Interactivity, Presence, and Targeted Patient Care: Mapping e-Health Intervention Effects Over Time for Cancer Patients with Depression.

This study examined the interplay of depression and different types of e-health interventions on breast cancer patients' perceived healthcare competence, emotional processing, and social well-being over time. The three e-health interventions--Internet Only as a control condition, CHESS (Comprehensive Health Enhancement Support System) Only, and CHESS with a Human Mentor, a cancer information specialist--provided varying degrees of interactivity and presence. A total of 328 women with breast cancer participated in one of the three interventions for a 6-month period. Women were further split into two groups based on reported levels of depression. For perceived healthcare competence and social well-being, results revealed significant interaction effects for intervention type by depression over time, such that breast cancer patients with higher levels of depression benefited most from the CHESS with Mentor intervention over the 6-month study period. For emotional processing, depressed cancer patients benefited more from the CHESS with Mentor than the other two interventions, regardless of time. These findings have (a) theoretical implications on how mental health factors can intersect with interactivity and presence to influence psychosocial outcomes, (b) conceptual implications for the role of human interaction within e-health systems, and (c) practical implications for the development of e-health interventions for cancer patients with depression.

Treatment seeking as a mechanism of change in a randomized controlled trial of a mobile health intervention to support recovery from alcohol use disorders.

BACKGROUND: We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking. METHODS: We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization. RESULTS: Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%. CONCLUSIONS: The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

A smartphone application to support recovery from alcoholism: a randomized clinical trial.

IMPORTANCE: Patients leaving residential treatment for alcohol use disorders are not typically offered evidence-based continuing care, although research suggests that continuing care is associated with better outcomes. A smartphone-based application could provide effective continuing care. OBJECTIVE: To determine whether patients leaving residential treatment for alcohol use disorders with a smartphone application to support recovery have fewer risky drinking days than control patients. DESIGN, SETTING, AND PARTICIPANTS: An unmasked randomized clinical trial involving 3 residential programs operated by 1 nonprofit treatment organization in the Midwestern United States and 2 residential programs operated by 1 nonprofit organization in the Northeastern United States. In total, 349 patients who met the criteria for DSM-IV alcohol dependence when they entered residential treatment were randomized to treatment as usual (n = 179) or treatment as usual plus a smartphone (n = 170) with the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), an application designed to improve continuing care for alcohol use disorders. INTERVENTIONS: Treatment as usual varied across programs; none offered patients coordinated continuing care after discharge. A-CHESS provides monitoring, information, communication, and support services to patients, including ways for patients and counselors to stay in contact. The intervention and follow-up period lasted 8 and 4 months, respectively. MAIN OUTCOMES AND MEASURES: Risky drinking days--the number of days during which a patient's drinking in a 2-hour period exceeded 4 standard drinks for men and 3 standard drinks for women, with standard drink defined as one that contains roughly 14 g of pure alcohol (12 oz of regular beer, 5 oz of wine, or 1.5 oz of distilled spirits). Patients were asked to report their risky drinking days in the previous 30 days on surveys taken 4, 8, and 12 months after discharge from residential treatment. RESULTS: For the 8 months of the intervention and 4 months of follow-up, patients in the A-CHESS group reported significantly fewer risky drinking days than did patients in the control group, with a mean of 1.39 vs 2.75 days (mean difference, 1.37; 95% CI, 0.46-2.27; P = .003). CONCLUSIONS AND RELEVANCE: The findings suggest that a multifeatured smartphone application may have significant benefit to patients in continuing care for alcohol use disorders. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01003119.

Predictive modeling of addiction lapses in a mobile health application.

The chronically relapsing nature of alcoholism leads to substantial personal, family, and societal costs. Addiction-comprehensive health enhancement support system (A-CHESS) is a smartphone application that aims to reduce relapse. To offer targeted support to patients who are at risk of lapses within the coming week, a Bayesian network model to predict such events was constructed using responses on 2,934 weekly surveys (called the Weekly Check-in) from 152 alcohol-dependent individuals who recently completed residential treatment. The Weekly Check-in is a self-monitoring service, provided in A-CHESS, to track patients' recovery progress. The model showed good predictability, with the area under receiver operating characteristic curve of 0.829 in the 10-fold cross-validation and 0.912 in the external validation. The sensitivity/specificity table assists the tradeoff decisions necessary to apply the model in practice. This study moves us closer to the goal of providing lapse prediction so that patients might receive more targeted and timely support.

