Dutch GP healthcare consumption in COVID-19 heterogeneous regions: an interregional time-series approach in 2020-2021.

BACKGROUND: Many countries observed a sharp decline in the use of general practice services after the outbreak of the COVID-19 pandemic. However, research has not yet considered how changes in healthcare consumption varied among regions with the same restrictive measures but different COVID-19 prevalence. AIM: To investigate how the COVID-19 pandemic affected healthcare consumption in Dutch general practice during 2020 and 2021, among regions with known heterogeneity in COVID-19 prevalence, from a pre-pandemic baseline in 2019. DESIGN & SETTING: Population-based cohort study using electronic health records. The study was undertaken in Dutch general practices involved in regional research networks. METHOD: An interrupted time-series analysis of changes in healthcare consumption from before to during the pandemic was performed. Descriptive statistics were used on the number of potential COVID-19-related contacts, reason for contact, and type of contact. RESULTS: The study covered 3 595 802 contacts (425 639 patients), 3 506 637 contacts (433 340 patients), and 4 105 413 contacts (434 872 patients) in 2019, 2020, and 2021, respectively. Time-series analysis revealed a significant decrease in healthcare consumption after the outbreak of the pandemic. Despite interregional heterogeneity in COVID-19 prevalence, healthcare consumption decreased comparably over time in the three regions, before rebounding to a level significantly higher than baseline in 2021. Physical consultations transitioned to phone or digital over time. CONCLUSION: Healthcare consumption decreased irrespective of the regional prevalence of COVID-19 from the start of the pandemic, with the Delta variant triggering a further decrease. Overall, changes in care consumption appeared to reflect contextual factors and societal restrictions rather than infection rates.

The Design of a Persuasive Game to Motivate People with Asthma in Adherence to Their Maintenance Medication.

Objective: This study aimed to design a persuasive game, using objective adherence data, to motivate people with asthma to adhere to their medication regimen. Methods: A participatory user-centered design approach was employed, involving end-users and other stakeholders throughout the study. The approach consisted of four phases. Semi-structured interviews and a survey were conducted to understand user needs and reasons for poor adherence (Phase 1: define). Key themes were identified, leading to the formulation of behavior change strategies and design and game requirements. Several design directions were ideated, resulting in a concept for a serious game (Phase 2: ideate). Two rounds of user-tests were performed to evaluate a prototype of the serious game in terms of usability, perceived impact on medication adherence and motivation (Phase 3: prototype and Phase 4: evaluate). Results: Findings from semi-structured interviews (n = 6) and the online survey (n = 20) revealed that people's non-adherence was often attributed to the perception of asthma as an episodic condition, the delayed experienced effect of maintenance inhalers, and lack of knowledge regarding difference of effect between maintenance and reliever inhalers. The study used behavior change strategies to translate these insights into design requirements for the development of the narrative-based persuasive game Ademgenoot. This six-week challenge-based game combines various behavior change strategies, including personal goal setting and continuous visual feedback, as well as persuasive game design elements, such as a narrative and rewards, with the aim of enhancing motivation to adhere to their medication regimen. User-testing (n = 8; round 1 and 2) showed that Ademgenoot is feasible in clinical practice and has the potential to support people with mild asthma in adherence to their maintenance medication. Discussion: Future efforts should be directed towards a larger evaluation to assess the impact on motivation and inhaler use behaviour.

A Natural Language Processing Model for COVID-19 Detection Based on Dutch General Practice Electronic Health Records by Using Bidirectional Encoder Representations From Transformers: Development and Validation Study.

