The conceptualisation and measurement of engagement in digital health.

Digital tools are an increasingly important component of healthcare, but their potential impact is commonly limited by a lack of user engagement. Digital health evaluations of engagement are often restricted to system usage metrics, which cannot capture a full understanding of how and why users engage with an intervention. This study aimed to examine how theory-based, multifaceted measures of engagement with digital health interventions capture different components of engagement (affective, cognitive, behavioural, micro, and macro) and to consider areas that are unclear or missing in their measurement. We identified and compared two recently developed measures that met these criteria (the Digital Behaviour Change Intervention Engagement Scale and the TWente Engagement with Ehealth Technologies Scale). Despite having similar theoretical bases and being relatively strongly correlated, there are key differences in how these scales aim to capture engagement. We discuss the implications of our analysis for how affective, cognitive, and behavioural components of engagement can be conceptualised and whether there is value in distinguishing between them. We conclude with recommendations for the circumstances in which each scale may be most useful and for how future measure development could supplement existing scales.

Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results.

OBJECTIVE: The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. DESIGN: Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. RESULTS: Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. CONCLUSION: Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. TRIAL REGISTRATION NUMBER: ISRCTN41353774.

Potential associations between behavior change techniques and engagement with mobile health apps: a systematic review.

Introduction: Lack of engagement is a common challenge for digital health interventions. To achieve their potential, it is necessary to understand how best to support users' engagement with interventions and target health behaviors. The aim of this systematic review was to identify the behavioral theories and behavior change techniques being incorporated into mobile health apps and how they are associated with the different components of engagement. Methods: The review was structured using the PRISMA and PICOS frameworks and searched six databases in July 2022: PubMed, Embase, CINAHL, APA PsycArticles, ScienceDirect, and Web of Science. Risk of bias was evaluated using the Cochrane Collaboration Risk of Bias 2 and the Mixed Methods Appraisal Tools. Analysis: A descriptive analysis provided an overview of study and app characteristics and evidence for potential associations between Behavior Change Techniques (BCTs) and engagement was examined. Results: The final analysis included 28 studies. Six BCTs were repeatedly associated with user engagement: goal setting, self-monitoring of behavior, feedback on behavior, prompts/cues, rewards, and social support. There was insufficient data reported to examine associations with specific components of engagement, but the analysis indicated that the different components were being captured by various measures. Conclusion: This review provides further evidence supporting the use of common BCTs in mobile health apps. To enable developers to leverage BCTs and other app features to optimize engagement in specific contexts and individual characteristics, we need a better understanding of how BCTs are associated with different components of engagement. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022312596.

"I see myself": Craving imagery among individuals with addictive disorders.

Craving has been put forward as a core feature of addictive disorders.The present qualitative study investigated the experience of craving among individuals with addictive disorders and recent experiences of cravings.Eleven individuals with Gambling Disorder and ten with Alcohol Use Disorder (n = 21) were recruited. A semi-structured interview explored: (1) modes of thought during craving (mental imagery or verbal thoughts), (2) craving content, (3) coping strategies and (4) craving context.The thematic analysis showed that cravings were initially dominated by imagery, with a subsequent conflict between imagery and verbal thoughts. Craving content included imagery of preparative rituals, anticipation, and sensory activation, imagery of the addictive behavior "me, there and then imagery" and anticipating that "something good will come out of it." Some participants related to craving as a symptom of sickness, and coping with craving were through distraction, reminding oneself of negative consequences, or via sensory control: avoiding stimuli associated with the addiction. Craving contexts included typical settings of drinking or gambling and engagement of both positive and negative emotions. Alcohol craving was described as an expected relief from internal stimuli, such as anxiety or stress, whereas gambling craving was more often described as an expectancy of financial reward.Craving was experienced mainly through imagery containing the preparative routines and expected outcomes. Future research and clinical practice should incorporate mode of thought in cravings to better understand its role in the maintenance of the disorders and their treatment.Supplemental data for this article is available online at https://doi.org/10.1080/10550887.2022.2058299 .

Tell me all about it: Narrated memories are less emotional than imagined memories.