The effects of expression: how providing emotional support online improves cancer patients' coping strategies.

BACKGROUND: Emotional support has traditionally been conceived as something a breast cancer patient receives. However, this framework may obscure a more complex process, facilitated by the emerging social media environment, which includes the effects of composing and sending messages to others. Accordingly, this study explores the effects of expression and reception of emotional support messages in online groups and the importance of bonding as a mediator influencing the coping strategies of breast cancer patients. METHODS: Data were collected as part of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of diagnosis of primary breast cancer or recurrence. Expression and reception of emotionally supportive messages were tracked and coded for 237 breast cancer patients. Analysis resulted from merging 1) computer-aided content analysis of discussion posts, 2) action log analysis of system use, and 3) longitudinal survey data. RESULTS: As expected, perceived bonding was positively related to all four coping strategies (active coping: ß = 0.251, P = .000; positive reframing: ß = 0.288, P = .000; planning: ß = 0.213, P = .006; humor: ß = 0.159, P = .009). More importantly, expression (γ = 0.138, P = .027), but not reception (γ = -0.018, P = .741), of emotional support increases perceived bonding, which in turn mediates the effects on patients' positive coping strategies. CONCLUSIONS: There is increasing importance for scholars to distinguish the effects of expression from reception to understand the processes involved in producing psychosocial benefits. This study shows that emotional support is more than something cancer patients receive; it is part of an active, complex process that can be facilitated by social media.

Predictors of Online Health Information Seeking Among Women with Breast Cancer: The Role of Social Support Perception and Emotional Well-Being.

This study attempts to examine the role of social support perception and emotional well-being on online information seeking among cancer patients within the context of CHESS, a well-established Interactive Cancer Communication System (ICCS). Factor and regression analyses conducted among 231 breast cancer patients revealed that social support perception and emotional well-being interacted with each other to influence online health information seeking. Patients with low social support perception and high emotional well-being were most likely to seek health information, whereas patients with high social support perception and high emotional well-being sought out the same information least. Practical implications of the study findings were further discussed.

The effect of a computer-based intervention on adult children of alcoholics.

OBJECTIVES: People who grow up with a family member who has a substance use disorder (SUD) are at risk for serious problems, and yet support for family members focuses mainly on the individual with the SUD. Technology may offer a way to make support widely available to family members of those with SUDs. This small randomized trial examined an online system of resources called CHESS (Comprehensive Health Enhancement Support System) for adult children of alcoholics (ACOAs), a population at greater risk for SUDs, depression, and other difficulties than adults whose parents were not alcoholics. METHODS: The study randomized 23 self-identified ACOAs to 3 interventions for 8 weeks. The goal was to increase participants' treatment compliance and psychological health. The interventions were therapy only, CHESS only, and CHESS plus therapy. We used 2 measures: compliance with treatment, gauged by attendance in group therapy for the 2 groups assigned to therapy, and aspects of psychological health or distress, measured by a survey with items from 7 scales. RESULTS: The CHESS-plus-therapy group had an attendance rate in group therapy of 81.5% compared to 42.8% for the therapy-only group. The CHESS-only intervention had the largest effect size on 5 of the 7 measures of psychological health or distress. In 4 of the 5 cases, the effect size was large; in 1 case, it was moderate. CONCLUSIONS: The findings of this pilot study are based on a small sample, but they suggest the need for more research and the potentially important role of technology in behavioral health treatment.

How Patients Recovering From Alcoholism Use a Smartphone Intervention.