BACKGROUND: Natural language processing (NLP) models such as bidirectional encoder representations from transformers (BERT) hold promise in revolutionizing disease identification from electronic health records (EHRs) by potentially enhancing efficiency and accuracy. However, their practical application in practice settings demands a comprehensive and multidisciplinary approach to development and validation. The COVID-19 pandemic highlighted challenges in disease identification due to limited testing availability and challenges in handling unstructured data. In the Netherlands, where general practitioners (GPs) serve as the first point of contact for health care, EHRs generated by these primary care providers contain a wealth of potentially valuable information. Nonetheless, the unstructured nature of free-text entries in EHRs poses challenges in identifying trends, detecting disease outbreaks, or accurately pinpointing COVID-19 cases. OBJECTIVE: This study aims to develop and validate a BERT model for detecting COVID-19 consultations in general practice EHRs in the Netherlands. METHODS: The BERT model was initially pretrained on Dutch language data and fine-tuned using a comprehensive EHR data set comprising confirmed COVID-19 GP consultations and non-COVID-19-related consultations. The data set was partitioned into a training and development set, and the model's performance was evaluated on an independent test set that served as the primary measure of its effectiveness in COVID-19 detection. To validate the final model, its performance was assessed through 3 approaches. First, external validation was applied on an EHR data set from a different geographic region in the Netherlands. Second, validation was conducted using results of polymerase chain reaction (PCR) test data obtained from municipal health services. Lastly, correlation between predicted outcomes and COVID-19-related hospitalizations in the Netherlands was assessed, encompassing the period around the outbreak of the pandemic in the Netherlands, that is, the period before widespread testing. RESULTS: The model development used 300,359 GP consultations. We developed a highly accurate model for COVID-19 consultations (accuracy 0.97, F1-score 0.90, precision 0.85, recall 0.85, specificity 0.99). External validations showed comparable high performance. Validation on PCR test data showed high recall but low precision and specificity. Validation using hospital data showed significant correlation between COVID-19 predictions of the model and COVID-19-related hospitalizations (F1-score 96.8; P<.001; R2=0.69). Most importantly, the model was able to predict COVID-19 cases weeks before the first confirmed case in the Netherlands. CONCLUSIONS: The developed BERT model was able to accurately identify COVID-19 cases among GP consultations even preceding confirmed cases. The validated efficacy of our BERT model highlights the potential of NLP models to identify disease outbreaks early, exemplifying the power of multidisciplinary efforts in harnessing technology for disease identification. Moreover, the implications of this study extend beyond COVID-19 and offer a blueprint for the early recognition of various illnesses, revealing that such models could revolutionize disease surveillance.

A Health App Platform Providing a Budget to Purchase Preselected Apps as an Innovative Way to Support Public Health: Qualitative Study With End Users and Other Stakeholders.

BACKGROUND: eHealth has the potential to improve health outcomes. However, this potential is largely untapped. Individuals face an overload of apps and have difficulties choosing suitable apps for themselves. In the FitKnip experiment, individuals were given access to a health app platform, where they could purchase reliable preselected health apps with a personal budget of €100 (US $107.35). By conducting a prospective study, we aimed to scientifically evaluate the FitKnip experiment as an innovative way to improve population health. OBJECTIVE: The aim of the experiment was to scientifically evaluate the FitKnip experiment as an innovative way to improve population health. More specifically, we conducted an in-depth qualitative evaluation of the concept and acceptability of FitKnip, its perceived impact on health empowerment, as well as the roles of stakeholders for the future implementation of a health app platform through focus group interviews. METHODS: This study followed a phenomenological research design and included 7 focus group interviews with end users and 1 with stakeholders, held between July and December 2020. End users were recruited through various institutions in the Netherlands, for example, insurance companies and local governments. All focus groups were semistructured using interview guides and were held via videoconferencing due to the COVID-19 pandemic measures. Each participant received access to a health app platform where they were enabled to purchase reliable, preselected health apps with a budget of €100 (US $107.35). The budget was valid for the entire research period. The health app platform offered 38 apps. A third party, a health care coalition, selected the apps to be included in FitKnip. The analyses were conducted according to the principles of the Framework Method. RESULTS: A priori formulated themes were concept, acceptability, health empowerment, and outcomes, and the roles of stakeholders for the future implementation of a health app platform. Both end users (n=31) and stakeholders (n=5) were enthusiastic about the concept of a health app platform. End users indicated missing apps regarding physical health and lifestyle and needing more guidance toward suitable apps. End users saw health empowerment as a precondition to using a health app platform and achieving health outcomes depending on the purchased mobile apps. End users and stakeholders identified potential providers and financing parties of FitKnip. Stakeholders recommended the establishment of a reputable national or international quality guidelines or certification for health and wellbeing apps, that can demonstrate the quality and reliability of mobile health applications. CONCLUSIONS: This study showed the need for a personalized and flexible platform. Next to this, a deeper understanding of the roles of stakeholders in such initiatives is needed especially on financing and reimbursement of health promotion and digital health services. A personalized, flexible health app platform is a promising initiative to support individuals in their health.