People often re-live memories by talking about them. Verbal thinking is usually less emotive than imagery-based thinking but it is not known if this finding generalises to recollection. We tested if narrating memories aloud reduces their affective charge compared with recollecting them using imagery. Participants were randomised to two conditions: imagery (recalling the memory silently as vividly as possible) or narration (describing the memory out loud as clearly as possible). After practicing with a neutral topic, they recalled three aversive (Experiments 1 and 2) or three happy (Experiment 3) memories using narration or imagery, and rated emotionality of the memory after each recall. Before and after the procedure, they completed the PANAS to measure effects on mood. Experiments 2 and 3 included a 24 h follow-up. Emotionality was consistently lower following narrated recollection than imaginal recollection: narrated M = 5.3, SD = 2.5; imaginal M = 7.2, SD = 2.0; effect size (difference in mean values divided by overall SD) = 0.78. Negative affect increased after recollection of aversive memories and positive affect decreased, but there were no effects of condition upon mood. Recalling a positive memory had no effect on mood. Follow-up data showed no lasting effects of recall mode on availability of memories or mood. We conclude that narration of emotional autobiographical memories reduces the emotionality of the recollection, but does not differentially change mood compared with image-based recall.

Mental Imagery to Reduce Alcohol-related harm in patients with alcohol dependence and alcohol-related liver damaGE: the MIRAGE pilot trial protocol.

INTRODUCTION: In the UK, alcohol use is the main driver of chronic liver disease and each year results in over 1 million unplanned hospital admissions and over 25 000 deaths from alcohol-related liver disease (ArLD). The only effective treatment to prevent progression of liver damage is reducing or ceasing alcohol consumption. Psychological and pharmacological therapies for alcohol misuse are ineffective in patients with ArLD. Functional imagery training (FIT) is a novel psychological therapy that builds on motivational interviewing techniques with multisensory imagery. This pilot trial aims to test the feasibility of training alcohol liaison nurses to deliver FIT therapy and of recruiting and retaining patients with ArLD and alcohol dependence to a randomised trial of FIT and treatment as usual (TAU) versus TAU alone. METHODS AND ANALYSIS: This is a randomised pilot trial of FIT and TAU versus TAU alone in 90 patients with ArLD and alcohol dependence admitted to one of four UK centres. The primary objectives are to estimate rates of screening, recruitment, randomisation, retention, adherence to FIT/TAU and a preliminary assessment of the FIT intervention in the ArLD population. Data from the pilot study will be used to finalise the design of a definitive randomised controlled trial to assess the effectiveness and cost-effectiveness of FIT. The proposed primary outcome measure for the definitive trial is self-reported alcohol use assessed using timeline follow-back. ETHICS AND DISSEMINATION: Research ethics approval was given by the Yorkshire and Humber-Bradford Leeds Research Ethics Committee (reference: 21/YH/0044). Eligible patients will be approached and written informed consent obtained prior to participation. Results will be disseminated through peer-reviewed open access journals, international conferences and a lay summary published on the Trials Unit website and made available to patient groups. TRIAL REGISTRATION NUMBER: ISRCTN41353774.

Associations Between Behavior Change Techniques and Engagement With Mobile Health Apps: Protocol for a Systematic Review.

BACKGROUND: Digitally enabled care along with an emphasis on self-management of health is steadily growing. Mobile health apps provide a promising means of supporting health behavior change; however, engagement with them is often poor and evidence of their impact on health outcomes is lacking. As engagement is a key prerequisite to health behavior change, it is essential to understand how engagement with mobile health apps and their target health behaviors can be better supported. Although the importance of engagement is emphasized strongly in the literature, the understanding of how different components of engagement are associated with specific techniques that aim to change behaviors is lacking. OBJECTIVE: The purpose of this systematic review protocol is to provide a synthesis of the associations between various behavior change techniques (BCTs) and the different components and measures of engagement with mobile health apps. METHODS: The review protocol was structured using the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) and the PICOS (Population, Intervention, Comparator, Outcome, and Study type) frameworks. The following seven databases will be systematically searched: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, APA PsycInfo, ScienceDirect, Cochrane Library, and Web of Science. Title and abstract screening, full-text review, and data extraction will be conducted by 2 independent reviewers. Data will be extracted into a predetermined form, any disagreements in screening or data extraction will be discussed, and a third reviewer will be consulted if consensus cannot be reached. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias 2 and the Risk Of Bias In Non-Randomized Studies - of Interventions (ROBINS-I) tools; descriptive and thematic analyses will be conducted to summarize the relationships between BCTs and the different components of engagement. RESULTS: The systematic review has not yet started. It is expected to be completed and submitted for publication by May 2022. CONCLUSIONS: This systematic review will summarize the associations between different BCTs and various components and measures of engagement with mobile health apps. This will help identify areas where further research is needed to examine BCTs that could potentially support effective engagement and help inform the design and evaluation of future mobile health apps. TRIAL REGISTRATION: PROSPERO CRD42022312596; https://tinyurl.com/nhzp8223. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/35172.

