Adaptive Treatment Research Articles

Prediction of Physical Activity Patterns in Older Patients Rehabilitating After Hip Fracture Surgery: Exploratory Study.

Building up physical activity is a highly important aspect in an older patient's rehabilitation process after hip fracture surgery. The patterns of physical activity during rehabilitation are associated with the duration of rehabilitation stay. Predicting physical activity patterns early in the rehabilitation phase can provide patients and health care professionals an early indication of the duration of rehabilitation stay as well as insight into the degree of patients' recovery for timely adaptive interventions. This study aims to explore the early prediction of physical activity patterns in older patients rehabilitating after hip fracture surgery at a skilled nursing home. The physical activity of patients aged ≥70 years with surgically treated hip fracture was continuously monitored using an accelerometer during rehabilitation at a skilled nursing home. Physical activity patterns were described in our previous study, and the 2 most common patterns were used in this study for pattern prediction: the upward linear pattern (n=15) and the S-shape pattern (n=23). Features from the intensity of physical activity were calculated for time windows with different window sizes of the first 5, 6, 7, and 8 days to assess the early rehabilitation moment in which the patterns could be predicted most accurately. Those features were statistical features, amplitude features, and morphological features. Furthermore, the Barthel Index, Fracture Mobility Score, Functional Ambulation Categories, and the Montreal Cognitive Assessment score were used as clinical features. With the correlation-based feature selection method, relevant features were selected that were highly correlated with the physical activity patterns and uncorrelated with other features. Multiple classifiers were used: decision trees, discriminant analysis, logistic regression, support vector machines, nearest neighbors, and ensemble classifiers. The performance of the prediction models was assessed by calculating precision, recall, and F1-score (accuracy measure) for each individual physical activity pattern. Furthermore, the overall performance of the prediction model was calculated by calculating the F1-score for all physical activity patterns together. The amplitude feature describing the overall intensity of physical activity on the first day of rehabilitation and the morphological features describing the shape of the patterns were selected as relevant features for all time windows. Relevant features extracted from the first 7 days with a cosine k-nearest neighbor model reached the highest overall prediction performance (micro F1-score=1) and a 100% correct classification of the 2 most common physical activity patterns. Continuous monitoring of the physical activity of older patients in the first week of hip fracture rehabilitation results in an early physical activity pattern prediction. In the future, continuous physical activity monitoring can offer the possibility to predict the duration of rehabilitation stay, assess the recovery progress during hip fracture rehabilitation, and benefit health care organizations, health care professionals, and patients themselves.

Transdiagnostic Ecological Momentary Intervention for Improving Self-Esteem in Youth Exposed to Childhood Adversity