Use of the Smoking Cessation App Ex-Smokers iCoach and Associations With Smoking-Related Outcomes Over Time in a Large Sample of European Smokers: Retrospective Observational Study.

BACKGROUND: Digital interventions are increasingly used to support smoking cessation. Ex-smokers iCoach was a widely available app for smoking cessation used by 404,551 European smokers between June 15, 2011, and June 21, 2013. This provides a unique opportunity to investigate the uptake of a freely available digital smoking cessation intervention and its effects on smoking-related outcomes. OBJECTIVE: We aimed to investigate whether there were distinct trajectories of iCoach use, examine which baseline characteristics were associated with user groups (based on the intensity of use), and assess if and how these groups were associated with smoking-related outcomes. METHODS: Analyses were performed using data from iCoach users registered between June 15, 2011, and June 21, 2013. Smoking-related data were collected at baseline and every 3 months thereafter, with a maximum of 8 follow-ups. First, group-based modeling was applied to detect distinct trajectories of app use. This was performed in a subset of steady users who had completed at least 1 follow-up measurement. Second, ordinal logistic regression was used to assess the baseline characteristics that were associated with user group membership. Finally, generalized estimating equations were used to examine the association between the user groups and smoking status, quitting stage, and self-efficacy over time. RESULTS: Of the 311,567 iCoach users, a subset of 26,785 (8.6%) steady iCoach users were identified and categorized into 4 distinct user groups: low (n=17,422, 65.04%), mild (n=4088, 15.26%), moderate (n=4415, 16.48%), and intensive (n=860, 3.21%) users. Older users and users who found it important to quit smoking had higher odds of more intensive app use, whereas men, employed users, heavy smokers, and users with higher self-efficacy scores had lower odds of more intensive app use. User groups were significantly associated with subsequent smoking status, quitting stage, and self-efficacy over time. For all groups, over time, the probability of being a smoker decreased, whereas the probability of being in an improved quitting stage increased, as did the self-efficacy to quit smoking. For all outcomes, the greatest change was observed between baseline and the first follow-up at 3 months. In the intensive user group, the greatest change was seen between baseline and the 9-month follow-up, with the observed change declining gradually in moderate, mild, and low users. CONCLUSIONS: In the subset of steady iCoach users, more intensive app use was associated with higher smoking cessation rates, increased quitting stage, and higher self-efficacy to quit smoking over time. These users seemed to benefit most from the app in the first 3 months of use. Women and older users were more likely to use the app more intensively. Additionally, users who found quitting difficult used the iCoach app more intensively and grew more confident in their ability to quit over time.

The delivery of Ask-Advise-Connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: results of a pre-post implementation study.

BACKGROUND: The Ask-Advise-Connect approach can help primary care providers to increase the number of smokers that attempt to quit smoking and enrol into cessation counselling. The approach has not yet been implemented in general practice in the Netherlands. The aim of this study was to investigate the influence of a comprehensive implementation strategy on the delivery of Ask-Advise-Connect for smoking cessation within Dutch general practice during the COVID-19 pandemic. METHODS: A pre-post study was conducted between late 2020 and early 2022, and included 106 Dutch primary care providers (GPs, practice nurses and doctor's assistants). Participation lasted nine months: during the first three months participants delivered smoking cessation care as usual (pre-intervention); the implementation strategy came into effect after three months and participants were followed up for another six months (post-intervention). The implementation strategy consisted of two meetings in which participants were educated about Ask-Advise-Connect, made agreements on the implementation of Ask-Advise-Connect and reflected on these agreements. Participants also received online educational materials and a desk card as reminder. The changes in the proportions of 'Ask' and 'Advise' over time were modelled using linear mixed effects models. A descriptive analysis was conducted with regard to referrals to cessation counselling. RESULTS: Participants provided consultations to 29,112 patients (both smokers and non-smokers). Results of the linear mixed effects model show that the proportion of patients that were asked about smoking ('Ask') significantly decreased in the first three months (pre-intervention), but slightly increased again after the implementation strategy came into effect (post-intervention). No significant change over time was found with regard to the proportion of patients advised to quit smoking ('Advise'). Descriptive statistics suggested that more participants proactively (vs. passively) referred patients to cessation counselling post-intervention ('Connect'). CONCLUSIONS: The findings indicate that a comprehensive implementation strategy can support primary care providers in offering smoking cessation care to patients, even under stressful COVID-19 conditions. Additional implementation efforts are needed to increase the proportion of patients that receive a quit advice and proactive referral.

