Gamified Assessment of the Emotion Regulation Abilities in Youth: Validation of the REThink Online System.

Objective: Emotional problems in the youth population are a major issue that can have a significant negative impact for their future development as adults. Their emotion regulation (ER) abilities represent a preventive measure for those emotional problems. REThink is an online therapeutic game that was proved to be effective in rigorous studies, and is based on the rational emotive behavioral therapy, with seven levels built to train various emotional regulation skills. Each level has a section that can be used for the assessment of the targeted skills within the level. The present study aimed at investigating the reliability and validity of the evaluation modules from the REThink game regarding the assessment of ER abilities in children/adolescents. Methods: In accordance with established guidelines, 110 children and adolescents aged 8-14 years old were recruited. Following parental informed consent, the participants filled out the standard questionnaires and, subsequently, they played the evaluation module of the REThink game. The reliability aspect was investigated by evaluating internal consistency, while validity was evaluated by using concurrent and predictive validity analyses. Results: The results revealed statistically significant positive associations between the game scores obtained by the participants and the emotion regulation scale. In terms of predictive validity, there were significant negative associations between game scores and the presence of emotional and behavioral problems. Moreover, in terms of the reliability of the REThink game, an acceptable value for the internal consistency was observed. Conclusion: In conclusion, the REThink therapeutic game was proved to be a valid measure for assessing emotion regulation abilities in children and adolescents. Clinical Trial Registration No. NCT04788901.

Self-Monitoring via Digital Health in Weight Loss Interventions: A Systematic Review Among Adults with Overweight or Obesity.

OBJECTIVE: Self-monitoring is a core component of behavioral obesity treatment, but it is unknown how digital health has been used for self-monitoring, what engagement rates are achieved in these interventions, and how self-monitoring and weight loss are related. METHODS: This systematic review examined digital self-monitoring in behavioral weight loss interventions among adults with overweight or obesity. Six databases (PubMed, Embase, Scopus, PsycInfo, CINAHL, and ProQuest Dissertations & Theses) were searched for randomized controlled trials with interventions ≥ 12 weeks, weight outcomes ≥ 6 months, and outcomes on self-monitoring engagement and their relationship to weight loss. RESULTS: Thirty-nine studies from 2009 to 2019 met inclusion criteria. Among the 67 interventions with digital self-monitoring, weight was tracked in 72% of them, diet in 81%, and physical activity in 82%. Websites were the most common self-monitoring modality, followed by mobile applications, wearables, electronic scales, and, finally, text messaging. Few interventions had digital self-monitoring engagement rates ≥ 75% of days. Rates were higher in digital- than in paper-based arms in 21 out of 34 comparisons and lower in just 2. Interventions with counseling had similar rates to standalone interventions. Greater digital self-monitoring was linked to weight loss in 74% of occurrences. CONCLUSIONS: Self-monitoring via digital health is consistently associated with weight loss in behavioral obesity treatment.

Updates in technology-based interventions for attention deficit hyperactivity disorder.

PURPOSE OF REVIEW: Technological advancement has led to the development of novel treatment approaches for attention deficit hyperactivity disorder (ADHD). This review aims to review recent studies which employ the use of technology to treat ADHD, with particular focus on studies published during a 1-year period from February 2019 to February 2020. RECENT FINDINGS: Most recent studies involved children aged 12 years and below. Interventions included cognitive training through games, neurofeedback and a combination of several approaches. More novel approaches included trigeminal nerve stimulation and brain-computer interface, and studies had utilized technology such as X-box Kinect and eye tracker. There was a shift towards delivering intervention at home and in school, enabled by technology. The study outcomes were variable and mainly included executive functioning measures and clinical ratings. These interventions were generally safe with few reported adverse events. SUMMARY: Technology has enabled interventions to be delivered outside of the clinic setting and presented an opportunity for increased access to care and early intervention. Better quality studies are needed to inform on the efficacy of these interventions.