Targeting low self-esteem in youth exposed to childhood adversity is a promising strategy for preventing adult mental disorders. Ecological momentary interventions (EMIs) allow for the delivery of youth-friendly, adaptive interventions for improving self-esteem, but robust trial-based evidence is pending. To examine the efficacy of SELFIE, a novel transdiagnostic, blended EMI for improving self-esteem plus care as usual (CAU) compared with CAU only. This was a 2-arm, parallel-group, assessor-blinded, randomized clinical trial conducted from December 2018 to December 2022. The study took place at Dutch secondary mental health services and within the general population and included youth (aged 12-26 years) with low self-esteem (Rosenberg Self-Esteem Scale [RSES] <26) exposed to childhood adversity. A novel blended EMI (3 face-to-face sessions, email contacts, app-based, adaptive EMI) plus CAU or CAU only. The primary outcome was RSES self-esteem at postintervention and 6-month follow-up. Secondary outcomes included positive and negative self-esteem, schematic self-beliefs, momentary self-esteem and affect, general psychopathology, quality of life, observer-rated symptoms, and functioning. A total of 174 participants (mean [SD] age, 20.7 [3.1] years; 154 female [89%]) were included in the intention-to-treat sample, who were primarily exposed to childhood emotional abuse or neglect, verbal or indirect bullying, and/or parental conflict. At postintervention, 153 participants (87.9%) and, at follow-up, 140 participants (80.5%), provided primary outcome data. RSES self-esteem was, on average, higher in the experimental condition (blended EMI + CAU) than in the control condition (CAU) across both postintervention and follow-up as a primary outcome (B = 2.32; 95% CI, 1.14-3.50; P < .001; Cohen d-type effect size [hereafter, Cohen d] = 0.54). Small to moderate effect sizes were observed suggestive of beneficial effects on positive (B = 3.85; 95% CI, 1.83-5.88; P < .001; Cohen d = 0.53) and negative (B = -3.78; 95% CI, -6.59 to -0.98; P = .008; Cohen d = -0.38) self-esteem, positive (B = 1.58; 95% CI, 0.41-2.75; P = .008; Cohen d = 0.38) and negative (B = -1.71; 95% CI, -2.93 to -0.48; P = .006; Cohen d = -0.39) schematic self-beliefs, momentary self-esteem (B = 0.29; 95% CI, 0.01-0.57; P = .04; Cohen d = 0.24), momentary positive affect (B = 0.23; 95% CI, 0.01-0.45; P = .04; Cohen d = 0.20), momentary negative affect (B = -0.33; 95% CI, -0.59 to -0.03, P = .01, Cohen d = -0.27), general psychopathology (B = -17.62; 95% CI, -33.03 to -2.21; P = .03; Cohen d = -0.34), and quality of life (B = 1.16; 95% CI, 0.18-2.13; P = .02; Cohen d = 0.33) across postintervention and follow-up. No beneficial effects on symptoms and functioning were observed. A transdiagnostic, blended EMI demonstrated efficacy on the primary outcome of self-esteem and signaled beneficial effects on several secondary outcomes. Further work should focus on implementing this novel EMI in routine public mental health provision. Dutch Trial Register Identifier:NL7129(NTR7475).

Tools for Urban Climate Adaptation Plans: A Case Study on Bologna and Outcomes for Heat Wave Impact Reduction

The purpose of this paper is to describe the process of building a coherent frame for the identification of local environmental urban vulnerabilities, coping with heat waves’ increasing threats, and adopting specific adaptation policies in the Emilia-Romagna region. A microclimate model (ENVI-met) was used to simulate temperature regimes in five areas of Bologna, providing ex ante maps enabling us to locate the most vulnerable areas. Adaptation measures were suggested with the support of WMO Guidance 1234 and included recommendations about the introduction of high-albedo building materials and nature-based solutions. The step-by-step methodology developed, coupling local vulnerabilities with adaptation recommendation, integrates a scientific methodology into a political decision. The results, allowing us to widely represent this city’s vulnerability, are considered outstanding with respect to supporting the city’s adaptation ambitions and are now part of the running Bologna General Urban Plan (PUG), which regulates building interventions, introducing the obligation for enterprises to respect or ameliorate the microclimate in all the areas in which they intervene. This tool can be replicated and adapted to any municipal area, as it integrates authoritative WMO solutions with accurate microclimate assessment, thus providing locally tailored adaptation interventions. This paper aims to support the vision, shared by both science and policy makers, of transforming cities into widely resilient systems.

A Scoping Review of the Use of Robotics Technologies for Supporting Social-Emotional Learning in Children with Autism.

This scoping review synthesises the current research into robotics technologies for promoting social-emotional learning in children with autism spectrum disorder. It examines the types of robotics technologies employed, their applications, and the gaps in the existing literature. Our scoping review adhered to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) reporting guidelines. The systematic search of relevant databases allowed us to identify studies that use robotics technologies for fostering social, emotional, and cognitive skills in young children with autism. Our review has revealed that various robots, such as Nao, Kaspar, and Zeno, have been used to support the development of social and emotional skills through imitation games, turn-taking, joint attention, emotional recognition, and conversation. As most of these studies were conducted in clinical settings, there is a need for further research in classroom and community-based environments. Additionally, the literature calls for more high-quality longitudinal studies to assess the long-term effectiveness and sustainability of robot-assisted therapy and to assess adaptive and personalised interventions tailored to individual needs. More emphasis is recommended on professional development for educators, parents, and health professionals to incorporate robotics technologies as evidence-based interventions as a pathway for creating inclusive learning environments for children with autism.

