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INTRODUCTION: Millions of people living with HIV (PLWH) take oral antiretroviral therapy (ART), which requires a lifetime of consistent medication adherence. The relationship between adherence and poor HIV outcomes is well documented. Newer ART regimens that include dolutegravir (DTG) could be more forgiving, but empirical evidence on the relationship between adherence and viral suppression under DTG is only emerging. METHODS: In this observational cohort study (secondary analysis of data from a randomized trial), we used data from 313 ART clients from a large HIV clinic in Kampala, Uganda. Over the 4-year study period (January 2018-January 2022), 91% switched from non-DTG regimens to DTG regimens. We measured adherence using Medication Event Monitoring Systems-caps and extracted prescription information and viral load measures from electronic health records. We estimated unadjusted linear regressions and adjusted models that included individual and time fixed-effects. RESULTS: Under non-DTG regimens, 96% of participants were virally suppressed (defined as viral load < 200 copies/ml) when adherence was 90% or higher in the 3 months before viral load measurement. Viral suppression was 32 percentage points lower when adherence was between 0% and 49% (95% CI -0.44, -0.20, p < 0.01), 12 percentage points lower when adherence was between 50% and 79% (95% CI -0.23, -0.02, p < 0.01), and not significantly different when adherence was between 80% and 89% (effect of 0.00, 95% CI -0.06, 0.07, p = 0.81). In contrast, for participants taking DTG, there was no statistically significant difference in viral suppression among any of the four adherence levels; more than 95% were virally suppressed at each adherence level. On average, switching to DTG increased viral suppression by 6 percentage points in our adjusted models (95% CI 0.00, 0.13, p = 0.03). CONCLUSIONS: There was no significant association between adherence levels and viral suppression among PLWH taking DTG regimens, suggesting a high degree of forgiveness for missed doses. The use of DTG should be prioritized over older regimens, particularly for those with low adherence. CLINICAL TRIAL NUMBER: NCT03494777.
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Infecciones por VIH , Compuestos Heterocíclicos con 3 Anillos , Cumplimiento de la Medicación , Oxazinas , Piperazinas , Piridonas , Carga Viral , Humanos , Uganda , Piridonas/uso terapéutico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/virología , Masculino , Femenino , Cumplimiento de la Medicación/estadística & datos numéricos , Compuestos Heterocíclicos con 3 Anillos/uso terapéutico , Adulto , Carga Viral/efectos de los fármacos , Oxazinas/uso terapéutico , Piperazinas/uso terapéutico , Estudios de Cohortes , Persona de Mediana Edad , Fármacos Anti-VIH/uso terapéuticoRESUMEN
INTRODUCTION: Habits are a common strategy for successfully countering medication non-adherence, yet existing interventions do not support participants during the long habit formation period, resulting in high attrition. We test a novel intervention combining text messages and incentives with anchoring to support antiretroviral therapy (ART) pill-taking habits. METHODS: In a randomized, parallel controlled trial, a sample of 155 participants 18 years and older who initiated ART within 3 months were recruited at Mildmay Uganda between October 2021 and April 2022. All participants were educated on the anchoring strategy and chose an anchor, that is existing routines, to pair with pill-taking. Participants were randomized to either usual care (C = 49), daily text message reminders to follow their anchoring plan (Messages group; T1 = 49) or messages and incentives conditional on pill-taking in line with their anchor (Incentives group; T2 = 57). Assessments occurred at baseline, month 3 (end of intervention) and month 9 (end of observation period). The primary outcomes are electronically measured mean adherence and pill-taking consistent with participants' anchor time. RESULTS: The primary outcome of pill-taking in line with the anchoring plan was higher in the Incentives group during the 3-month intervention (12.2 p.p. [95% CI: 2.2 22.2; p = .02]), and remained significantly higher after the incentives were withdrawn (months 4-6 (14.2 p.p. [95% CI 1.1 27.2; p = .03]); months 7-9 (14.1 p.p. [95% CI -0.2 28.5; p = .05])). Mean adherence was higher in both treatment groups relative to the control group during the intervention (T1 vs. C, p = .06; T2 vs. C, p = .06) but not post-intervention. CONCLUSIONS: The promising approach of using incentives to support habit formation among ART treatment initiators needs to be evaluated in a fully powered study to further our understanding of the habit formation process and to evaluate its cost-effectiveness.