OBJECTIVE: Mobile technology has the potential to radically improve addiction treatment and continuing care by offering emotional and instrumental support anywhere and just in time. This is particularly important in addiction because timing is critical to preventing relapse. Although most experts consider alcoholism to be a chronic disease, providers do not typically offer ongoing support for relapse prevention after patients complete treatment, even though a central characteristic of alcoholism and other addictive behaviors is their chronically relapsing nature. A-CHESS is a smartphone-based system for preventing relapse to heavy drinking among people leaving active alcohol dependence treatment. A-CHESS is designed to improve competence, social relatedness, and motivation, the three tenets of Self-Determination Theory. This paper reports on the relative impact and use of A-CHESS four months after patients entered the study and discusses implications of the results on treating addiction and chronic diseases generally. METHODS: A total of 349 individuals with alcohol dependence leaving residential treatment were randomly assigned to either receive A-CHESS+Treatment as Usual or Treatment as Usual (standard aftercare). Patients came from two treatment agencies, one in the Midwest and one in the Northeast. Patients assigned to A-CHESS received a smartphone for 8 months and were followed for 12. The authors analyzed use patterns during the first 4 months of use by those receiving A-CHESS. RESULTS: Participants used A-CHESS heavily and sustained their use over time. Ninety-four percent of A-CHESS participants used the application during the first week after residential treatment. At week 16, almost 80% continued to access A-CHESS. Participants with alcohol and drug-dependence showed higher levels of system use than those with alcohol dependence only. Participants with a mental health diagnosis had slightly lower levels of use at the end of the intervention period (week 16), although more than 70% still accessed the system. CONCLUSIONS: These findings illustrate that patients with alcohol dependence, alcohol and drug dependence, and mental health issues will use smartphone applications such as A-CHESS for ongoing support, resources and information, thus extending patient care if given the opportunity. Further analysis is needed to determine if sustained A-CHESS use improves outcomes.

Social and psychological determinants of levels of engagement with an online breast cancer support group: posters, lurkers, and nonusers.

Despite the benefits and growing availability of online cancer support groups, many breast cancer patients still do not actively participate in them. To better understand cancer patients' online information- and support-seeking behaviors, this study explores how various social and psychological characteristics predict different levels of engagement with an online breast cancer support group: posters, lurkers, and nonusers. The study sample included 231 recently diagnosed breast cancer patients. Data included baseline survey scores of demographic, disease-related, and psychosocial factors and automatically collected discussion group use data over the 4-month intervention. Patterns of engagement with the cancer support group differed according to the patients' characteristics, suggesting that (a) cancer patients have very different orientations to and engagement with an online support group, and (b) deficits in social and psychological resources may not be barriers to participation in a cancer support group, but rather motivators to interact with other patients. The authors discuss the theoretical and practical implications of their findings.

The process and effect of supportive message expression and reception in online breast cancer support groups.

OBJECTIVE: To better understand the process and effect of social support exchanges within computer-mediated social support (CMSS) groups for breast cancer patients, this study examines (1) the dynamic interplay between emotional support giving and receiving and (2) the relative effects of emotional support giving and receiving on patients' psychosocial health outcomes. METHODS: Data was collected from 177 patients who participated in online cancer support groups within the Comprehensive Health Enhancement Support System (CHESS) during the 4-month intervention. Data included (1) pretest and/or post-test survey scores of demographic, disease-related, and psychosocial factors, (2) automatically collected CHESS usage data, and (3) computer-aided content analysis of social support messages posts. RESULTS: Hierarchical regression analyses revealed that those who receive higher levels of support from others have fewer breast cancer-related concerns (ß = - 0.15, p<0.05), while those who give higher levels of support to others reframe their own problems in a positive light and adopt more positive strategies for coping (ß = 0.16, p<0.05). In addition to these positive effects, partial correlation analysis indicated that these two supportive behaviors are reciprocal. CONCLUSIONS: We concluded that supportive exchanges of receiving and giving play positive, but different, roles in predicting psychosocial health outcomes. Moreover, emotional support giving and receiving tend to reinforce each other. Our findings help practitioners, health-care providers, and health system designers make sense of diverse social support processes among cancer patients participating within CMSS groups.

Creating a bond between caregivers online: effect on caregivers' coping strategies.