Daily Functioning of Veterans With Type 2 Diabetes: Protocol for an Ambulatory Assessment Study.

Diabetes impacts nearly 25% of veterans. Many veterans do not engage in recommended physical activity and other diabetes self-management behaviors. Type 2 diabetes is generally asymptomatic; as such, the long-term consequences of inadequate self-management and benefits of consistent self-management are not salient in the short term. Furthermore, self-management behaviors typically take place outside of medical visits; however, self-management-related factors are only assessed during medical visits, likely missing large amounts of variability. Thus, ambulatory assessment methods such as ecological momentary assessment (EMA), accelerometry, and continuous glucose monitoring are needed to understand the dynamics of daily self-management and identify potential intervention targets. The overarching goal of this study is to understand daily, time-varying factors (comorbid affective symptoms and social context) that influence physical activity, diabetes self-management, glycemic management, daily functioning, and quality of life in participants' natural environments. We are recruiting veterans with type 2 diabetes (target N=100). Participants are required to complete a battery of baseline assessments related to mental health, psychosocial factors, and self-management behaviors. Participants then receive 5 momentary EMA surveys and 1 daily EMA survey per day, in which veterans report comorbid affective symptoms (mood, stress, and pain), social support, social interactions, physical activity, and other self-management behaviors. Momentary surveys are delivered randomly during daily preprogrammed intervals over a 14-day sampling period. Accelerometry and continuous glucose monitoring are also used to assess physical activity and blood glucose, respectively. The first 6 participants also completed interviews assessing their experience in the study and barriers to participation. These test participants informed modifications to the protocol for the remaining participants. The project received funding in April of 2023. Enrollment began in March of 2023 and is planned to be completed in April 2025. Among the 6 test participants, the overall EMA response rate was 87% (range 74%-95%). The response rate for the EMA survey including daily items (67%, range 21%-93%) was lower than the earlier shorter EMA surveys (89%, range 81%-96%). The mean rate of valid accelerometer wear of at least 20 hours per day was 93% (SD 11%), and continuous glucose monitoring data were available for 91% (SD 17%) of days on average. Participants reported few barriers to completing EMA surveys but noted the random timing of questions made it difficult to plan around, and the end-of-day survey was long. Two participants reported survey items reminded or motivated them to engage in diabetes self-management behaviors. Assessment tools developed from this study can inform clinical decision-making by considering barriers to self-management that occur in daily life. Clinical applications include tailored, adaptive technology-supported interventions to improve self-management that provide the right type and amount of support at the right time by adapting to an individual's changing internal and contextual state. DERR1-10.2196/53874.

Is Intrinsic Cardioprotection a Laboratory Phenomenon or a Clinically Relevant Tool to Salvage the Failing Heart?

Cardiovascular diseases, especially ischemic heart disease, as a leading cause of heart failure (HF) and mortality, will not reduce over the coming decades despite the progress in pharmacotherapy, interventional cardiology, and surgery. Although patients surviving acute myocardial infarction live longer, alteration of heart function will later lead to HF. Its rising incidence represents a danger, especially among the elderly, with data showing more unfavorable results among females than among males. Experiments revealed an infarct-sparing effect of ischemic "preconditioning" (IPC) as the most robust form of innate cardioprotection based on the heart's adaptation to moderate stress, increasing its resistance to severe insults. However, translation to clinical practice is limited by technical requirements and limited time. Novel forms of adaptive interventions, such as "remote" IPC, have already been applied in patients, albeit with different effectiveness. Cardiac ischemic tolerance can also be increased by other noninvasive approaches, such as adaptation to hypoxia- or exercise-induced preconditioning. Although their molecular mechanisms are not yet fully understood, some noninvasive modalities appear to be promising novel strategies for fighting HF through targeting its numerous mechanisms. In this review, we will discuss the molecular mechanisms of heart injury and repair, as well as interventions that have potential to be used in the treatment of patients.