Exploring barriers, motivators and solutions to achieve a healthy lifestyle among undergraduate student nurses.

BACKGROUND: Many preregistration student nurses tend to be overweight or obese and have unhealthy lifestyles. AIMS: This study aimed to quantify the prevalence of these issues, to identify barriers to adopting a healthy lifestyle as well as potential solutions, and to explore the use of smartphone health apps. METHODS: An online questionnaire examined diet and physical activity habits, general health and attitudes to eHealth. An in-class questionnaire with a new sample assessed current lifestyle, barriers to healthier living, support needed to achieve goals and the use of health apps. FINDINGS: Half of student nurses were overweight or obese and only 41% met the recommended levels of physical activity. An in-class questionnaire revealed that more than half of them wanted to have a better diet and to exercise more. CONCLUSION: Generally, student nurses were not satisfied with their current lifestyles. A lack of motivation and time were the most frequently reported barriers; an intervention focusing on motivational support could be an acceptable and effective means of achieving and sustaining positive behaviour change.

Mobile health as a primary mode of intervention for women at risk of or diagnosed with gestational diabetes mellitus: a scoping review.

OBJECTIVE: The objective of this review was to map the knowledge related to the use of mobile health (mHealth) as a primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of or diagnosed with gestational diabetes mellitus. We also sought to understand if mHealth for women at risk of or diagnosed with gestational diabetes mellitus incorporated relevant behavior change theory and techniques. INTRODUCTION: Prevention and management of gestational diabetes mellitus and its associated adverse outcomes are important to maternal and infant health. Women with gestational diabetes mellitus report high burden of disease management and barriers to lifestyle change post-delivery, which mHealth interventions may help to overcome. Evidence suggests apps could help gestational diabetes mellitus prevention and management; however, less is known about broader applications of mHealth from preconception to interconception, and whether relevant behavior change techniques are incorporated. INCLUSION CRITERIA: Studies that focused on mHealth use as the primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications were considered for inclusion. Telehealth or telemedicine were excluded as these have been reviewed elsewhere. METHODS: Six databases were searched: MEDLINE, CINAHL, Embase, Cochrane Library, Scopus, and TRIP. No limits were applied to database exploration periods to ensure retrieval of all relevant studies. Gray literature sources searched were OpenGrey, ISRCTN Registry, ClinicalTrials.gov, EU Clinical Trials Register, and ANZCTR. Two reviewers independently screened abstracts and assessed full texts against the inclusion criteria. Data were extracted using an adapted version of the JBI data extraction instrument. Data are presented in narrative form accompanied by tables and figures. RESULTS: This review identified 2166 sources, of which 96 full texts were screened. Thirty eligible reports were included, covering 25 different mHealth interventions. Over half (n = 14) of the interventions were for self-managing blood glucose during pregnancy. Common features included tracking blood glucose levels, real-time feedback, communication with professionals, and educational information. Few (n = 6) mHealth interventions were designed for postpartum use and none for interconception use. Five for postpartum use supported behavior change to reduce the risk oftype 2 diabetes and included additional features such as social support functions and integrated rewards. Early development and feasibility studies used mixed methods to assess usability and acceptability. Later stage evaluations of effectiveness typically used randomized controlled trial designs to measure clinical outcomes such as glycemic control and reduced body weight. Three mHealth interventions were developed using behavior change theory. Most mHealth interventions incorporated two behavior change techniques shown to be optimal when combined, and those delivering behavior change interventions included a wider range. Nevertheless, only half of the 26 techniques listed in a published behavior change taxonomy were tried. CONCLUSIONS: mHealth for gestational diabetes mellitus focuses on apps to improve clinical outcomes. This focus could be broadened by incorporating existing resources that women value, such as social media, to address needs, such as peer support. Although nearly all mHealth interventions incorporated behavior change techniques, findings suggest future development should consider selecting techniques that target women's needs and barriers to engagement. Lack of mHealth interventions for prevention of gestational diabetes mellitus recurrence and type 2 diabetes mellitus suggests further development and evaluation are required.