Anticipated barriers and facilitators for implementing smart inhalers in asthma medication adherence management.

Smart inhalers are electronic monitoring devices which are promising in increasing medication adherence and maintaining asthma control. A multi-stakeholder capacity and needs assessment is recommended prior to implementation in healthcare systems. This study aimed to explore perceptions of stakeholders and to identify anticipated facilitators and barriers associated with the implementation of smart digital inhalers in the Dutch healthcare system. Data were collected through focus group discussions with female patients with asthma (n = 9) and healthcare professionals (n = 7) and through individual semi-structured interviews with policy makers (n = 4) and smart inhaler developers (n = 4). Data were analysed using the Framework method. Five themes were identified: (i) perceived benefits, (ii) usability, (iii) feasibility, (iv) payment and reimbursement, and (v) data safety and ownership. In total, 14 barriers and 32 facilitators were found among all stakeholders. The results of this study could contribute to the design of a tailored implementation strategy for smart inhalers in daily practice.

Translation, cultural adaptation and validity assessment of the Dutch version of the eHealth Literacy Questionnaire: a mixed-method approach.

BACKGROUND: The digitalization of healthcare requires users to have sufficient competence in using digital health technologies. In the Netherlands, as well as in other countries, there is a need for a comprehensive, person-centered assessment of eHealth literacy to understand and address eHealth literacy related needs, to improve equitable uptake and use of digital health technologies. OBJECTIVE: We aimed to translate and culturally adapt the original eHealth Literacy Questionnaire (eHLQ) to Dutch and to collect initial validity evidence. METHODS: The eHLQ was translated using a systematic approach with forward translation, an item intent matrix, back translation, and consensus meetings with the developer. A validity-driven and multi-study approach was used to collect validity evidence on 1) test content, 2) response processes and 3) internal structure. Cognitive interviews (n = 14) were held to assess test content and response processes (Study 1). A pre-final eHLQ version was completed by 1650 people participating in an eHealth study (Study 2). A seven-factor Confirmatory Factor Analysis (CFA) model was fitted to the data to assess the internal structure of the eHLQ. Invariance testing was performed across gender, age, education and current diagnosis. RESULTS: Cognitive interviews showed some problems in wording, phrasing and resonance with individual's world views. CFA demonstrated an equivalent internal structure to the hypothesized (original) eHLQ with acceptable fit indices. All items loaded substantially on their corresponding latent factors (range 0.51-0.81). The model was partially metric invariant across all subgroups. Comparison of scores between groups showed that people who were younger, higher educated and who had a current diagnosis generally scored higher across domains, however effect sizes were small. Data from both studies were triangulated, resulting in minor refinements to eight items and recommendations on use, score interpretation and reporting. CONCLUSION: The Dutch version of the eHLQ showed strong properties for assessing eHealth literacy in the Dutch context. While ongoing collection of validity evidence is recommended, the evidence presented indicate that the eHLQ can be used by researchers, eHealth developers and policy makers to identify eHealth literacy needs and inform the development of eHealth interventions to ensure that people with limited digital access and skills are not left behind.

Implementation of ask-advise-connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: a mixed-methods evaluation using the CFIR framework.

BACKGROUND: The Ask-Advise-Connect (AAC) approach can help primary care providers to increase the number of people who attempt to quit smoking and enrol into cessation counselling. We implemented AAC in Dutch general practice during the COVID-19 pandemic. In this study we describe how AAC was received in Dutch general practice and assess which factors played a role in the implementation. METHODS: A mixed-methods approach was used to evaluate the implementation of AAC. Implementation took place between late 2020 and early 2022 among 106 Dutch primary care providers (general practitioners (GPs), practice nurses and doctor's assistants). Quantitative and qualitative data were collected through four online questionnaires. A descriptive analysis was conducted on the quantitative data. The qualitative data (consisting of answers to open-ended questions) were inductively analysed using axial codes. The Consolidated Framework for Implementation Research was used to structure and interpret findings. RESULTS: During the study, most participants felt motivated (84-92%) and able (80-94%) to apply AAC. At the end of the study, most participants reported that the AAC approach is easy to apply (89%) and provides advantages (74%). Routine implementation of the approach was, however, experienced to be difficult. More GPs (30-48%) experienced barriers in the implementation compared to practice nurses and doctor's assistants (7-9%). The qualitative analysis showed that especially external factors, such as a lack of time or priority to discuss smoking due to the COVID-19 pandemic, negatively influenced implementation of AAC. CONCLUSIONS: Although AAC was mostly positively received in Dutch general practice, implementation turned out to be challenging, especially for GPs. Lack of time to discuss smoking was a major barrier in the implementation. Future efforts should focus on providing additional implementation support to GPs, for example with the use of e-health.