Behavior Change Content, Understandability, and Actionability of Chronic Condition Self-Management Apps Available in France: Systematic Search and Evaluation.

BACKGROUND: The quality of life of people living with chronic conditions is highly dependent on self-management behaviors. Mobile health (mHealth) apps could facilitate self-management and thus help improve population health. To achieve their potential, apps need to target specific behaviors with appropriate techniques that support change and do so in a way that allows users to understand and act upon the content with which they interact. OBJECTIVE: Our objective was to identify apps targeted toward the self-management of chronic conditions and that are available in France. We aimed to examine what target behaviors and behavior change techniques (BCTs) they include, their level of understandability and actionability, and the associations between these characteristics. METHODS: We extracted data from the Google Play store on apps labelled as Top in the Medicine category. We also extracted data on apps that were found through 12 popular terms (ie, keywords) for the four most common chronic condition groups-cardiovascular diseases, cancers, respiratory diseases, and diabetes-along with apps identified through a literature search. We selected and downloaded native Android apps available in French for the self-management of any chronic condition in one of the four groups and extracted background characteristics (eg, stars and number of ratings), coded the presence of target behaviors and BCTs using the BCT taxonomy, and coded the understandability and actionability of apps using the Patient Education Material Assessment Tool for audiovisual materials (PEMAT-A/V). We performed descriptive statistics and bivariate statistical tests. RESULTS: A total of 44 distinct native apps were available for download in France and in French: 39 (89%) were found via the Google Play store and 5 (11%) were found via literature search. A total of 19 (43%) apps were for diabetes, 10 for cardiovascular diseases (23%), 8 for more than one condition in the four groups (18%), 6 for respiratory diseases (14%), and 1 for cancer (2%). The median number of target behaviors per app was 2 (range 0-7) and of BCTs per app was 3 (range 0-12). The most common BCT was self-monitoring of outcome(s) of behavior (31 apps), while the most common target behavior was tracking symptoms (30 apps). The median level of understandability was 42% and of actionability was 0%. Apps with more target behaviors and more BCTs were also more understandable (ρ=.31, P=.04 and ρ=.35, P=.02, respectively), but were not significantly more actionable (ρ=.24, P=.12 and ρ=.29, P=.054, respectively). CONCLUSIONS: These apps target few behaviors and include few BCTs, limiting their potential for behavior change. While content is moderately understandable, clear instructions on when and how to act are uncommon. Developers need to work closely with health professionals, users, and behavior change experts to improve content and format so apps can better support patients in coping with chronic conditions. Developers may use these criteria for assessing content and format to guide app development and evaluation of app performance. TRIAL REGISTRATION: PROSPERO CRD42018094012; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=94012.

Behavior Change Techniques Incorporated in Fitness Trackers: Content Analysis.

BACKGROUND: The use of fitness trackers as tools of self-management to promote physical activity is increasing. However, the content of fitness trackers remains unexplored. OBJECTIVE: The aim of this study was to use the Behavior Change Technique Taxonomy v1 (BCTTv1) to examine if swim-proof fitness trackers below Aus $150 (US$ 105) incorporate behavior change techniques (BCTs) that relate to self-management strategies to increase physical activity and reduce sedentary behavior and to determine if content of the fitness trackers correspond to physical activity guidelines. METHODS: A total of two raters used the BCTTv1 to code 6 fitness trackers that met the inclusion criteria. The inclusion criteria were the ability to track activity, be swim proof, be compatible with Android and Apple operating systems, and cost below Aus $150. RESULTS: All fitness trackers contained BCTs known to promote physical activity, with the most frequently used BCTs overlapping with self-management strategies, including goal setting, self-monitoring, and feedback on behavior. Fitbit Flex 2 (Fitbit Inc) contained the most BCTs at 20. Huawei Band 2 Pro (Huawei Technologies) and Misfit Shine 2 (Fossil Group) contained the least BCTs at 11. CONCLUSIONS: Fitness trackers contain evidence-based BCTs that overlap with self-management strategies, which have been shown to increase physical activity and reduce sedentary behavior. Fitness trackers offer the prospect for physical activity interventions that are cost-effective and easily accessed by a wide population.