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Infecciones por VIH , Cumplimiento de la Medicación , Motivación , Sistemas Recordatorios , Envío de Mensajes de Texto , Humanos , Uganda , Cumplimiento de la Medicación/estadística & datos numéricos , Masculino , Femenino , Infecciones por VIH/tratamiento farmacológico , Adulto , Proyectos Piloto , Persona de Mediana Edad , Fármacos Anti-VIH/uso terapéutico , Adulto Joven , Antirretrovirales/uso terapéuticoRESUMEN
Animal agriculture is a leading contributor to greenhouse gas emissions and other harmful environmental impacts, which underscores the need to shift away from the consumption of animal-based products. One promising nudge intervention is making plant-based meals the default option, so we tested this approach at six different university events across four academic institutions for effecting sustainable dietary change. Event attendees pre-selected their meal on one of two randomly assigned RSVP forms: one with a plant-based default and one with a meal with meat default. The results from our randomized controlled trial showed that participants had a 43-percentage point greater probability of selecting the plant-based meal when it was indicated as the default option. This effect was similar across events and academic institutions, which indicates that this default intervention is generalizable and can be successfully implemented at university events. The combined effect of using plant-based defaults at these six events was an estimated reduction of 104,387 kg of CO2 emissions, 299.9 m2 of land use, 959.0 g of nitrogen use, and 259.5 g of phosphorus use, which represent roughly 45-46.2% reductions in harmful environmental impacts relative to the meals chosen when using a meat default. Given the significance and magnitude of these environmental benefits, our results support the widespread implementation of plant-based defaults for helping universities improve their sustainability.
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Ambiente , Humanos , Universidades , Masculino , Femenino , Adulto , Comidas , Adulto Joven , Preferencias Alimentarias/psicología , Carne , Conducta de Elección , Dieta Vegetariana , Efecto Invernadero/prevención & control , Gases de Efecto InvernaderoRESUMEN
The purpose of this study was to: (1) compare the relative efficacy of different combinations of three behavioral intervention strategies (i.e., personalized reminders, financial incentives, and anchoring) for establishing physical activity habits using an mHealth app and (2) to examine the effects of these different combined interventions on intrinsic motivation for physical activity and daily walking habit strength. A four-arm randomized controlled trial was conducted in a sample of college students (N = 161) who had a self-reported personal wellness goal of increasing their physical activity. Receiving cue-contingent financial incentives (i.e., incentives conditional on performing physical activity within ± one hour of a prespecified physical activity cue) combined with anchoring resulted in the highest daily step counts and greatest odds of temporally consistent walking during both the four-week intervention and the full eight-week study period. Cue-contingent financial incentives were also more successful at increasing physical activity and maintaining these effects post-intervention than traditional non-cue-contingent incentives. There were no differences in intrinsic motivation or habit strength between study groups at any time point. Financial incentives, particularly cue-contingent incentives, can be effectively used to support the anchoring intervention strategy for establishing physical activity habits. Moreover, mHealth apps are a feasible method for delivering the combined intervention technique of financial incentives with anchoring.
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Ejercicio Físico , Promoción de la Salud , Motivación , Estudiantes , Humanos , Femenino , Masculino , Ejercicio Físico/psicología , Estudiantes/psicología , Adulto Joven , Universidades , Promoción de la Salud/métodos , Aplicaciones Móviles , Adulto , Caminata/psicología , Conductas Relacionadas con la Salud , Adolescente , Telemedicina/economía , Señales (Psicología)RESUMEN
BACKGROUND: This study tests behavioral economics incentives to improve adherence to antiretroviral treatment (ART), with 1 approach being low cost. SETTING: Three hundred twenty-nine adults at Mildmay Hospital in Kampala, Uganda, on ART for at least 2 years and showing adherence problems received the intervention for about 15 months until the study was interrupted by a nation-wide COVID-19 lockdown. METHODS: We randomized participants into 1 of 3 (1:1:1) groups: usual care ("control" group; n = 109) or 1 of 2 intervention groups where eligibility for nonmonetary prizes was based on showing at least 90% electronically measured ART adherence ("adherence-linked" group, n = 111) or keeping clinic appointments as scheduled ("clinic-linked"; n = 109). After 12 months, participants could win a larger prize for consistently high adherence or viral suppression. Primary outcomes were mean adherence and viral suppression. Analysis was by intention-to-treat using linear regression. This trial is registered with ClinicalTrials.gov, NCT03494777 . RESULTS: Neither incentive arm increased adherence compared with the control; we estimate a 3.9 percentage point increase in "adherence-linked" arm [95% confidence interval (CI): -0.70 to 8.60 ( P = 0.10)] and 0.024 in the "clinic-linked" arm [95% CI: -0.02 to 0.07 ( P = 0.28)]. For the prespecified subgroup of those with initial low adherence, incentives increased adherence by 7.60 percentage points (95% CI: 0.01, 0.15; P = 0.04, "adherence-linked") and 5.60 percentage points (95% CI: -0.01, 0.12; P = 0.10, "clinic-linked"). We find no effects on clinic attendance or viral suppression. CONCLUSIONS: Incentives did not improve viral suppression or ART adherence overall but worked for the prespecified subgroup of those with initial low adherence. More effectively identifying those in need of adherence support will allow better targeting of this and other incentive interventions.