Developing a Digital Medication Adherence Intervention for and With Patients With Asthma and Low Health Literacy: Protocol for a Participatory Design Approach.

BACKGROUND: Current eHealth interventions are poorly adopted by people with low health literacy (LHL) as they often fail to meet their needs, skills, and preferences. A major reason for this poor adoption is the generic, one-size-fits-all approach taken by designers of these interventions, without addressing the needs, skills, and preferences of disadvantaged groups. Participatory design approaches are effective for developing interventions that fit the needs of specific target groups; yet, very little is known about the practical implications of executing a participatory design project for and with people with LHL. OBJECTIVE: This study aimed to demonstrate the application of participatory design activities specifically selected to fit the needs and skills of people with LHL and how these were manifested within an overarching eHealth design process. In addition, the study aims to present reflections and implications of these activities that could support future designers to engage people with LHL in their design processes. METHODS: We used the design process of a smart asthma inhaler for people with asthma and LHL to demonstrate participatory design activities. The study was framed under 5 stages of design thinking: empathize, define, ideate, prototype, and test within 2 major iteration cycles. We integrated 3 participatory design activities deemed specifically appropriate for people with LHL: co-constructing stories, experience prototype exhibition, and video prototype evaluation. RESULTS: Co-constructing stories was found to deepen the understanding of the participant's motivation to use or not to use maintenance medication. This understanding informed and facilitated the subsequent development of diverse preliminary prototypes of possible interventions. Discussing these prototypes in the experience prototype exhibition helped provoke reactions, thoughts, and feelings about the interventions, and potential scenarios of use. Through the video prototype evaluation, we were able to clearly communicate the goal and functionality of the final version of our intervention and gather appropriate responses from our participants. CONCLUSIONS: This study demonstrates a participatory design approach for and with patients with asthma and LHL. We demonstrated that careful consideration and selection of activities can result in participants that are engaged and feel understood. This paper provides insight into the practical implications of participatory activities with people with LHL and supports and inspires future designers to engage with this disadvantaged target group.

Care by general practitioners for patients with asthma or COPD during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on general practitioners' (GP) care for patients with asthma and/or COPD is largely unknown. To describe the impact of the pandemic on asthma or COPD-related GP care, we analysed routinely recorded electronic health records data from Dutch general practices and out-of-hours (OOH) services. During the COVID-19 pandemic (2020), the contact rates for asthma and/or COPD were significantly lower in GP practices and OOH services compared with the pre-pandemic period (2019) (respectively, 15% lower and 28% lower). The proportion of telephone contacts increased significantly with 13%-point in GP practices and 12%-point at OOH services, while the proportion of face-to-face contacts decreased. Furthermore, the proportion of high urgent contacts with OOH services decreased by 8.5%-point. To conclude, the overall contact rates in GP practices and OOH services decreased, while more contacts were remote. Lower contact rates have, after a short follow-up, not resulted in more patients with exacerbations in OOH care. However, this might still be expected after a longer follow-up.

How to use participatory design to develop an eHealth intervention to reduce preprocedural stress and anxiety among children visiting the hospital: The Hospital Hero app multi-study and pilot report.