Global hotspots of climate change adaptation and mitigation in agriculture

As countries prioritize climate action under the Paris Agreement, determining the overlap in agricultural areas requiring both adaptation and mitigation (A&amp;amp;M) interventions could lead to more efficient use of resources and support for farmers. Here, we identify global priorities for A&amp;amp;M by evaluating global datasets on greenhouse gas (GHG) emissions and climate hazards related to agriculture. We show that joint A&amp;amp;M hotspots cover &amp;lt;23% of global agricultural emissions and include 52% of the areas with significant climate hazards. The major portion of the joint area is croplands (ranging from 213 to 364 Mha), followed by pastures (3–74 Mha), and is concentrated in countries with limited ability to investment in adaptation actions. The most substantial A&amp;amp;M hotspots are situated across South Asia, with smaller areas in South East Asia, Africa, and Latin America. We highlight three findings from this analysis. First, most emissions and climate hazards do not occur in the same agricultural areas, suggesting the need for different strategies to address adaptation and mitigation separately in these areas. Second, in the areas where emissions and climate hazards do overlap, coordinated climate interventions that address emission reductions and adaptation at the same time would be a more effective use of scarce climate action investments. Third, A&amp;amp;M hotspots span national borders, emphasizing the importance of setting priorities and implementing action at regional and international scales. While our analysis highlights that focusing on adaptation and mitigation actions in the agricultural landscapes where they are most needed could help make the best use of climate finance, we recognize the pragmatic and justice-related implications may limit the extent of such prioritization. Balancing these considerations is essential for effective climate finance allocation and equitable climate action outcomes.

Patient perspectives of recovery from myalgic encephalomyelitis/chronic fatigue syndrome: An interpretive description study.

Myalgic encephalomyelitis (ME), also called chronic fatigue syndrome (CFS), is characterised by persistent fatigue, postexertional malaise, and cognitive dysfunction. It is a complex, long-term, and debilitating illness without widely effective treatments. This study describes the treatment choices and experiences of ME/CFS patients who have experienced variable levels of recovery. Interpretive description study consisting of semi-structured qualitative interviews with 33people who met the US Centers for Disease Control (2015) diagnostic criteria for ME/CFS and report recovery or symptom improvement. Twenty-six participants endorsed partial recovery, and seven reported full recovery from ME/CFS. Participants reported expending significant time and energy to identify, implement, and adapt therapeutic interventions, often without the guidance of a medical practitioner. They formulated individualised treatment plans reflecting their understanding of their illness and personal resources. Most fully recovered participants attributed their success to mind-body approaches. Patients with ME/CFS describe independently constructing and managing treatment plans, due to a lack of health system support. Stigmatised and dismissive responses from clinicians precipitated disengagement from the medical system and prompted use of other forms of treatment.

Digital Adaptive Behavioral Interventions to Improve HIV Prevention and Care: Innovations in Intervention Approach and Experimental Design.

Recent advances in digital technologies can be leveraged to adapt HIV prevention and treatment services to the rapidly changing needs of individuals in everyday life. However, to fully take advantage of these technologies, it is critical to effectively integrate them with human-delivered components. Here, we introduce a new experimental approach for optimizing the integration and adaptation of digital and human-delivered behavioral intervention components for HIV prevention and treatment. Typically, human-delivered components can be adapted on a relatively slow timescale (e.g., every few months or weeks), while digital components can be adapted much faster (e.g., every few days or hours). Thus, the systematic integration of these components requires an experimental approach that involves sequential randomizations on multiple timescales. Selecting an experimental approach should be motivated by the type of adaptive intervention investigators would like to develop, and the scientific questions they have about its construction.

