunities for improvement include alleviating technological burdens for on-site staff, electronic health record (EHR) modifications to accurately capture workload and modality (telehealth vs. in-person), and standardizing protocols to streamline communication between on-site and remote clinical staff (implementation). Finally, interviewees encouraged its spread (maintenance) and thought there was great potential for service expansion. CONCLUSIONS: Interviewees expressed support for continuing TMH-V locally and spread to other sites. Ensuring adequate infrastructure (e.g., EHR integration and technology support) and workforce capacity are key for successful spread. Given the shortage of mental health (MH) clinicians in rural settings, TMH-V represents a promising intervention to increase the access to high-quality emergency MH care.

Exploring mHealth potential to improve kidney function: secondary analysis of a randomized trial of diabetes self-care in diverse adults.

BACKGROUND: Many individuals living with chronic kidney disease (CKD) have comorbid Type 2 diabetes (T2D). We sought to explore if efficacious interventions that improve glycemic control may also have potential to reduce CKD progression. METHODS: REACH is a text message-delivered self-management support intervention, which focused on medication adherence, diet, and exercise that significantly improved glycemic control in N = 506 patients with T2D. Using data from the trial, we characterized kidney health in the full sample and explored the intervention's effect on change in estimated glomerular filtration rate (eGFR) at 12 months in a subsample of N=271 patients with eGFR data. RESULTS: In a diverse sample with respect to race/ethnicity and socioeconomic status, 37.2% had presence of mild or heavy proteinuria and/or an eGFR < 60 mL/min/1.73 m2. There was a trending interaction effect between intervention and presence of proteinuria at baseline (b = 6.016, p = .099) such that patients with proteinuria at baseline who received REACH had less worsening of eGFR. CONCLUSIONS: Future research should examine whether diabetes directed self-management support reduces CKD progression in ethnically diverse individuals with albuminuria. In highly comorbid populations, such as T2D and CKD, text-based support can be further tailored according to individuals' multimorbid disease self-management needs and is readily scalable for individuals with limited resources. TRIAL REGISTRATION: This study was registered with ClinicalTrials.gov ( NCT02409329 ).

Development and Initial Feasibility of a Hospital-Based Acceptance and Commitment Therapy Intervention to Improve Retention in Care for Out-of-Care Persons with HIV: Lessons Learned from an Open Pilot Trial.

Roughly 40% of persons with HIV (PWH) are not consistently involved in HIV care in the US. Finding out-of-care PWH is difficult, but hospitalization is common and presents an opportunity to re-engage PWH in outpatient care. The aims of this study were to (1) develop an Acceptance and Commitment Therapy (ACT)-based intervention for hospitalized, out-of-care PWH who endorse avoidance-coping to improve HIV treatment engagement; (2) examine the intervention's initial feasibility and acceptability; and (3) to revise the study protocol (including the intervention), based on stakeholder feedback, in preparation for a randomized controlled trial (RCT) comparing ACT to treatment as usual. Therapists and HIV care experts developed a four-session ACT-based intervention to be delivered during hospitalization. Fifteen hospitalized patients with poorly controlled HIV enrolled in the open trial, eight completed four sessions, two completed three sessions, and seven provided qualitative feedback. Patients universally liked the intervention and the holistic approach to mental health and HIV care. Refinements included repeating key concepts, including representative graphics, and translating to Spanish. Among the patients who attended ≥3 ACT sessions, 5/10 attended a HIV-care follow-up visit and 5/7 who had labs had a viral load <20 2-months post-intervention. Next steps include conducting a randomized clinical trial exploring the impact of the refined intervention to treatment as usual on retention in care and viral load. ClinicalTrials.gov Identifier: NCT04481373.

A review of the research during 2010-2019 on evidence-based treatments for couple relationship distress.

The current article presents a review of the published research from 2010 to 2019 on the treatment of couple relationship distress; 37 studies met all criteria for inclusion. Behavioral Couple Therapy, Cognitive Behavioral Couple Therapy, Emotionally Focused Therapy, and Integrative Behavioral Couple Therapy meet criteria as "well-established" approaches, Insight-Oriented Couple Therapy is a "possibly efficacious" approach, and several other others are "experimental" treatments for treating couple relationship distress (Southam-Gerow & Prinstein, 2014). Furthermore, several less-intensive interventions-the Marriage Check-up, OurRelationship, and Hold Me Tight programs-have generated substantial support for their ability to improve relationships and are classified as "well-established" or "probably efficacious" interventions. We recommend that future research focus on expanding the reach of evidence-based interventions across a range of settings and populations, deepening our understanding of the mechanisms of change and underlying factors in the change process across approaches, and improving treatment success through treatment matching and progress monitoring.

Changes in family involvement occasioned by FAMS mobile health intervention mediate changes in glycemic control over 12 months.