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Economía del Comportamiento , Infecciones por VIH , Cumplimiento de la Medicación , Motivación , Humanos , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/psicología , Uganda , Masculino , Adulto , Femenino , Fármacos Anti-VIH/uso terapéutico , Fármacos Anti-VIH/economía , Persona de Mediana Edad , COVID-19/psicología , COVID-19/epidemiología , Carga ViralRESUMEN
BACKGROUND: Delay discounting is the depreciation in a reward's perceived value as a function of the time until receipt. Monetary incentive programs that provide rewards contingent on meeting daily physical activity (PA) goals may change participants' delay discounting preferences. PURPOSE: Determine if monetary incentives provided in close temporal proximity to meeting PA goals changed delay discounting, and if such changes mediated intervention effects. METHODS: Inactive adults (n = 512) wore accelerometers during a 12-month intervention where they received proximal monetary incentives for meeting daily moderate-to-vigorous PA (MVPA) goals or delayed incentives for study participation. Delay discount rate and average MVPA were assessed at baseline, end of intervention, and a 24-month follow-up. Using structural equation modeling, we tested effects of proximal versus delayed rewards on delay discounting and whether any changes mediated intervention effects on MVPA. PA self-efficacy was also evaluated as a potential mediator, and both self-efficacy and delay discounting were assessed as potential moderators of intervention effects. RESULTS: Proximal rewards significantly increased participants' delay discounting (ß = 0.238, confidence interval [CI]: -0.078, 0.380), indicating greater sensitivity to reinforcement timing. This change did not mediate incentive-associated increases in MVPA at the end of the 12-month intervention (ß = -0.016, CI: -0.053, 0.019) or at a 24-month follow-up (ß = -0.020, CI: -0.059, 0.018). Moderation effects were not found. CONCLUSIONS: Incentive-induced increases in delay discounting did not deleteriously impact MVPA. This finding may help assuage concerns about using monetary incentives for PA promotion, but further research regarding the consequences of changes in delay discounting is warranted.
This study examined the effects of providing proximal monetary incentives for meeting daily exercise goals on people's tendency to value immediate versus delayed rewards. Inactive adults (n = 512) participated in a year-long program where they wore an accelerometer each day and received either (i) small monetary rewards in close temporal proximity to instances of meeting daily exercise goals or (ii) larger rewards at 2-month intervals for ongoing participation. Those receiving proximal incentives showed an increased preference for immediate rewards, yet this reported change did not compromise long-term physical activity gains. In a comparison analysis, we found that proximal monetary incentives were not associated with changes in exercise self-efficacy. Overall, the findings suggest that monetary incentives for exercise do not negatively impact people's activity levels, though more research is needed to fully understand the implications of changes in reward timing preferences.
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Descuento por Demora , Motivación , Adulto , Humanos , Recompensa , Ejercicio FísicoRESUMEN
Prior evidence suggests that Hispanic and non-Hispanic individuals differ in potential risk factors for the development of dementia. Here we determine whether specific brain regions are associated with cognitive performance for either ethnicity along various stages of Alzheimer's disease. For this cross-sectional study, we examined 108 participants (61 Hispanic vs. 47 Non-Hispanic individuals) from the 1Florida Alzheimer's Disease Research Center (1Florida ADRC), who were evaluated at baseline with diffusion-weighted and T1-weighted imaging, and positron emission tomography (PET) amyloid imaging. We used FreeSurfer to segment 34 cortical regions of interest. Baseline Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used as measures of cognitive performance. Group analyses assessed free-water measures (FW) and volume. Statistically significant FW regions based on ethnicity x group interactions were used in a stepwise regression function to predict total MMSE and MoCA scores. Random forest models were used to identify the most predictive brain-based measures of a dementia diagnosis separately for Hispanic and non-Hispanic groups. Results indicated elevated FW values for the left inferior temporal gyrus, left middle temporal gyrus, left banks of the superior temporal sulcus, left supramarginal gyrus, right amygdala, and right entorhinal cortex in Hispanic AD subjects compared to non-Hispanic AD subjects. These alterations occurred in the absence of different volumes of these regions in the two AD groups. FW may be useful in detecting individual differences potentially reflective of varying etiology that can influence cognitive decline and identify MRI predictors of cognitive performance, particularly among Hispanics.