Predicting high-risk periods for weight regain following initial weight loss.

The aim of this study was to develop a predictive algorithm of "high-risk" periods for weight regain after weight loss. Longitudinal mixed-effects models and random forest regression were used to select predictors and develop an algorithm to predict weight regain on a week-to-week basis, using weekly questionnaire and self-monitoring data (including daily e-scale data) collected over 40 weeks from 46 adults who lost ≥5% of baseline weight during an initial 12-week intervention (Study 1). The algorithm was evaluated in 22 adults who completed the same Study 1 intervention but lost <5% of baseline weight and in 30 adults recruited for a separate 30-week study (Study 2). The final algorithm retained the frequency of self-monitoring caloric intake and weight plus self-report ratings of hunger and the importance of weight-management goals compared with competing life demands. In the initial training data set, the algorithm predicted weight regain the following week with a sensitivity of 75.6% and a specificity of 45.8%; performance was similar (sensitivity: 81%-82%, specificity: 30%-33%) in testing data sets. Weight regain can be predicted on a proximal, week-to-week level. Future work should investigate the clinical utility of adaptive interventions for weight-loss maintenance and develop more sophisticated predictive models of weight regain.

Examining engagement effects in an adaptive preventive intervention for college student drinking.

This study determined the characteristics of engagement and whether engagement in an adaptive preventive intervention (API) was associated with reduced binge drinking and alcohol-related consequences. Incoming students were recruited for a sequential multiple assignment randomized trial (SMART; N = 891, 62.4% female, 76.8% non-Hispanic White) with an assessment-only control group. The API occurred during the first semester of college, with outcomes assessed at the end of the semester. The API involved two stages. Stage 1 included universal intervention components (personalized normative feedback [PNF] and self-monitoring). Stage 2 bridged heavy drinkers to access additional resources. We estimated the effect of engagement in Stage 1 only and in the whole API (Stages 1 and 2) among the intervention group, and the effect of the API versus control had all students assigned an API engaged, on alcohol-related outcomes. Precollege binge drinking, intention to pledge a fraternity/sorority, and higher conformity motives were most associated with lower odds of Stage 1 engagement. Action (readiness to change) and PNF engagement were associated with Stage 2 engagement. API engagement was associated with significant reductions in alcohol-related consequences among heavy drinkers. Compared to the control, we estimated the API would reduce the relative increase in alcohol-related consequences from baseline to follow-up by 25%, had all API students engaged. Even partial engagement in each component of the "light-touch" API rendered benefits. Analyses suggested that had all students in the intervention group engaged, the API would significantly reduce the change in alcohol-related consequences over the first semester in college. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Feasibility and acceptability of an mHealth app integrating pain-cognitive behavioral therapy and pharmacologic support for patients with advanced cancer.