Brief Online Negative Affect Focused Functional Imagery Training Improves 2-Week Drinking Outcomes in Hazardous Student Drinkers: a Pilot Randomised Controlled Trial.

BACKGROUND: Negative affect plays an important role in motivating problematic alcohol use. Consequently, training imagery-based adaptive responses to negative affect could reduce problematic alcohol use. The current study tested whether personalised online functional imagery training (FIT) to utilise positive mental imagery in response to negative affect would improve drinking outcomes in hazardous negative affect drinking students. METHOD: Participants were 52 hazardous student drinkers who drink to cope with negative affect. Participants in the active group (n = 24) were trained online over 2 weeks to respond to personalised negative drinking triggers by retrieving a personalised adaptive strategy they might use to mitigate negative affect, whereas participants in the control group (n = 28) received standard risk information about binge drinking at university. Measures of daily drinking quantity, drinking motives, self-efficacy and use of protective behavioural strategies were obtained at baseline and 2 weeks follow-up. RESULTS: There were three significant interactions between group and time in a per-protocol analysis: the active intervention group showed increased self-efficacy of control over negative affect drinking and control over alcohol consumption and decreased social drinking motives from baseline to 2-week follow-up, relative to the control intervention group. There were no effects on drinking frequency. CONCLUSION: These findings provide initial evidence that online training to respond to negative affect drinking triggers by retrieving mental imagery of adaptive strategies can improve drinking-related outcomes in hazardous, student, negative affect drinkers. The findings support the utility of FIT interventions for substance use.

How do women with a history of gestational diabetes mellitus use mHealth during and after pregnancy? Qualitative exploration of women's views and experiences.

BACKGROUND: Women experiencing gestational diabetes face challenges during and after pregnancy that could be supported with mobile health. Mobile health isn't routinely implemented and little is known regarding its use to aid information seeking, peer support and behaviour change. Understanding women's experiences of mHealth is critical to ensuring acceptance and use, particularly with relation to postpartum and interconception periods, where support is currently lacking. This study therefore aimed to explore the views and experiences of women with previous gestational diabetes, on using mHealth resources before, during and after pregnancy.Women's expectations for future mHealth were also explored. SETTING: Ten female participants from across the United Kingdom, experiencing GDM within the past five years, were convenience sampled from a group of individuals participating in a webinar. The webinar about technology to support GDM management was advertised online and all of those who registered were invited, via email, to take part. DESIGN: Women's views and experiences were explored using semi-structured telephone interviews. Audio recorded data were transcribed, coded and analysed using NVivo 12. Thematic analysis was used to analyse data, creating main and sub-themes. Data are presented in narrative form. PARTICIPANTS: Ten women living across the United Kingdom who had experienced gestational diabetes within the past five years, participated. FINDINGS: All ten women used mHealth, valuing social media for dietary information and peer support. Few mHealth resources were recommended by professionals and women discussed discontentment with the information they provided. Information found online was often valued over that provided by professionals. Some women used apps for behaviour change, but disliked certain features and poor engagement hindered their use. Women desired an app to overcome lack of motivation and prepare them for future healthy pregnancies. KEY CONCLUSIONS: Information provided to women by professionals was viewed as 'limited' and mHealth resources were rarely recommended. In response, women used social media to meet informational and emotional needs. Postpartum behaviour change is important to women and could be facilitated with tailored mHealth focused on increasing motivation. To maximise adoption and engagement future mHealth should be integrated with existing resources women value and be co-produced with professionals. IMPLICATIONS FOR PRACTICE: Current lack of engagement in mHealth for GDM by healthcare professionals means opportunities to influence or contest poor information are missed. We recommend increased participation by professionals to reduce opportunities for information miss-spread and reliance on peer driven information. Increasing digital confidence among professionals to support women navigate online spaces and take part in co-design is recommended.

mHealth as a primary mode of intervention for women at risk of, or diagnosed with, gestational diabetes: a scoping review protocol.