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Enfermedad de Alzheimer , Disfunción Cognitiva , Humanos , Estudios Transversales , Imagen por Resonancia Magnética , Encéfalo/diagnóstico por imagen , Tomografía de Emisión de Positrones , AguaRESUMEN
The global prevalence of depression has risen over the past three decades across all socioeconomic groups and geographic regions, with a particularly rapid increase in prevalence among adolescents (aged 12-17 years) in the United States. Depression imposes large health, economic, and societal costs, including reduced life span and quality of life, medical costs, and reduced educational attainment and workplace productivity. A wide range of treatment modalities for depression are available, but socioeconomic disparities in treatment access are driven by treatment costs, lack of culturally tailored options, stigma, and provider shortages, among other barriers. This review highlights the need for comparative research to better understand treatments' relative efficacy, cost-effectiveness, scalability, and potential heterogeneity in efficacy across socioeconomic groups and country and cultural contexts. To address the growing burden of depression, mental health policy could consider reducing restrictions on the supply of providers, implementing digital interventions, reducing stigma, and promoting healthy lifestyles.
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Depresión , Humanos , Depresión/terapia , Adolescente , Análisis Costo-Beneficio , Estigma Social , Niño , Estados Unidos , Calidad de Vida , Factores Socioeconómicos , Costo de Enfermedad , Accesibilidad a los Servicios de Salud/economíaRESUMEN
LAY ABSTRACT: Existing research has identified an increased risk of depression among autistic adults, which can negatively impact their adaptive functioning abilities and socioeconomic outcomes. Mobile app-based meditation is a feasible, accessible, and effective self-care solution for depression among neurotypical adults, but there is limited evidence for the long-term benefits of app-based meditation among autistic adults. Habits are a key behavioral strategy for maintaining behavior change, and anchoring is one effective habit formation intervention that has yet to be tested among autistic adults. This study demonstrates that it is both feasible and effective to integrate the anchoring habit formation strategy into an app-based meditation intervention for establishing meditation habits among autistic adults. In addition, the study shows that app-based meditation habits were successful at maintaining reductions in depressive symptoms over 6 months. These results demonstrate the power of anchoring-based habit formation interventions for establishing healthy habits among autistic adults, which offers a promising behavioral intervention technique for establishing other healthy habits among autistic adults. The study also shows that app-based meditation habits are an effective long-term self-care solution for managing depressive symptoms among autistic adults that should be used by mental health providers and policymakers. Future research should test this combined anchoring and app-based meditation intervention technique among larger samples of autistic adults and over longer durations to better understand the mechanisms underlying the success of this intervention.
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PURPOSE: The optimal treatment of intra-articular distal radius fractures in older adults (>65 years) remains uncertain despite numerous randomized trials. The purpose of this study was to examine the moderating effect of age on patient-reported benefits of volar locked plating versus cast immobilization for intra-articular distal radius fractures. METHODS: A meta-analysis of randomized controlled trials was conducted to compare volar locked plating and cast immobilization of intra-articular distal radius fractures. Meta-regression analyses were used to examine the moderating effect of age on improvements in patient-reported outcome measures from operative treatment of distal radius factures. Modeling results were then used to estimate improvements in Disability of the Arm, Shoulder, and Hand (DASH) scores from surgery that are associated with ages ranging from 65 to 90 years. RESULTS: Twelve randomized controlled trials including 1,806 patients were included. Age was a significant moderator of patient-reported benefits after operative treatment, with decreasing DASH score benefits from surgery associated with older ages. Model predictions show that a majority of patients aged <70 years will experience a clinically meaningful improvement in DASH scores from surgery. Patients aged 70-80 years have decreasing DASH benefits with age, but many may still experience a clinically meaningful improvement from surgery. Patients aged >80 years are unlikely to experience a clinically meaningful improvement in DASH scores with surgical management. CONCLUSIONS: Older ages are associated with decreased benefits from surgical management with volar locked plating as compared to cast immobilization. Patients aged >80 years are unlikely to experience a clinically significant improvement with surgery. Surgeons and policymakers may use these data to counsel patients, health systems, and professional organizations on the risks and benefits of operative treatment in older adults. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis 1, Meta-Analysis of Randomized Controlled Trials.