Numerous studies have investigated the effect of Interactive Cancer Communication Systems (ICCSs) on system users' improvements in psychosocial status. Research in this area, however, has focused mostly on cancer patients, rather than on caregivers, and on the direct effects of ICCSs on improved outcomes, rather than on the psychological mechanisms of ICCS effects. To understand the underlying mechanisms, this study examines the mediating role of perceived caregiver bonding in the relation between one ICCS (the Comprehensive Health Enhancement Support System [CHESS]) use and caregivers' coping strategies. To test the hypotheses, a secondary analysis of data was conducted on 246 caregivers of lung cancer patients. These caregivers were randomly assigned to (a) the Internet, with links to high-quality lung cancer websites, or (b) access to CHESS, which integrated information, communication, and interactive coaching tools. Findings suggest that perceived bonding has positive effects on caregivers' appraisal and problem-focused coping strategies, and it mediates the effect of ICCS on the coping strategies 6 months after the intervention has begun.

Empathic exchanges in online cancer support groups: distinguishing message expression and reception effects.

Past studies on the efficacy of participation in online cancer support groups have primarily focused on the role of expression in the accrual of health benefits for participants. Unfortunately, few steps have been taken to determine whether this observed effect arises solely from the internal mental processes underlying the act of expressing or, perhaps, owes something to a nuanced, multidimensional understanding of expression that includes reception of responses to what is expressed. To test for the multilayered effect, we attend to one of the key concepts in the online support community scholarship: empathy. Our findings suggest that it is a combination of empathy expression and reception that is crucial to attaining optimal benefits for cancer patients. Further, our finding supports the buffering hypothesis that empathic expression provides a salutary effect for patients who experienced a higher degree of concern associated with their cancer diagnosis and follow-up treatments.

Expression and reception of treatment information in breast cancer support groups: how health self-efficacy moderates effects on emotional well-being.

OBJECTIVES: To examine the effects of exchanging treatment information within computer-mediated breast cancer support groups on emotional well-being, and to explore whether this relationship is moderated by health self-efficacy. SAMPLE: 177 breast cancer patients using an electronic Health (eHealth) program with discussion group. MEASURE: expression and reception of treatment information; emotional well-being scale (0, 4 months). ANALYSES: hierarchical regression. RESULTS: Effects of expression and reception of treatment information on emotional well-being were significantly greater for those who have higher health self-efficacy. CONCLUSIONS: Results conditionally support prior research finding positive effects of treatment information exchanges among breast cancer patients. Such exchanges had a positive impact on emotional well-being for those with higher health self-efficacy, but they had a negative influence for those with lower health self-efficacy. PRACTICE IMPLICATIONS: Given that the association between emotional well-being and exchanging treatment information was moderated by health self-efficacy, clinicians should explain the role of health self-efficacy before encouraging patients to use eHealth systems for treatment exchanges.

Communicating about self and others within an online support group for women with breast cancer and subsequent outcomes.

Research suggests communicating too much about one's self within an online support group may amplify breast cancer patients' focus on their own problems and exacerbate negative emotions while focusing on others may have the opposite effects. This study explored how pronoun usage within an online support group was associated with subsequent mental health outcomes. There were 286 patients recruited into the study who filled out the pre-test and 231 completed post-tests four months later with survey measures including breast cancer-related concerns and negative emotions. Messages were analyzed using a program counting first person and relational pronouns. A positive relationship was found between use of first person pronouns and negative emotions.

Caregivers' differing needs across key experiences of the advanced cancer disease trajectory.

OBJECTIVES: Familial caregivers are providing increasing amounts of care to advanced cancer patients. Increased understanding of caregivers' needs is vital in providing necessary support to lessen caregiver burden and morbidity. Current literature has identified caregiver and patient needs at broad stages of the cancer trajectory; however, such broad stages may be too general to inform a practice of targeting specific interventions when they have the greatest utility. This study examines a variety of particular needs across a number of more discrete illness-related transition experiences specifically in the advanced cancer disease trajectory. METHODS: One hundred fifty-nine female informal caregivers of people with advanced cancer completed a needs assessment survey. RESULTS: Analyses of these cross-sectional retrospective-report data reveal that cancer caregiver needs vary across specific key experiences occurring within the broader stages of illness identified by current literature. Furthermore, caregivers have unique needs during bereavement. SIGNIFICANCE OF RESULTS: Although the sample characteristics are demographically limited, this study provides preliminary evidence that the broad stages are not specific enough increments for effectively examining caregiver needs and supports the need for more precise distribution of cancer-related information at more discrete times in the illness course.