Examining Development Processes for Text Messaging Interventions to Prevent Cardiovascular Disease: Systematic Literature Review.

BACKGROUND: Interventions delivered by mobile phones have the potential to prevent cardiovascular disease (CVD) by supporting behavior change toward healthier lifestyles and treatment adherence. To allow replication and adaptation of these interventions across settings, it is important to fully understand how they have been developed. However, the development processes of these interventions have not previously been systematically examined. OBJECTIVE: This study aimed to systematically describe and compare the development process of text messaging interventions identified in the Text2PreventCVD systematic review. METHODS: We extracted data about the development process of the 9 interventions identified in the Text2PreventCVD systematic review. Data extraction, which was guided by frameworks for the development of complex interventions, considered the following development stages: intervention planning, design, development, and pretesting. Following data extraction, we invited the developers of the interventions to contribute to our study by reviewing the accuracy of the extracted data and providing additional data not reported in the available publications. RESULTS: A comprehensive description of the development process was available for 5 interventions. Multiple methodologies were used for the development of each intervention. Intervention planning involved gathering information from stakeholder consultations, literature reviews, examination of relevant theory, and preliminary qualitative research. Intervention design involved the use of behavior change theories and behavior change techniques. Intervention development involved (1) generating message content based on clinical guidelines and expert opinions; (2) conducting literature reviews and primary qualitative research to inform decisions about message frequency, timing, and level of tailoring; and (3) gathering end-user feedback concerning message readability, intervention acceptability, and perceived utility. Intervention pretesting involved pilot studies with samples of 10 to 30 participants receiving messages for a period ranging from 1 to 4 weeks. CONCLUSIONS: The development process of the text messaging interventions examined was complex and comprehensive, involving multiple studies to guide decisions about the scope, content, and structure of the interventions. Additional research is needed to establish whether effective messaging systems can be adapted from work already done or whether this level of development is needed for application in other conditions and settings.

Mobile Phone Apps Targeting Medication Adherence: Quality Assessment and Content Analysis of User Reviews.

BACKGROUND: With the accessibility and widespread use of mobile phones, mobile phone apps targeting medication adherence may be useful tools to help patients take medications as prescribed. OBJECTIVE: Our objectives were to (1) characterize and assess mobile phone medication adherence apps guided by a conceptual framework on the focus of adherence interventions and (2) conduct a content analysis of Web-based reviews to explore users' perspectives and experiences with mobile phone medication adherence apps. METHODS: We searched for mobile phone medication adherence apps using keyword searches in Apple and Android operating systems. We characterized all apps in terms of number of downloads, ratings, languages, cost, and disease target. We categorized apps according to 4 key features of (1) alerting to take medication, (2) tracking medication taking, (3) reminding to refill or indicating amount of medication left, and (4) storing medication information. We then selected representative apps from each operating system for detailed quality assessment and user testing. We also downloaded Web-based reviews for these selected apps and conducted a qualitative content analysis using an inductive approach involving steps of initial open coding, construction of categories, and abstraction into themes. RESULTS: We identified 704 apps (443 from Apple and 261 from Android). The majority of apps across both operating systems had 1 or 2 features-specifically, 37.2% (165/443) and 38.1% (169/443) of Apple apps, respectively, and 41.4% (108/261) and 31.4% (108/261) of Android apps, respectively. Quality assessment and user testing of 20 selected apps revealed apps varied in quality and commonly focused on behavioral strategies to enhance medication adherence through alerts, reminders, and logs. A total of 1323 eligible Web-based reviews from these 20 selected apps were analyzed, and the following themes emerged: (1) features and functions appreciated by users, which included the ability to set up customized medication regimen details and reminders, monitor other health information (eg, vitals, supplements, and manage multiple people or pets), support health care visits (eg, having a list of medications and necessary health information in 1 app); (2) negative user experiences that captured technical difficulties (glitches, confusing app navigation, and poor interoperability), dosage schedule, and reminder setup inflexibility; and (3) desired functions and features related to optimization of information input, improvement of reminders, and upgrading app performance (better synchronization or backup of data and interoperability). CONCLUSIONS: A large number of mobile phone medication adherence apps are currently available. The majority of apps have features representing a behavioral approach to intervention. Findings of the content analysis offer mostly positive feedback as well as insights into current limitations and improvements that could be addressed in current and future medication adherence apps.