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Fracturas Intraarticulares , Fracturas del Radio , Fracturas de la Muñeca , Humanos , Anciano , Fracturas del Radio/cirugía , Resultado del Tratamiento , Placas Óseas , Fijación Interna de Fracturas/métodos , Rango del Movimiento Articular , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
INTRODUCTION: We assessed racial and ethnic disparities in the use of prostate biopsy or MRI following an elevated PSA result. METHODS: We retrospectively evaluated insurance claims from Optum's de-identified Clinformatics Data Mart database from January 1, 2011 to December 31, 2017. This was a large commercially insured cohort from across the United States. We included all male enrollees over 40 years old receiving an elevated PSA result with no prior prostate biopsy or MRI and no confirmed urinary tract infection within 6 weeks of PSA test. RESULTS: A total of 765,409 participants met inclusion criteria with 43,711 (5.71%) receiving a PSA result above 4 ng/mL. Of these, 7,399 received either a prostate biopsy or MRI within 180 days. Men between ages 40-54 (29.48%) were most likely to receive prostate biopsy or MRI after an elevated PSA, followed by those between 55-64 (24.91%), 65-74 (18.56%), 75-84 (6.33%), and above 85 (3.62%). Compared to White patients, Black patients were more likely to receive either a prostate biopsy or MRI (OR: 1.16, 95% CI: 1.01, 1.32) following an elevated PSA level, while Asian (OR: 0.72, 95% CI: 0.54, 0.96) and Hispanic (OR: 0.83, 95% CI: 0.70, 0/97) patients were less likely. CONCLUSIONS: Physicians appear to be following the reported statistical incidence of prostate cancer by race and ethnicity when using prostate biopsy or MRI for patients with elevated PSA levels. These results demonstrate the importance of publishing statistical data on disease incidence by race and ethnicity for informing physicians' decision-making.
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Neoplasias de la Próstata , Humanos , Masculino , Estados Unidos/epidemiología , Adulto , Neoplasias de la Próstata/diagnóstico , Próstata/diagnóstico por imagen , Antígeno Prostático Específico , Estudios Retrospectivos , Detección Precoz del Cáncer , Biopsia , Imagen por Resonancia MagnéticaRESUMEN
Objectives: Mindfulness meditation apps are used by millions of adults in the USA to improve mental health. However, many new app subscribers quickly abandon their use. The purpose of this study was to determine the behavioral, demographic, and socioeconomic factors associated with the abandonment of meditation apps during the COVID-19 pandemic. Method: A survey was distributed to subscribers of a popular meditation app, Calm, at the start of the COVID-19 pandemic in March 2020 that assessed meditation app behavior and meditation habit strength, as well as demographic and socioeconomic information. App usage data were also collected from the start of each participant's subscription until May 2021. A total of 3275 respondents were included in the analyses. Participants were divided into three cohorts according to their subscription start date: (1) long-term subscribers (> 1 year before pandemic start), (2) pre-pandemic subscribers (< 4 months before pandemic start), and (3) pandemic subscribers (joined during the pandemic). Results: Meditating after an existing routine was associated with a lower risk of app abandonment for pre-pandemic subscribers (hazard ratio = 0.607, 95% CI: 0.422, 0.874; p = 0.007) and for pandemic subscribers (hazard ratio = 0.434, 95% CI: 0.285, 0.66; p < 0.001). Additionally, meditating "whenever I can" was associated with lower risk of abandonment among pandemic subscribers (hazard ratio = 0.437, 95% CI: 0.271, 0.706; p < 0.001), and no behavioral factors were significant predictors of app abandonment among the long-term subscribers. Conclusions: These results show that combining meditation with an existing daily routine was a commonly utilized strategy for promoting persistent meditation app use during the COVID-19 pandemic for many subscribers. This finding supports existing evidence that pairing new behaviors with an existing routine is an effective method for establishing new health habits. Preregistration: This study is not pre-registered.