OBJECTIVE: To synthesize current knowledge on the use of mHealth as a primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of, or diagnosed with, gestational diabetes mellitus. INTRODUCTION: Prevention and management of gestational diabetes mellitus and its associated adverse outcomes are of paramount importance to both maternal and infant health. However, women with experience of gestational diabetes mellitus report several barriers to effective disease management and lifestyle change. Supporting women through use of mHealth technology may help overcome these barriers. Recent evidence suggests mobile apps may be useful for the prevention and management of gestational diabetes mellitus, however, less is known about the broader application of mHealth from preconception to interconception. INCLUSION CRITERIA: Studies considered for inclusion are those focused on the use of mHealth as the primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of, or diagnosed with, gestational diabetes mellitus. Studies will be limited to those published in English, with no date restrictions. METHODS: The following databases will be searched: MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Ovid), Cochrane Database (Wiley), Scopus, and TRIP. Unpublished studies and gray literature will be searched using Open Grey, ISRCTN Registry, ClinicalTrials.gov, EU Clinical Trials register, and ANZCTR. Two reviewers will independently screen abstracts. Reviewers will assess full texts of selected citations against the inclusion criteria. Any disagreements will be discussed with a third reviewer. Data will be extracted and presented in diagrammatic or tabular form with an accompanying narrative in line with review objectives.

Say it aloud: Measuring change talk and user perceptions in an automated, technology-delivered adaptation of motivational interviewing delivered by video-counsellor.

Motivational Interviewing is a widely used counselling technique. A fundamental principle of this technique is that hearing oneself argue for change strengthens motivation. This study presents the first analysis of participants' dialogue with an automated motivational interviewer. The objective was to explore communication with, and perceptions of, a technology-delivered adaptation of motivational interviewing (TAMI) delivered by a pre-recorded video-counsellor. Eighteen participants undertook the video interview and evaluated it after one week. Interviews were scored for change and sustain talk. Participants' written evaluations were subjected to thematic analysis. Interviews lasted 10 min 30s (SD 3 min 0 s). Change talk was observed in a mean of 16 of 25 responses (SD 3.35, range 11-21). Sustain talk was less frequent (mean = 3.4 replies, SD = 2.5, range 0 to 8). Participants disliked seeing their own image in the webcam and desired a personalised interaction where each question depended on the answer given to the previous one. Positive appraisals included space to think about motivation and plans, and hearing themselves voicing goals. A brief, generic, automated TAMI elicited change talk and was perceived as motivating.

The Motivational Thought Frequency Scales for increased physical activity and reduced high-energy snacking.

OBJECTIVES: The Motivational Thought Frequency (MTF) Scale has previously demonstrated a coherent four-factor internal structure (Intensity, Incentives Imagery, Self-Efficacy Imagery, Availability) in control of alcohol and effective self-management of diabetes. The current research tested the factorial structure and concurrent associations of versions of the MTF for increasing physical activity (MTF-PA) and reducing high-energy snacks (MTF-S). DESIGN: Study 1 examined the internal structure of the MTF-PA and its concurrent relationship with retrospective reports of vigorous physical activity. Study 2 attempted to replicate these results, also testing the internal structure of the MTF-S and examining whether higher MTF-S scores were found in participants scoring more highly on a screening test for eating disorder. METHODS: In Study 1, 626 participants completed the MTF-PA online and reported minutes of activity in the previous week. In Study 2, 313 participants undertook an online survey that also included the MTF-S and the Eating Attitudes Test (EAT-26). RESULTS: The studies replicated acceptable fit for the four-factor structure on the MTF-PA and MTF-S. Significant associations of the MTF-PA with recent vigorous activity and of the MTF-S with EAT-26 scores were seen, although associations were stronger in Study 1. CONCLUSIONS: Strong preliminary support for both the MTF-PA and MTF-S was obtained, although more data on their predictive validity are needed. Associations of the MTF-S with potential eating disorder illustrate that high scores may not always be beneficial to health maintenance.

A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT.

BACKGROUND: Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility. OBJECTIVE: This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial. DESIGN: Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework. SETTING: Four sites across the UK. PARTICIPANTS: Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months. INTERVENTIONS: Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone. MAIN OUTCOME MEASURES: Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data. RESULTS: A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted. CONCLUSIONS: The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries. FUTURE WORK: Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN13587999. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.