Technological innovations in infection control: A rapid review of the acceptance of behavior monitoring systems and their contribution to the improvement of hand hygiene.

BACKGROUND: Hand hygiene is crucial for preventing nosocomial infections; however, adherence rates need further attention. Prevention of nosocomial infections through regular hand hygiene monitoring and feedback is recommended by the World Health Organization. Technology holds the potential for achieving this goal. The aim of this study was to assess the influence of technological behavior monitoring innovations on hand hygiene adherence and their acceptance by healthcare professionals. METHODS: A rapid review of the literature was conducted. A literature search was performed in electronic databases (Cochrane Library, Scopus, PubMed, CINAHL, PsycINFO, PsycARTICLES, PSYNDEX) and via citation tracking in November 2017. Records were screened for eligibility. Included studies were analyzed and synthesized in a narrative, tabular way. RESULTS: Overall, 2,426 studies were identified, and 12 were included. Findings indicated that behavior monitoring technology improves hand hygiene adherence, resulting in adherence increases between 6.40%-54.97%. The majority of systems provided real-time feedback. Factors influencing acceptance of technology by healthcare professionals include transparency and confidentiality, user attitude and environment, device function, and device usability. CONCLUSIONS: Recognizing the importance of hand hygiene adherence, active communication between behavior monitoring technology and healthcare workers seems to mediate improvement in sustainable hand hygiene adherence behavior.

Step Tracking with Goals Increases Children's Weight Loss in Behavioral Intervention.

BACKGROUND: This study examined the influence of step goals with pedometers to improve children's weight loss, physical activity, and psychosocial health during obesity treatment. METHODS: Overweight and obese children ages 8-17 years (n = 105) participated in a 10-week family-based weight management intervention, including physical activity, nutrition, and behavioral modification. A quasi-experimental design was used to group eight cohorts into three conditions: no pedometer (n = 24), pedometer only (n = 25), and pedometer with step goals (i.e., 500 steps/day weekly increase above baseline; n = 56). Height and weight were measured at baseline and week 10 and used to calculate BMI. Analysis of covariance was performed to examine difference by condition for change in weight, BMI, and BMI z-score, controlling for age and baseline value. Differences in steps per day and psychosocial health were compared between the two pedometer conditions. RESULTS: Participants were 12.4 ± 2.5 years of age, including 70% girls and 64% African Americans. The pedometer with goals condition significantly reduced BMI (p = 0.02) and BMI z-score (p = 0.01) compared with the no-pedometer group. The pedometer with goals condition significantly increased steps per day (+1185 ± 425 steps/day) compared with the pedometer-only condition (-162 ± 620 steps/day; p < 0.05). Both pedometer groups similarly increased in subjective health and quality of life. CONCLUSIONS: Providing children with pedometers and individualized step goals was an effective approach to produce weight loss. Further work is needed to increase the strength of interventions to achieve clinically meaningful weight reduction for children with obesity.

The NULevel trial of a scalable, technology-assisted weight loss maintenance intervention for obese adults after clinically significant weight loss: study protocol for a randomised controlled trial.