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BACKGROUND: Mobile health (mHealth) apps can promote physical activity; however, the pragmatic nature (ie, how well research translates into real-world settings) of these studies is unknown. The impact of study design choices, for example, intervention duration, on intervention effect sizes is also understudied. OBJECTIVE: This review and meta-analysis aims to describe the pragmatic nature of recent mHealth interventions for promoting physical activity and examine the associations between study effect size and pragmatic study design choices. METHODS: The PubMed, Scopus, Web of Science, and PsycINFO databases were searched until April 2020. Studies were eligible if they incorporated apps as the primary intervention, were conducted in health promotion or preventive care settings, included a device-based physical activity outcome, and used randomized study designs. Studies were assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) frameworks. Study effect sizes were summarized using random effect models, and meta-regression was used to examine treatment effect heterogeneity by study characteristics. RESULTS: Overall, 3555 participants were included across 22 interventions, with sample sizes ranging from 27 to 833 (mean 161.6, SD 193.9, median 93) participants. The study populations' mean age ranged from 10.6 to 61.5 (mean 39.6, SD 6.5) years, and the proportion of males included across all studies was 42.8% (1521/3555). Additionally, intervention lengths varied from 2 weeks to 6 months (mean 60.9, SD 34.9 days). The primary app- or device-based physical activity outcome differed among interventions: most interventions (17/22, 77%) used activity monitors or fitness trackers, whereas the rest (5/22, 23%) used app-based accelerometry measures. Data reporting across the RE-AIM framework was low (5.64/31, 18%) and varied within specific dimensions (Reach=44%; Effectiveness=52%; Adoption=3%; Implementation=10%; Maintenance=12.4%). PRECIS-2 results indicated that most study designs (14/22, 63%) were equally explanatory and pragmatic, with an overall PRECIS-2 score across all interventions of 2.93/5 (SD 0.54). The most pragmatic dimension was flexibility (adherence), with an average score of 3.73 (SD 0.92), whereas follow-up, organization, and flexibility (delivery) appeared more explanatory with means of 2.18 (SD 0.75), 2.36 (SD 1.07), and 2.41 (SD 0.72), respectively. An overall positive treatment effect was observed (Cohen d=0.29, 95% CI 0.13-0.46). Meta-regression analyses revealed that more pragmatic studies (-0.81, 95% CI -1.36 to -0.25) were associated with smaller increases in physical activity. Treatment effect sizes were homogenous across study duration, participants' age and gender, and RE-AIM scores. CONCLUSIONS: App-based mHealth physical activity studies continue to underreport several key study characteristics and have limited pragmatic use and generalizability. In addition, more pragmatic interventions observe smaller treatment effects, whereas study duration appears to be unrelated to the effect size. Future app-based studies should more comprehensively report real-world applicability, and more pragmatic approaches are needed for maximal population health impacts. TRIAL REGISTRATION: PROSPERO CRD42020169102; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=169102.
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Aplicaciones Móviles , Telemedicina , Masculino , Humanos , Niño , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Ejercicio Físico , Promoción de la Salud , Telemedicina/métodos , Proyectos de InvestigaciónRESUMEN
OBJECTIVE: Describe the landscape of tobacco-related topics, funders and institutional networks in Africa. DATA SOURCES: We searched PubMed, Embase and African Index Medicus for published articles from January 1996 to August 2018 in any language. STUDY SELECTION: Two researchers independently reviewed titles and abstracts for a focus on nicotine or tobacco product(s) and describe data or recommendations specific to Africa. Ultimately, 818 articles were identified. DATA EXTRACTION: Three independent coders conducted qualitative analyses of articles and extracted funders, study populations, countries of research focus, research topics, tobacco products, study design and data source. A bibliometric analysis estimated coauthorship networks between the countries of authors' primary institutional affiliation. DATA SYNTHESIS: All 54 African countries were represented in two or more articles. The coauthorship network included 2714 unique authors representing 90 countries. Most articles employed a cross-sectional study design with primary data collection, focused on cigarettes and studied use behaviour. Few articles examined tobacco farming or interventions for cessation or prevention. The most frequently cited funder was the US National Institutes of Health (27.2%). A range of coauthorship patterns existed between African institutions with some coauthoring with one institution while others coauthored with 761 institutions in other African countries. CONCLUSIONS: The literature review identified the need for implementation research for tobacco control interventions and policies, economic and development impacts of tobacco use research, and tobacco industry and tobacco production and farming research. Numbers of research collaborations between institutions in Africa vary, suggesting the need for regional institutional capacity building.
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BACKGROUND: The intensive data typically collected by mobile health (mHealth) apps allows factors associated with persistent use to be investigated, which is an important objective given users' well-known struggles with sustaining healthy behavior. OBJECTIVE: Data from a commercial meditation app (n=14,879; 899,071 total app uses) were analyzed to assess the validity of commonly given habit formation advice to meditate at the same time every day, preferably in the morning. METHODS: First, the change in probability of meditating in 4 nonoverlapping time windows (morning, midday, evening, and late night) on a given day over the first 180 days after creating a meditation app account was calculated via generalized additive mixed models. Second, users' time of day preferences were calculated as the percentage of all meditation sessions that occurred within each of the 4 time windows. Additionally, the temporal consistency of daily meditation behavior was calculated as the entropy of the timing of app usage sessions. Linear regression was used to examine the effect of time of day preference and temporal consistency on two outcomes: (1) short-term engagement, defined as the number of meditation sessions completed within the sixth and seventh month of a user's account, and (2) long-term use, defined as the days until a user's last observed meditation session. RESULTS: Large reductions in the probability of meditation at any time of day were seen over the first 180 days after creating an account, but this effect was smallest for morning meditation sessions (63.4% reduction vs reductions ranging from 67.8% to 74.5% for other times). A greater proportion of meditation in the morning was also significantly associated with better short-term engagement (regression coefficient B=2.76, P<.001) and long-term use (B=50.6, P<.001). The opposite was true for late-night meditation sessions (short-term: B=-2.06, P<.001; long-term: B=-51.7, P=.001). Significant relationships were not found for midday sessions (any outcome) or for evening sessions when examining long-term use. Additionally, temporal consistency in the performance of morning meditation sessions was associated with better short-term engagement (B=-1.64, P<.001) but worse long-term use (B=55.8, P<.001). Similar-sized temporal consistency effects were found for all other time windows. CONCLUSIONS: Meditating in the morning was associated with higher rates of maintaining a meditation practice with the app. This is consistent with findings from other studies that have hypothesized that the strength of existing morning routines and circadian rhythms may make the morning an ideal time to build new habits. In the long term, less temporal consistency in meditation sessions was associated with more persistent app use, suggesting there are benefits from maintaining flexibility in behavior performance. These findings improve our understanding of how to promote enduring healthy lifestyles and can inform the design of mHealth strategies for maintaining behavior changes.