People with secondary progressive multiple sclerosis (SPMS) often have problems with walking and balance, which lead them to fall. Undertaking exercise and learning about falls prevention could help reduce injury risk and improve mobility. We developed a mobility, balance and falls programme called Balance Right in MS (BRiMS). Before testing its effectiveness in a large-scale trial, we needed to conduct a small-scale version of the trial. We asked people with SPMS who had balance and mobility problems to be assigned by chance to undertake the BRiMS programme plus their usual care, or to continue with usual care only. Questionnaires were used to ask people about their mobility, falls and quality of life, and we measured their balance and activity levels. We interviewed participants about BRiMS and being in the trial, and collected information about costs. Fifty-six people entered the trial from three areas of the south-west and from Ayrshire. At completion of the study we were able to review 44 people. The key measures were completed by 98% of those we assessed, but only around half (62%) of the diaries detailing falls were returned. As this was a feasibility trial, the numbers were too small for us to look at differences between the groups. Participants liked the BRiMS programme; some did a lot of exercise and learning activities, but most did not manage the amount we asked them to do. People reported feeling a little overwhelmed by the educational content of BRiMS, and that this should be reduced in future. They told us that they felt that their balance had improved and that they fell less frequently after the BRiMS programme. Our assessment of the trial methods we used showed that it would be possible to conduct a full-scale trial using this design, but that we need to adapt the BRiMS programme further to make it more user-friendly.

Functional imagery training versus motivational interviewing for weight loss: a randomised controlled trial of brief individual interventions for overweight and obesity.

OBJECTIVE: Functional Imagery Training (FIT) is a new brief motivational intervention based on the Elaborated Intrusion theory of desire. FIT trains the habitual use of personalised, affective, goal-directed mental imagery to plan behaviours, anticipate obstacles, and mentally try out solutions from previous successes. It is delivered in the client-centred style of Motivational Interviewing (MI). We tested the impact of FIT on weight loss, compared with time- and contact-matched MI. DESIGN: We recruited 141 adults with BMI (kg/m²) ≥25, via a community newspaper, to a single-centre randomised controlled trial. Participants were allocated to one of two active interventions: FIT or MI. Primary data collection and analyses were conducted by researchers blind to interventions. All participants received two sessions of their allocated intervention; the first face-to-face (1 h), the second by phone (maximum 45 min). Booster calls of up to 15 min were provided every 2 weeks for 3 months, then once-monthly until 6 months. Maximum contact time was 4 h of individual consultation. Participants were assessed at Baseline, at the end of the intervention phase (6 months), and again 12 months post-baseline. MAIN OUTCOME MEASURES: Weight (kg) and waist circumference (WC, cm) reductions at 6 and 12 months. RESULTS: FIT participants (N = 59) lost 4.11 kg and 7.02 cm of WC, compared to .74 kg and 2.72 cm in the MI group (N = 55) at 6 months (weight mean difference (WMD) = 3.37 kg, p < .001, 95% CI [-5.2, -2.1], waist-circumference mean difference (WCMD) = 4.3 cm, p < .001, 95% CI [-6.3,-2.6]). Between-group differences were maintained and increased at month 12: FIT participants lost 6.44 kg (W) and 9.1 cm (WC) compared to the MI who lost .67 kg and 2.46 cm (WMD = 5.77 kg, p < .001, 95% CI [-7.5, -4.4], WCMD = 6.64 cm, p < .001, 95% CI [-7.5, -4.4]). CONCLUSION: FIT is a theoretically informed motivational intervention which offers substantial benefits for weight loss and maintenance of weight reduction, compared with MI alone, despite including no lifestyle education or advice.

The revised four-factor motivational thought frequency and state motivation scales for alcohol control.

INTRODUCTION: Elaborated Intrusion (EI) Theory holds that both functional and dysfunctional motivational cognitions are characterized by their intensity, cognitive availability and involvement of imagery, and can be assessed in terms of their frequency and cross-sectional nature. Recently published data on the Motivational Thought Frequency (MTF-A) and State Motivation (SM-A) scales for alcohol control, which were based on EI theory, have shown acceptable fit for a three-subscale structure (Intensity, Imagery, Availability). However, subsequent analyses on the MTF's adaptation to diabetic regimen adherence suggested superior fit from a four-factor model, splitting Imagery into Incentives and Self-Efficacy Imagery. The current paper reanalyzed data on the MTF-A and SM-A, including an additional item on each and using a more robust statistical approach. METHODS: Participants (n = 504) reporting recent high-risk drinking or were currently trying to control alcohol consumption volunteered to complete an online survey that included the MTF-A, SM-A, Alcohol Use Disorders Identification Test and Readiness to Change Questionnaire. Confirmatory factor analyses employed robust maximum likelihood (MLR) with Yuan-Bentler χ2 adjustment, and presented internal consistencies using omega. RESULTS: After omission of multivariate outliers, SM-A data were available from 399 participants, and MTF-A data from 351. Better fit was found for the four-factor model on both measures, and high internal consistencies were obtained for all subscales. Incentives Imagery and Self-Efficacy Imagery were both associated with greater alcohol problems and readiness to change. CONCLUSIONS: The four-factor structures are statistically superior and more theoretically coherent, and allow a focused assessment of key targets of motivational interventions.