BACKGROUND: Effective weight loss interventions are widely available but, after weight loss, most individuals regain weight. This article describes the protocol for the NULevel trial evaluating the effectiveness and cost-effectiveness of a systematically developed, inexpensive, scalable, technology-assisted, behavioural intervention for weight loss maintenance (WLM) in obese adults after initial weight loss. METHODS/DESIGN: A 12-month single-centre, two-armed parallel group, participant randomised controlled superiority trial is underway, recruiting a total of 288 previously obese adults after weight loss of ≥5 % within the previous 12 months. Participants are randomly assigned to intervention or control arms, with a 1:1 allocation, stratified by sex and percentage of body weight lost (<10 % vs ≥10 %). Change in weight (kg) from baseline to 12 months is the primary outcome. Weight, other anthropometric variables and 7-day physical activity (assessed via accelerometer) measures are taken at 0 and 12 months. Questionnaires at 0, 6 and 12 months assess psychological process variables, health service use and participant costs. Participants in the intervention arm initially attend an individual face-to-face WLM consultation with an intervention facilitator and then use a mobile internet platform to self-monitor and report their diet, daily activity (via pedometer) and weight through daily weighing on wirelessly connected scales. Automated feedback via mobile phone, tailored to participants' weight regain and goal progress is provided. Participants in the control arm receive quarterly newsletters (via links embedded in text messages) and wirelessly connected scales. Qualitative process evaluation interviews are conducted with a subsample of up to 40 randomly chosen participants. Acceptability and feasibility of procedures, cost-effectiveness, and relationships among socioeconomic variables and WLM will also be assessed. DISCUSSION: It is hypothesised that participants allocated to the intervention arm will show significantly lower levels of weight regain from baseline than those in the control arm. To date, this is the first WLM trial using remote real-time weight monitoring and mobile internet platforms to deliver a flexible, efficient and scalable intervention, tailored to the individual. This trial addresses a key research need and has the potential to make a vital contribution to the evidence base to inform future WLM policy and provision. TRIAL REGISTRATION: http://www.isrctn.com/ISRCTN14657176 (registration date 20 March 2014).

Smart home-based health platform for behavioral monitoring and alteration of diabetes patients.

BACKGROUND: Researchers and medical practitioners have long sought the ability to continuously and automatically monitor patients beyond the confines of a doctor's office. We describe a smart home monitoring and analysis platform that facilitates the automatic gathering of rich databases of behavioral information in a manner that is transparent to the patient. Collected information will be automatically or manually analyzed and reported to the caregivers and may be interpreted for behavioral modification in the patient. METHOD: Our health platform consists of five technology layers. The architecture is designed to be flexible, extensible, and transparent, to support plug-and-play operation of new devices and components, and to provide remote monitoring and programming opportunities. RESULTS: The smart home-based health platform technologies have been tested in two physical smart environments. Data that are collected in these implemented physical layers are processed and analyzed by our activity recognition and chewing classification algorithms. All of these components have yielded accurate analyses for subjects in the smart environment test beds. CONCLUSIONS: This work represents an important first step in the field of smart environment-based health monitoring and assistance. The architecture can be used to monitor the activity, diet, and exercise compliance of diabetes patients and evaluate the effects of alternative medicine and behavior regimens. We believe these technologies are essential for providing accessible, low-cost health assistance in an individual's own home and for providing the best possible quality of life for individuals with diabetes.

[Training of dogs--legal assessment of the use of electric collars]. / Ausbildung von Hunden--Rechtliche Bewertung des Einsatzes von Elektroreizgeräten.