Background: Medical procedures can cause considerable stress and anxiety among children. Current interventions mainly diminish stress and anxiety during procedures, while stress and anxiety often build up at home. Moreover, interventions often focus on either distraction or preparation. eHealth can combine multiple strategies and provide a low-cost solution that can be used outside the hospital. Objective: To develop an eHealth solution to diminish preprocedural stress and anxiety, and to evaluate the app on use, usability and user experience in practice. We also aimed to gain in-depth insights in children's and caregivers' opinions and experiences to inform future improvements. Methods: This is a multi-study report on the development (Study 1) and evaluation (Study 2) of a first version of the developed app. In study 1 we adopted a participatory design approach in which children's experiences were central to the design process. We performed an experience journey session with stakeholders (n = 13) to map the child's outpatient journey, identify pains and gains, and formulate the desired experience journey. Iterative development and testing with children (n = 8) and caregivers (n = 6) resulted in a working prototype. The prototype was tested with children, resulting in a first version of the Hospital Hero app. The app was evaluated on use, user-experience and usability during an eight-week pilot study in practice (Study 2). We triangulated data from online interviews with children and caregivers (n = 21) and online questionnaires (n = 46). Results: Multiple stress and anxiety experience touchpoints were identified. The Hospital Hero app supports children in their hospital journey by facilitating preparation at home and providing distraction at the hospital. The pilot study showed that the app was evaluated positively on usability and user-experience and is considered feasible. Qualitative data showed five themes: (1) user-friendliness, (2) coherence and power of storytelling, (3) motivation and reward, (4) fit with real hospital journey, (5) procedural comfort. Discussion: Using participatory design, we developed a child-centered solution that supports children in the entire hospital journey and may diminish preprocedural stress and anxiety. Future efforts should create a more tailored journey, define an optimal engagement window and formulate implementation strategies.

Setting Physical Activity Goals with a Virtual Coach: Vicarious Experiences, Personalization and Acceptance.

Goal-setting is often used in eHealth applications for behavior change as it motivates and helps to stay focused on a desired outcome. However, for goals to be effective, they need to meet criteria such as being specific, measurable, attainable, relevant and time-bound (SMART). Moreover, people need to be confident to reach their goal. We thus created a goal-setting dialog in which the virtual coach Jody guided people in setting SMART goals. Thereby, Jody provided personalized vicarious experiences by showing examples from other people who reached a goal to increase people's confidence. These experiences were personalized, as it is helpful to observe a relatable other succeed. Data from an online study with a between-subjects with pre-post measurement design (n=39 participants) provide credible support that personalized experiences are seen as more motivating than generic ones. Motivational factors for participants included information about the goal, path to the goal, and the person who accomplished a goal, as well as the mere fact that a goal was reached. Participants also had a positive attitude toward Jody. We see these results as an indication that people are positive toward using a goal-setting dialog with a virtual coach in eHealth applications for behavior change. Moreover, contrary to hypothesized, our observed data give credible support that participants' self-efficacy was lower after the dialog than before. These results warrant further research on how such dialogs affect self-efficacy, especially whether these lower post-measurements of self-efficacy are associated with people's more realistic assessment of their abilities.

My future-self has (not) quit smoking: An experimental study into the effect of a future-self intervention on smoking-related self-identity constructs.

OBJECTIVES: Envisioning one's (non)smoking future may make (un)desired future identities more accessible, salient, and personally relevant and facilitate smoking cessation. The current study assessed whether a future-self intervention can weaken smoker self-identity and expected identity loss when quitting smoking, and strengthen quitter- and nonsmoker self-identity, while accounting for personal factors-socioeconomic position, nicotine dependence, consideration of future consequences, and clarity of the envisioned future-self. Additionally, it examined the association between smoking-related identity and quitting intention and behavior. METHODS: This longitudinal online experimental study randomized 233 adult smokers to an intervention condition (where they completed mental imagery, visual, and verbal tasks about a future (non)smoking self), or to a passive control condition. Smoker-, quitter-, nonsmoker self-identity and identity loss were measured post-intervention and after one- and three-months. Quit intention and attempts were measured at baseline and after one month. RESULTS: There was a consistent increase in non-smoker self-identity, and decrease in smoker self-identity and identity loss over a period of six months for all participants, but no significant difference in smoking-related identity between the intervention and control group. While personal factors did not moderate the effect of the intervention, we found that smoking-related identity constructs do vary with nicotine dependence, consideration of future consequences, and clarity of the envisioned future-self. Quitting behavior is primarily associated with non-smoker self-identity. CONCLUSIONS: Although the future-self intervention did not significantly influence smoking-related identity or behavior, identity-in particular, non-smoker self-identity-is important to consider in smoking cessation interventions. More research is needed to find effective operationalizations for identity-based interventions in the context of smoking.

Quality of life, health-related quality of life, and associated factors in Huntington's disease: a systematic review.