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Meditación , Aplicaciones Móviles , Humanos , Estudios Longitudinales , Conductas Relacionadas con la Salud , Estilo de Vida SaludableRESUMEN
BACKGROUND: Chronic (ie, long-term) elevated stress is associated with a number of mental and physical health conditions. Mindfulness meditation mobile apps are a promising tool for stress self-management that can overcome several barriers associated with in-person interventions; however, to date, poor app-based intervention adherence has limited the efficacy of these mobile health tools. Anchoring, or pairing, a new behavior with an existing routine has been shown to effectively establish habits that are maintained over time, but this strategy typically only works for those with high initial motivation and has yet to be tested for maintaining meditation with a mobile app. OBJECTIVE: This study will test novel combinations of behavioral economics-based incentives with the anchoring strategy for establishing and maintaining adherence to an effective dose of meditation with a mobile app. METHODS: This 16-week study will use a 5-arm, parallel, partially blinded (participants only), randomized controlled design. We will implement a fractional factorial study design that varies the use of self-monitoring messages and financial incentives to support participants' use of their personalized anchoring strategy for maintaining adherence to a ≥10 minute-per-day meditation prescription during an 8-week intervention period, followed by an 8-week postintervention observation period. Specifically, we will vary the use of self-monitoring messages of either the target behavior (ie, meditation tracking) or the outcome associated with the target behavior (ie, mood symptom tracking). We will also vary the use of financial incentives conditional on either meditation at any time of day or meditation performed at approximately the same time of day as participants' personalized anchors. RESULTS: Continuous meditation app use data will be used to measure weekly meditation adherence over the 16-week study period as a binary variable equal to 1 if participants complete ≥10 minutes of meditation for ≥4 days per week and 0 otherwise. We will measure weekly anchoring plan adherence as a binary variable equal to 1 if participants complete ≥10 minutes of meditation within +1 or -1 hour of the timing of their chosen anchor on ≥4 days per week and 0 otherwise. In addition to these primary measures of meditation and anchoring plan adherence, we will also assess the secondary measures of stress, anxiety, posttraumatic stress disorder, sleep disturbance, and meditation app habit strength at baseline, week 8, and week 16. CONCLUSIONS: This study will fill an important gap in the mobile health literature by testing novel intervention approaches for establishing and maintaining adherence to app-based mindfulness meditation. If successful, this study will identify an accessible and scalable stress self-management intervention that can help combat stress in the United States. TRIAL REGISTRATION: ClinicalTrials.gov NCT05217602; https://clinicaltrials.gov/ct2/show/NCT05217602. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39930.
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OBJECTIVES: The interaction between emerging physician practice models and the use of health information exchange (HIE) remains understudied. We examined associations between the use of emerging practice models and the use of HIE. We also examined barriers to HIE adoption among physicians who were not utilizing HIE. STUDY DESIGN: Survey data came from a 2019-2021 statewide census of all physicians in Arizona collected at the time of license renewal (n = 3312, or 17.9% of all practicing physicians). METHODS: Primary outcomes were physician-reported HIE use for patient care summaries and for laboratory results. Secondary outcomes were 5 common HIE barriers among non-HIE users. The primary predictor was physician practice model: accountable care organization (ACO), clinically integrated network (CIN), or integrated delivery network (IDN) vs traditional care delivery model. Covariates included physician specialty, age, gender, and county of practice. RESULTS: Compared with physicians in traditional care delivery models, physicians in ACOs, CINs, or IDNs had significantly higher odds of using HIE to share both patient care summaries (P < .01) and laboratory results (P < .05 for ACOs), although associations varied across provider and practice characteristics. ACO providers not using HIE were more likely to cite a lack of connectivity and lack of information as HIE barriers. CONCLUSIONS: Providers in an emerging practice model are more likely to use HIE than those in a traditional care delivery model. However, nuances in these associations suggest a persistence of previously identified HIE gaps, and the barriers cited provide guidance for increasing HIE use among different practice types.
