What enhancements increase adherence in self-guided, web-based interventions? New study provides insights

Moskowitz, J. T., Addington, E. L., Shiu, E., Bassett, S. M., Schuette, S., Kwok, I., Freedman, M.E., Leykin, Y., Saslow, L. R., Cohn, M. A., & Cheung, E. O. (2023). Facilitator Contact, Discussion Boards, and Virtual Badges as Adherence Enhancements to a Web-Based, Self-guided, Positive Psychological Intervention for Depression: Randomized Controlled Trial. Journal of Medical Internet Research, 23(9), e25922. https://doi.org/10.2196/25922

Summarized by Ariel Ervin

Notes of Interest:

• Although self-guided, web-based interventions can help support people with elevated depressive symptoms, achieving high levels of adherence is difficult.
• Three enhancements were developed to assess whether online discussion boards, facilitator contact (FC), and/or virtual badges (VB) can increase adherence in a self-guided, web-based intervention for depression.
• Participants, on average, accessed 5.61 of the 8 skills available in the intervention.
• People in the combined FC & VB condition accessed more skills than the people in the intervention condition.
• People who receive VB (compared to those who don’t receive it) are predictive of increased adherence of people who had moderately severe depression at baseline.
• Letting participants choose which enhancements they want to access can increase their overall interest and engagement with the program/intervention.
• Given the vast number of technological advances and options researchers have, future studies need to consider more immersive options for web-based interventions.

Introduction (Reprinted from the Abstract)

Background: Adherence to self-guided interventions tends to be very low, especially in people with depression. Prior studies have demonstrated that enhancements may increase adherence, but little is known about the efficacy of various enhancements in comparison to, or in combination with, one another.

Objective: The aim of our study is to test whether 3 enhancements—facilitator contact (FC), an online discussion board (ODB), and virtual badges (VB)—alone, or in combination, improve adherence to a self-guided, web-based intervention for depression. We also examined whether age, gender, race, ethnicity, comfort with technology, or baseline depression predicted adherence or moderated the effects that each enhancement had on adherence.

Methods: Participants were recruited through web-based sources and, after completing at least 4 out of 7 daily emotion reports, were sequentially assigned to 1 of 9 conditions—the intervention alone; the intervention plus 1, 2, or all 3 enhancements; or an emotion reporting control condition. The intervention was a positive psychological program consisting of 8 skills that specifically targeted positive emotions, and it was delivered over 5 weeks in a self-guided, web-based format. We operationalized adherence as the number of skills accessed.

Results: A total of 602 participants were enrolled in this study. Participants accessed, on average, 5.61 (SD 2.76) of 8 skills. The total number of enhancements participants received (0-3) did not predict the number of skills accessed. Participants who were assigned to the VB+FC condition accessed significantly more skills than those in the intervention only conditions. Furthermore, participants in arms that received the combination of both the VB and FC enhancements (VB+FC and VB+FC+online discussion board) accessed a greater number of skills relative to the number of skills accessed by participants who received either VB or FC without the other. Moderation analyses revealed that the receipt of VB (vs no VB) predicted higher adherence among participants with moderately severe depression at baseline.

Conclusions: The results suggested that the VB+FC combination significantly increased the number of skills accessed in a self-guided, web-based intervention for elevated depression. We have provided suggestions for refinements to these enhancements, which may further improve adherence.

Implications (Reprinted from the Discussion)

Web-based, self-guided interventions hold significant promise for people with elevated depressive symptoms. Attaining acceptable levels of adherence to these programs is critical to effectiveness, yet this has proven to be a challenge. We developed and tested 3 enhancements that we hypothesized would, either alone or in combination, improve adherence to a self-guided positive psychological intervention for people with elevated depression. The enhancements were an ODB, VB, and FC. Participants in the eight conditions that received the intervention content also received 1, 2, or all 3 or no enhancements. Our results suggest that the combination of VB and FC is especially impactful and points to areas for future focus to improve adherence across the three enhancements.

For the ODB enhancement, participants had access to an online forum where they could anonymously post questions, share their experiences, and offer encouragement to other participants. Previous findings regarding the efficacy of discussion boards for improving adherence to web-based programs have been mixed. For example, one study found that an internet discussion board or support group resulted in lower adherence to the self-guided program compared with the self-guided program alone [47], although participants who were assigned to receive the discussion board had a greater reduction in depression at 6 months.

The engagement on the discussion board was quite low. Only a quarter of the participants posted on the board at least once, and qualitative feedback indicated that this low level of activity further discouraged participants from making use of the ODB. Therefore, it is perhaps not surprising that there was no indication that the ODB increased adherence to the program, either alone or in combination with other enhancements. Simple availability without engagement is not sufficient for an ODB to increase adherence to the intervention content. There are a number of ways that we could have increased engagement in the ODB, such as requiring participants to post as part of the home practice assignments or making it easier to navigate to the discussion board to lower the barriers to engagement.

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