BACKGROUND: Huntington's disease (HD) is a genetic, neurodegenerative disease. Due to the progressive nature of HD and the absence of a cure, (health-related) quality of life ((HR)QoL) is an important topic. Several studies have investigated (HR)QoL in HD, yet a clear synthesis of the existing literature is lacking to date. We performed a systematic review on self-reported (HR)QoL, and factors and intervention effects associated with (HR)QoL in premanifest and manifest HD gene expansion carriers (pHDGECs and mHDGECs, respectively). METHODS: PubMed, EMBASE, Web of Science, and PsycINFO were searched systematically from September 17th, 2021, up to August 11th, 2022. Methodological and conceptual quality of the included studies was assessed with two appraisal tools. RESULTS: 30 out of 70 eligible articles were included. mHDGECs experienced lower (HR)QoL compared to pHDGECs and controls, whereas mixed findings were reported when compared to other neurological diseases. Several factors were associated with (HR)QoL that might contribute to lower (HR)QoL in mHDGECs, including depressive symptoms, physical and psychological symptoms, lower functional capacity, lower support, and unmet needs. Multidisciplinary rehabilitation programs and a respiratory muscle training were beneficial for (HR)QoL in mHDGECs. DISCUSSION: (HR)QoL is experienced differently across the course of the disease. Although (HR)QoL is key for understanding the impact of HD and the effect of symptomatic treatment, there is a need to improve the methodological and conceptual shortcomings that were found in most studies, especially regarding the conceptual clarity when reporting on QoL and HRQoL. Suggestions for strengthening these shortcomings are provided in this review.

Effectiveness, usability and acceptability of a smart inhaler programme in patients with asthma: protocol of the multicentre, pragmatic, open-label, cluster randomised controlled ACCEPTANCE trial.

INTRODUCTION: Suboptimal asthma control is associated with incorrect inhaler use and poor medication adherence, which could lead to unfavourable clinical and economic outcomes. Smart inhaler programmes using electronic monitoring devices (EMDs) could support self-management and increase medication adherence and asthma control. However, evidence on long-term benefits and acceptability is scarce. This study aims to investigate the effectiveness of a smart inhaler asthma self-management programme on medication adherence and clinical outcomes in adults with uncontrolled asthma, to evaluate its acceptability and to identify subgroups who would benefit most based on patient characteristics. METHODS AND ANALYSIS: This open-label cluster randomised controlled trial of 12 months will be conducted in primary care in the Netherlands. General practices will be randomly assigned to either intervention or control group. We aim to include 242 patients. The intervention consists of (1) an EMD attached to the patient's inhaler that measures medication use; (2) a smartphone application to set medication reminders, receive motivational messages and track asthma symptoms; and (3) a portal for healthcare professionals to view data on medication use. The control group is passively monitored by the EMD but cannot view their inhaler data or receive feedback. Eligible patients are adults with suboptimal controlled asthma (Asthma Control Questionnaire score ≥0.75) with evidence of non-adherence established by the EMD during a 6-week run-in period. Primary outcome is the difference in mean medication adherence between intervention and control group. Secondary outcomes include asthma control, asthma-related quality of life, exacerbations, acceptance, cost-effectiveness and whether the effect of the intervention on medication adherence and asthma control is modified by patient characteristics (eg, self-efficacy, medication beliefs and eHealth literacy).Trial registration numberNL7854.

Mapping the evidence on identity processes and identity-related interventions in the smoking and physical activity domains: a scoping review protocol.

INTRODUCTION: Smoking and insufficient physical activity (PA), independently but especially in conjunction, often lead to disease and (premature) death. For this reason, there is need for effective smoking cessation and PA-increasing interventions. Identity-related interventions which aim to influence how people view themselves offer promising prospects, but an overview of the existing evidence is needed first. This is the protocol for a scoping review aiming to aggregate the evidence on identity processes and identity-related interventions in the smoking and physical activity domains. METHODS: The scoping review will be guided by an adaption by Levac et al of the 2005 Arksey and O'Malley methodological framework, the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses: Extension for Scoping Review (PRISMA-ScR) and the 2017 Joanna Briggs Institute guidelines. It will include scientific publications discussing identity (processes) and/or identity-related interventions in the context of smoking (cessation) and/or physical (in)activity, in individuals aged 12 and over. A systematic search will be carried out in multiple databases (eg, PubMed, Web of Science). Records will be independently screened against prepiloted inclusion/exclusion criteria by two reviewers, using the Active Learning for Systematic Reviews machine learning artificial intelligence and Rayyan QCRI, a screening assistant. A prepiloted charting table will be used to extract data from included full-text articles. Findings will be reported according to the PRISMA-ScR guidelines and include study quality assessment. ETHICS AND DISSEMINATION: Ethical approval is not required for scoping reviews. Findings will aid the development of future identity-related interventions targeting smoking and physical inactivity.