The use of an electric collar for training dogs is fundamentally forbidden. The verdict of the Federal German Administrative Court dated February 23, 2006 (ref. 3 C 14.05) provides legal clarity and indicates the approach to be taken to enable exceptions from the fundamental ban on electric collars. It is particularly to prevent the misuse of electric collars in the interests of animal welfare that federal legislation should further develop the approach specified in 1998 by including Article 3, No. 11 of the German act on the prevention of cruelty to animals (TierSchG). In this context, it is recommended to continue intensive specialist debate on the question of whether and, where applicable, to what extent the use of electric collars may be permitted, e.g. within the context of training dogs.

Parents' assessment and children's reactions to a passive restraint device used for behavior control in a private pediatric dental practice.

PURPOSE: The purpose of this study was to compare parents' acceptance of passive restraint with their personal perception of their own anxiety, their evaluation of their child's emotional state while being restrained and the treating dentist's perception of their levels of stress. METHODS: A convenience sample of 100 children who needed passive restraint in order to complete their restorative dental needs were included in the study. After the dental treatment was completed, surveys were mailed to the parents who were in the operatory during the restorative procedure, asking them to evaluate their level of stress, their view of how their child accepted the passive restraint device and their view of the success of the procedure. The treating dentist also evaluated their apparent levels of apprehension and the behavior of the children while being restrained, using the Sarnat Scale. There were 42 replies to the survey. RESULTS: The results showed that the difference between the percentage of parents that felt no anxiety vs. moderate to severe anxiety was not significant. Ten percent of the parents felt their child did not mind being restrained, while the balance was evenly split between feeling that their child was either unhappy but accepting or unhappy and not accepting of restraint. CONCLUSIONS: For the population studied, the use of passive restraint was acceptable to most parents, as those in this study did not view it negatively. They were clam while observing their child being treated and happy with their decision for its use. The results suggest that most parents will accept this modality for behavior control.

An interactive computer-administered self-assessment and self-help program for behavior therapy.

Behavior therapy for obsessive-compulsive disorder (OCD) is extremely effective and usually conveys lasting benefits. Unfortunately, behavior therapy is not widely available and is usually quite costly in the few settings where it can be obtained. The essential features of effective behavior therapy are identifying triggers of obsessions, rituals, and discomfort; designing personalized exposure and ritual prevention (E & RP) goals; and encouraging and monitoring E & RP sessions of sufficient frequency and duration for habituation to occur. A computer program (BT STEPS) was designed to assist OCD sufferers in carrying out self-assessment and self-help behavior therapy. The program has nine clinical steps, 12 computer-controlled interactive voice response (IVR) telephone calls (some used repeatedly), and more than 1000 digitized voice files that depend on the progress that patients report during calls. BT STEPS has been studied in two trials at three sites with a total of 65 patients. In both trials, patients who experienced behavior therapy had substantial reductions in OCD severity as assessed by the Yale-Brown Obsessive Compulsive Scale. Approximately two thirds of those who participated in two or more E & RP sessions were much or very much improved. Patients liked using the program, and 71% thought their lives improved as a result. BT STEPS makes behavior therapy for OCD patients potentially available to anyone with a touch-tone telephone. It is intended for use under the supervision of a clinician and can be used in conjunction with pharmacotherapy.

Effectiveness of computer-generated (virtual reality) graded exposure in the treatment of acrophobia.

OBJECTIVE: The authors' goal was to examine the efficacy of computer-generated (virtual reality) graded exposure in the treatment of acrophobia (fear of heights). METHOD: Twenty college students with acrophobia were randomly assigned to virtual reality graded exposure treatment (N = 12) or to a waiting-list comparison group (N = 8). Seventeen students completed the study. Sessions were conducted individually over 8 weeks. Outcome was assessed by using measures of anxiety, avoidance, attitudes, and distress associated with exposure to heights before and after treatment. RESULTS: Significant differences between the students who completed the virtual reality treatment (N = 10) and those on the waiting list (N = 7) were found on all measures. The treatment group was significantly improved after 8 weeks, but the comparison group was unchanged. CONCLUSIONS: The authors conclude that treatment with virtual reality graded exposure was successful in reducing fear of heights.