Mental imagery in dentistry: Phenomenology and role in dental anxiety.

Dental anxiety is a prevalent problem with marked psychological, physical and public health implications. Based on cognitive theory and evidence, we hypothesized that vivid, sensory image-based cognitions play a role in dental anxiety. A quantitative online survey (N = 306) and qualitative semi-structured interviews (N = 18) found that vivid sensory images were common irrespective of dental anxiety levels, but that their content, associated distress and responses varied. Participants reporting higher anxiety experienced intense and intrusive fear-provoking dental imagery focusing on unpleasant sensations, which were associated with the intrusive recollection of negative past experiences and avoidance of dentistry. Participants with lower anxiety ratings, reported images that were less distressing and centered around reassuring aspects and positive appointment outcomes, potentially acting as protective factors against dental anxiety and facilitating appointment attendance. The inclusion of components aimed at reducing intrusive memories and dental imagery rescripting may help improve interventions for dental anxiety.

The Soothing Sea: A Virtual Coastal Walk Can Reduce Experienced and Recollected Pain.

Virtual reality (VR) distraction has become increasingly available in health care contexts and is used in acute pain management. However, there has been no systematic exploration of the importance of the content of VR environments. Two studies tested how interacting with nature VR influenced experienced and recollected pain after 1 week. Study 1 (n = 85) used a laboratory pain task (cold pressor), whereas Study 2 (n = 70) was a randomized controlled trial with patients undergoing dental treatment. In Study 1, nature (coastal) VR reduced both experienced and recollected pain compared with no VR. In Study 2, nature (coastal) VR reduced experienced and recalled pain in dental patients, compared with urban VR and standard care. Together, these data show that nature can improve experience of health care procedures through the use of VR, and that the content of the VR matters: Coastal nature is better than urban.

Experiences of a Motivational Interview Delivered by a Robot: Qualitative Study.

BACKGROUND: Motivational interviewing is an effective intervention for supporting behavior change but traditionally depends on face-to-face dialogue with a human counselor. This study addressed a key challenge for the goal of developing social robotic motivational interviewers: creating an interview protocol, within the constraints of current artificial intelligence, which participants will find engaging and helpful. OBJECTIVE: The aim of this study was to explore participants' qualitative experiences of a motivational interview delivered by a social robot, including their evaluation of usability of the robot during the interaction and its impact on their motivation. METHODS: NAO robots are humanoid, child-sized social robots. We programmed a NAO robot with Choregraphe software to deliver a scripted motivational interview focused on increasing physical activity. The interview was designed to be comprehensible even without an empathetic response from the robot. Robot breathing and face-tracking functions were used to give an impression of attentiveness. A total of 20 participants took part in the robot-delivered motivational interview and evaluated it after 1 week by responding to a series of written open-ended questions. Each participant was left alone to speak aloud with the robot, advancing through a series of questions by tapping the robot's head sensor. Evaluations were content-analyzed utilizing Boyatzis' steps: (1) sampling and design, (2) developing themes and codes, and (3) validating and applying the codes. RESULTS: Themes focused on interaction with the robot, motivation, change in physical activity, and overall evaluation of the intervention. Participants found the instructions clear and the navigation easy to use. Most enjoyed the interaction but also found it was restricted by the lack of individualized response from the robot. Many positively appraised the nonjudgmental aspect of the interview and how it gave space to articulate their motivation for change. Some participants felt that the intervention increased their physical activity levels. CONCLUSIONS: Social robots can achieve a fundamental objective of motivational interviewing, encouraging participants to articulate their goals and dilemmas aloud. Because they are perceived as nonjudgmental, robots may have advantages over more humanoid avatars for delivering virtual support for behavioral change.