Mobile phone-delivered interventions have proven effective in improving glycemic control (HbA1c) in the short term among adults with type 2 diabetes (T2D). Family systems theory suggests engaging family/friend in adults' diabetes self-care may enhance or sustain improvements. In secondary analysis from a randomized controlled trial (N = 506), we examined intervention effects on HbA1c via change in diabetes-specific helpful and harmful family/friend involvement. We compared a text messaging intervention that did not target family/friend involvement (REACH), REACH plus family-focused intervention components targeting helpful and harmful family/friend involvement (REACH + FAMS), and a control condition. Over 6 months, both intervention groups experienced improvement in HbA1c relative to control, but at 12 months neither did. However, REACH + FAMS showed an indirect effect on HbA1c via change in helpful family/friend involvement at both 6 and 12 months while REACH effects were not mediated by family/friend involvement. Consistent with family systems theory, improvements in HbA1c mediated by improved family/friend involvement were sustained.

Exploring determinants and strategies for implementing self-management support text messaging interventions in safety net clinics.

Background: Text message-delivered interventions for chronic disease self-management have potential to reduce health disparities, yet limited research has explored implementing these interventions into clinical care. We partnered with safety net clinics to evaluate a texting intervention for type 2 diabetes called REACH (Rapid Encouragement/Education And Communications for Health) in a randomized controlled trial. Following evaluation, we explored potential implementation determinants and recommended implementation strategies. Methods: We interviewed clinic staff (n = 14) and a subset of intervention participants (n = 36) to ask about REACH's implementation potential. Using the Consolidated Framework for Implementation Research (CFIR) as an organizing framework, we coded transcripts and used thematic analysis to derive implementation barriers and facilitators. We integrated the CFIR-ERIC (Expert Recommendations for Implementing Change) Matching Tool, interview feedback, and the literature to recommend implementation strategies. Results: Implementation facilitators included low complexity, strong evidence and quality, available clinic resources, the need for a program to support diabetes self-management, and strong fit between REACH and both the clinics' existing workflows and patients' needs and resources. The barriers included REACH only being available in English, a lack of interoperability with electronic health record systems, patients' concerns about diabetes stigma, limited funding, and high staff turnover. Categories of recommended implementation strategies included training and education, offering flexibility and adaptation, evaluating key processes, and securing funding. Conclusion: Text message-delivered interventions have strong potential for integration in low-resource settings as a supplement to care. Pursuing implementation can ensure patients benefit from these innovations and help close the research to practice gap.

Moderating role of socioecological factors on web-based relationship interventions for lower income couples.

Low-income couples tend to face more external stressors and report less stable romantic relationships compared to higher income couples. A recent nationwide randomized controlled trial of the web-based OurRelationship and ePREP programs was conducted with a sample of 742 lower income couples within 200% of the federal poverty line to help improve relationship distress (Doss et al., 2020). Using a socioecological framework, the current study examined whether the presence of intrapersonal-level, couple-level, and community-level factors moderated those couples' gains in relationship satisfaction during the intervention period as well as maintenance of those gains over 4-month follow-up relative to waitlist-control. Using multilevel modeling, results revealed that both interventions were effective in serving lower income couples relative to couples in the waitlist control group with minimal evidence of moderation by individual-level, couple-level, or neighborhood factors. Thus, the interventions are effective in reducing relationship distress across many socioecological factors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Coparenting and parenting outcomes of online relationship interventions for low-income couples.

Web-based relationship programs are effective in improving low-income couples' relationship functioning. However, little is known about: (a) whether parenting couples presenting for relationship help also have difficulties in coparenting and parenting, (b) whether relationship-focused programs can improve these two domains, and (c) whether program effects differ across baseline levels of those domains. We examined these questions in a parenting subsample (Nindividuals = 934) and a coparenting subsample (Ndyads = 342) of low-income couples participating in a randomized controlled trial of two web-based relationship education programs-the OurRelationship (OR) program and the ePREP program. Although the majority of participants were relationally distressed at baseline, most coparents (83%) reported parenting well together. Parents "often" engaged in nurturing behaviors and "hardly ever" or "sometimes" felt overwhelmed by their parenting responsibilities. Among parents who had engaged in the harsh verbal discipline (59%) and physical discipline (28%) in the past month, the average frequency was 4.08 and 5.50 times per month, respectively. Moreover, compared to waitlist control parents, parents in OR but not ePREP reported significantly greater improvements in parental nurturance and harsh verbal discipline during the program. There was no evidence of program effects on coparenting, physical discipline, or parenting stress for OR or ePREP, nor was there any evidence of baseline functioning moderating program effects. Findings suggested that most low-income parents seeking relationship help did not have severe problems in coparenting or parenting and that effective relationship programs without a focus on coparenting and/or parenting had somewhat limited effects on these domains. (PsycInfo Database Record (c) 2021 APA, all rights reserved).