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Organizaciones Responsables por la Atención , Intercambio de Información en Salud , Médicos , Humanos , Estados Unidos , ArizonaRESUMEN
RATIONALE: In 2020, nearly 40 million people lived with HIV/AIDS (PLWHA) worldwide, of whom 70% were receiving antiretroviral therapy (ART). Two-thirds of PLWHA reside in Sub-Saharan Africa (SSA), where rates of viral load suppression are often suboptimal and frequently attributed to low ART adherence. Strong pill-taking habits are often reported as a key strategy among those who successfully maintain medication adherence, yet not enough is known about the barriers and facilitators in SSA to pill-taking in response to the same contextual cue, which is a necessary step in the habit formation process. OBJECTIVE: To address this knowledge gap and to inform a subsequent intervention to promote context-dependent repetition, called anchoring, we used a formative qualitative approach to collect in-depth narratives about barriers and facilitators of the anchoring intervention for establishing ART pill-taking habits at the Mildmay Hospital in Kampala, Uganda. METHODS: We conducted interviews with 25 randomly selected patients starting ART, 5 expert patients, and 10 providers at Mildmay, and performed a rapid analysis to inform the intervention in a timely manner. RESULTS: We found that pill taking in response to the same contextual cue, or anchor, was threatened by stigma and food insecurity and that the COVID-19 pandemic exacerbated these barriers. We also determined that important linguistic changes were needed to the instructional materials and reminder messages in the subsequent intervention to avoid words and phrases with negative connotations for this target population. CONCLUSIONS: Several important barriers and facilitators to context-dependent pill taking in Uganda were identified through our formative research that helped to inform important revisions to our subsequent intervention. These findings underscore the importance of understanding local barriers and facilitators when designing and planning interventions, particularly when implementing theory-based intervention approaches that have yet to be tested in a new setting.
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Síndrome de Inmunodeficiencia Adquirida , COVID-19 , Infecciones por VIH , Humanos , Uganda , Pandemias , Antirretrovirales/uso terapéutico , Cumplimiento de la Medicación , Infecciones por VIH/tratamiento farmacológico , África del Sur del Sahara , HábitosRESUMEN
BACKGROUND: Nonadherence to antiretroviral therapy (ART) among people living with HIV is a crucial barrier to attaining viral suppression globally. Existing behavioral interventions have successfully increased ART adherence, but typically show only short-term impact that dissipates after the interventions are withdrawn. OBJECTIVE: This study aims to test the feasibility, acceptability, and preliminary efficacy of a novel intervention that uses SMS text messages and conditional incentives to support ART initiators in establishing pill-taking habits. METHODS: A sample of 150 participants aged ≥18 years who have initiated ART in the preceding 3 months will be recruited from Mildmay Uganda in Kampala, Uganda. All (150/150, 100%) participants will be educated on the anchoring strategy and will choose an existing routine to pair with their daily ART adherence from a set of 3 suggested routines: getting dressed in the morning, eating breakfast, or eating dinner. Then, participants will be randomized to receive either usual care (control group: 50/150, 33.3%) or 1 of the 2 interventions delivered over 3 months: daily SMS text message reminders to follow their chosen anchoring plan (messages group; treatment group 1: 50/150, 33.3%) or daily SMS text messages and incentives conditional on taking their ART medication around the time of their chosen anchor (incentives group; treatment group 2: 50/150, 33.3%). Long-term ART adherence will be evaluated for 6 months after the intervention, and survey assessments will be conducted at baseline, 3 months, and 9 months. Outcomes include feasibility and acceptability measures and intervention efficacy outcomes defined by electronically measured mean medication adherence during the intervention and during the 6 months after the intervention, along with a measure of routine ART adherence based on taking medications around the time of participants' anchor during the intervention and during the 6 months after intervention. RESULTS: As of February 18, 2022, recruitment was completed. A total of 150 participants were recruited, and data collection is expected to end in December of 2022. Final results are expected to be submitted for publication by April 2023. CONCLUSIONS: This study is the first to use behavioral economics-based interventions in combination with the anchoring strategy to improve long-term ART adherence among treatment initiators. We hypothesize that the combination of SMS text message reminders and incentives will increase participants' use of their anchoring strategy, and thus medication adherence will be better maintained after the intervention ends in our intervention groups relative to the control group that uses only the anchoring strategy. Results of this pilot study will help to refine this combined intervention approach for testing at scale and broaden our understanding of the habit formation process. TRIAL REGISTRATION: ClinicalTrials.gov NCT05131165; https://clinicaltrials.gov/ct2/show/NCT05131165. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/42216.