Optimizing Smoking Cessation Counseling in a University Hospital: Results and Pitfalls.

Background: Healthcare professionals (HPs) can play a substantial role in smoking cessation counseling (SCC) but in practice often skip this task due to time constraints. This study evaluates the implementation of the rapid Ask-Advise-Connect (AAC) method in a University hospital setting. Methods: This mixed methods pre-post interventional study was performed at the Cardiology department of a University hospital and consisted of (1) a quantitative assessment of patient smoking registration and HP connection rates to external SCC from the Electronic Medical Record, (2) semi-structured interviews with 10 HPs to assess their attitudes toward AAC, and (3) a blended intervention aimed to implement AAC. The blended intervention consisted of face-to-face and online AAC psychoeducation for HPs followed-up with motivational messages on their smart pagers over a period of 6 weeks. Results: In total, 48,321 patient registrations and 67 HPs were included. Before AAC implementation, HPs assessed smoking status in 74.0% of patients and connected 9.3% of identified smokers with SCC. Post intervention, these percentages did not increase (73.2%, p = 0.20; and 10.9%, p = 0.18, respectively). Nonetheless, the vast majority (90%) of HPs feel it is important to discuss patient smoking, and view it as their duty to do so. Main barriers to AAC reported by HPs were forgetfulness and time pressure. Conclusion: This study shows that this AAC intervention does not increase Asking after smoking status or Connection of patients to SCC in a University Hospital. However, HPs hold positive attitudes toward AAC. A better understanding of the mechanisms required for optimizing HPs practice behavior is needed.

Study Protocol for the Development of a European eHealth Platform to Improve Quality of Life in Individuals With Huntington's Disease and Their Partners (HD-eHelp Study): A User-Centered Design Approach.

Background: Huntington's disease (HD) is an autosomal dominant neurodegenerative disease that affects the quality of life (QoL) of HD gene expansion carriers (HDGECs) and their partners. Although HD expertise centers have been emerging across Europe, there are still some important barriers to care provision for those affected by this rare disease, including transportation costs, geographic distance of centers, and availability/accessibility of these services in general. eHealth seems promising in overcoming these barriers, yet research on eHealth in HD is limited and fails to use telehealth services specifically designed to fit the perspectives and expectations of HDGECs and their families. In the European HD-eHelp study, we aim to capture the needs and wishes of HDGECs, partners of HDGECs, and health care providers (HCPs) in order to develop a multinational eHealth platform targeting QoL of both HDGECs and partners at home. Methods: We will employ a participatory user-centered design (UCD) approach, which focusses on an in-depth understanding of the end-users' needs and their contexts. Premanifest and manifest adult HDGECs (n = 76), partners of HDGECs (n = 76), and HCPs (n = 76) will be involved as end-users in all three phases of the research and design process: (1) Exploration and mapping of the end-users' needs, experiences and wishes; (2) Development of concepts in collaboration with end-users to ensure desirability; (3) Detailing of final prototype with quick review rounds by end-users to create a positive user-experience. This study will be conducted in the Netherlands, Germany, Czech Republic, Italy, and Ireland to develop and test a multilingual platform that is suitable in different healthcare systems and cultural contexts. Discussion: Following the principles of UCD, an innovative European eHealth platform will be developed that addresses the needs and wishes of HDGECs, partners and HCPs. This allows for high-quality, tailored care to be moved partially into the participants' home, thereby circumventing some barriers in current HD care provision. By actively involving end-users in all design decisions, the platform will be tailored to the end-users' unique requirements, which can be considered pivotal in eHealth services for a disease as complex and rare as HD.

Integrated disease management interventions for patients with chronic obstructive pulmonary disease.

BACKGROUND: People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations. OBJECTIVES: To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes. SEARCH METHODS: We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region. MAIN RESULTS: Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution. AUTHORS' CONCLUSIONS: This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.