275 Background: Up to 60% of patients with advanced cancer and chronic pain experience inadequate relief from analgesics. We developed an mHealth app that augments pharmacologic therapy by integrating CBT-based psychological support for patients with cancer pain, and evaluated its feasibility and acceptability. Methods: Patients were recruited from the Dana-Farber Cancer Institute (Boston, MA) and Stephenson Cancer Center (Oklahoma City, OK). Patients were ≥21 years old, diagnosed with an advanced solid tumor or hematologic malignancy, had moderate-to-severe pain (4 or greater on 0-10 scale) that was related to cancer or their cancer treatment, and were using opioids. Exclusion criteria were cognitive impairment, history of opioid use disorder, enrollment in hospice, and acute pain from a recent surgery. App content integrated pain-CBT treatment with pain education and opioid support, and utilized just-in-time adaptive interventions (e.g. algorithm-based advice for pain, stress, and sleep) in response to once daily symptom surveys, including once daily psychoeducational content to support pain self-management. Patients used the app for 2-4 weeks, after which they completed the E-Acceptability scale and semi-structured debriefing interview. Results: Fifteen patients (female=9, mean age=50.3) enrolled on the study and 93% opted to test the app for 28 days (1 patient chose to test the app for 14 days). Patients who tested the app for 28 days completed a median of 18 of the 28 daily surveys (54% total surveys completed). Within patients who tested the app, 11 patients (73%) completed ≥50% of their daily surveys, with 4 (27%) completing ≥75%, and 4 (27%) completing ≤25% of surveys. Overall satisfaction with the app was high (4.43/5-pt Likert scale). Patients also rated the app as understandable (4.93/5) and easy to use (4.57/5-pt Likert scale). In study interviews, many patients reported that the app improved their ability to self-manage their cancer-related pain by facilitating the creation of more intentional pain management routines, and by helping to modify maladaptive thinking patterns allowing them to better cope with their pain. Patients emphasized how salient, clear, and succinct the information was, particularly in the context of coping with stress and pain. Conclusions: The STAMP+CBT app was an acceptable and feasible method to integrate and deliver psychological/behavioral treatment with opioid support to support cancer pain management. Compliance may have been influenced by the app’s notification structure limiting survey engagement to a 45-minute period each day. A future, larger pilot study will further evaluate feasibility and acceptability in patients with advanced cancer. In addition to additional content, the updated version of the app retains notifications but allows patients to return to missed content for 24 hours.

1 Benefits of Speed of Processing Training in Older Adults

Objective:Physical, sensory, and cognitive function are all related to successful aging, quality of life, and independence in older age. Decline in cognitive function, in particular, can create difficulty in many Instrumental Activities of Daily Living such as driving and other aspects of everyday function. Loss of driving competence can subsequently lead to depression, isolation, loss of independence and reduced quality of life. Results from a large randomized controlled trial investigating the long-term impact of Speed of Processing Training will be presented demonstrating the impact of such training on cognitive and everyday function. Speed of Processing Training is an adaptive cognitive intervention administered on a computer that improves visual attention, and has been shown to enhance the connections needed for visual attention using task-driven and resting state fMRI.Participants and Methods:The ACTIVE clinical trial recruited a volunteer sample of 2,832 community dwelling older adults between the ages of 65 and 94 years at six different field sites in six different states. This study evaluated the impact of three cognitive interventions targeted at improving cognitive and everyday function which served as contract control conditions for each other. Participants were randomly assigned to speed of processing training, reasoning training, memory training, or a no-contact control group. Follow-up testing was collected in person for ten years, and at twenty years final archival data was collected from the Departments of Motor Vehicles at each of the six field sites, as well as the Medicare/Medicaid data across the twenty years since enrollment. Outcomes included measures of cognitive function, measures of IADL (including crash involvement and driving cessation), and secondary outcomes of mobility (falls, driving habits, life space), quality of life, mortality and health conditions (from Medicare Records).Results:Results will be presented with respect to everyday function including several longitudinal measures of mobility: number of miles driven per year and driving difficulty, rates of driving cessation, and crash involvement. Random effects modelling, cox proportional hazards, and rate ratios will be presented illustrating the positive impact of cognitive training on these outcome measures. In particular, Speed of Processing Training was found to sustain driving competence with respect to continued driving relative to other types of training, and to reduce the risk of crash involvement over ten years. Furthermore, decline in Speed of Processing was the only cognitive measure predictive of crash involvement longitudinally in the no-contact control group. Positive benefits were also observed for Health Related Quality of Life (HRQoL), and depression.Conclusions:The ACTIVE clinical trial, among other studies, has demonstrated that cognitive training can have long-term positive benefit on the everyday abilities, quality of life, and continued independence of older adults.