Reducing the digital divide for low-income women with breast cancer: a feasibility study of a population-based intervention.

A fundamental challenge to helping underserved women and their families cope with breast cancer is providing them with easily accessible, reliable health care information and support. This is especially true for low-income families living in rural areas where resources are few and frequently distant as well as low-income families in urban areas where access to information and support can be complex and overwhelming. The Internet is one mechanism that has tremendous potential to help these families cope with breast cancer. This article describes a feasibility test of the potential for the National Cancer Institute's (NCI's) Cancer Information Service (CIS) to provide access to an Internet-based system that has been shown to improve quality of life for underserved breast cancer patients. The test was conducted in rural Wisconsin (low socioeconomic status [SES] Caucasian women) and in Detroit, Michigan (low SES African American women), and compares the effectiveness of several different dissemination strategies. Using these results we propose a model for how CIS telephone and partnership program services could efficiently disseminate such information and support systems. In doing so we believe that important steps can be taken to close the digital divide that separates low-income families from the resources they need to effectively face cancer. This is the first of two articles coming from this study. A companion article reports on an evaluation of the use and impact of this system on the women who were given access to it.

Use and Impact of eHealth System by Low-income Women With Breast Cancer.

This article is the second of a two-part series reporting on a population-based study intended to use an eHealth system to examine the feasibility of reaching underserved women with breast cancer (Gustafson, McTavish et al., Reducing the digital divide for low-income women with breast cancer, 2004; Madison Center for Health Systems Research and Analysis, University of Wisconsin; Comprehensive Health Enhancement Support System [CHESS]) and determine how they use the system and what impact it had on them. Participants included women recently diagnosed with breast cancer whose income was at or below 250% of poverty level and were living in rural Wisconsin (n = 144; all Caucasian) or Detroit (n = 85; all African American). Because this was a population-based study all 229 participants received CHESS. A comparison group of patients (n = 51) with similar demographics was drawn from a separate recently completed randomized clinical trial. Use rates (e.g., frequency and length of use as well as type of use) as well as impact on several dimensions of quality of life and participation in health care are reported. Low-income subjects in this study logged on and spent more time on CHESS than more affluent women in a previous study. Urban African Americans used information and analysis services more and communication services less than rural Caucasians. When all low-income women from this study are combined and compared with a low-income control group from another study, the CHESS group was superior to that control group in 4 of 8 outcome variables at both statistically and practically significant levels (social support, negative emotions, participation in health care, and information competence). When African Americans and Caucasians are separated the control group's sample size becomes 30 and 21 thus reducing power. Statistical significance is retained, however, in all four outcomes for Caucasians and in two of four for African Americans. Practical significance is retained for all four outcomes. We conclude that an eHealth system like CHESS will be used extensively and have a positive impact on low-income women with breast cancer.

Cultural differences in use of an electronic discussion group.

This article describes how 121 women newly diagnosed with breast cancer used a computer mediated discussion group to cope with their diagnosis. These data are part of a larger data set from a randomized clinical trial assessing the impact of a computer-based system called CHESS (the Comprehensive Health Enhancement Support System) on health outcomes. The larger study found significant improvement in health outcomes for those in the experimental group (those receiving CHESS), especially for women of color. Since discussion group is by far the most heavily used service of CHESS, one might conclude that these benefits (both overall and greater for women of color) should be attributed to amount of discussion group use. This study looks at how women of color and Caucasian women used the CHESS discussion group over the period of the study. Content analysis of messages in the discussion group showed that women of color used the discussion group differently from Caucasian women-they used it less frequently but their messages were more focused on breast cancer, suggesting they used discussion group more instrumentally.