Reducing the rate of central line-associated bloodstream infections; a quality improvement project

BackgroundThe burden of central line-associated bloodstream infections is significant and has negative implications for healthcare, increasing morbidity and mortality risks, increasing inpatient hospital stays, and increasing the cost of hospitalization. Efforts to reduce the incidence of central line-associated bloodstream infections have utilized quality improvement projects that implement, measure, and monitor outcomes. However, variations in location, healthcare organization, patient risks, and practice gaps are key to the success of interventions and approaches. This study aims to evaluate interventions of a quality improvement project on the reduction of central line-associated bloodstream infection rates at a university teaching hospital.MethodsThis was a retrospective review of a quality improvement project that was implemented using the Plan-Do-Study-Act quality improvement cycle. Active surveillance of processes and outcomes was performed in the critical care areas; compliance to central line care bundles, and central line-associated bloodstream infections. Interrupted time series was used to analyze trends pre and post-intervention and regression modeling to estimate data segments preceding and succeeding the interventions.ResultsThere were 350 central line insertions, 3912 catheter days, and 20 central line-associated bloodstream infection events during the intervention period. Compliance with central line care bundles was at 94%. There was a trend in the reduction of central line-associated bloodstream infections by 18% that did not reach statistical significance (p = 0.252).ConclusionsImprovement projects to reduce central line-associated bloodstream infections face challenges and complexities associated with implementing interventions in real-world healthcare settings. There is a great need to continuously monitor, evaluate, readjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for non-adherence as keys to achieving desired outcomes.

Improving Supportive and Palliative Care Integration in Adolescent and Young Adult Cancer.

Purpose: Timely supportive and palliative care (SPC) integration in adolescent and young adult (AYA) cancer management is recommended in curative and palliative settings. However, multiple barriers exist to implementing this goal. Liverpool Cancer Therapy Center (LCTC) serviced a growing AYA (15-39 years) population without AYA-dedicated services and the vast majority receiving no SPC engagement. Concerned this was placing AYA patients' wellbeing at risk, we determined a cultural change was required and that the newly established AYA Supportive and Palliative Care (AYASPC) Service could facilitate this. Methods: The AYASPC Service conducted a 6-month quality improvement project aiming to increase its referrals from a baseline average of one per month to four per month, to increase confidence in making SPC referrals and to enhance appreciation for specialized AYA care. Interventions included formalizing an AYASPC referral pathway with broad indications, and educating clinicians on holistic AYA care, the AYASPC Service's model of care (MoC) and AYASPC referral benefits. Results: During the project, 27 AYASPC referrals were made. Referrals consistently exceeded the Service's baseline, and from 3 months onward exceeded the project target. Additionally, referrals were made earlier (29.6% at diagnosis), for a variety of cancer diagnoses with varied prognoses, and for indications beyond traditional issues of complex symptoms and end-of-life care. Clinicians also expressed greater confidence in supporting AYAs and making SPC referrals. Conclusion: In a brief timeframe, the AYASPC Service's innovative and adaptable MoC and project interventions sustainably improved AYASPC access and affected a positive cultural shift around AYA care and advocacy.

Green Climate Fund adaptation's interventions on food security: metrics and health outcomes

Abstract Introduction The Green Climate Fund (GCF) is the largest public climate fund, it claims to use an innovative approach in climate adaptation actions, however, it has faced significant criticism since its inception. 2016-2025 is the Decade of Action on Nutrition and climate change's impact on food security is one of the biggest threats to human health. Current models predict that Africa will be the most affected continent. Food security is a polyhedric concept that requires definitions and indicators to acquire meaning and provide in-field applications. Methods Among the GCF's projects the ones that address the result area “health, food, and water security” in the African countries have been selected. The means of verification (MoV) has been searched in every funding proposal, simplified approval process, and other relevant documents, if not found, were requested to the Fund and local managers. Projects have been divided into ‘International’ or ‘Local’ based on GCF's definitions. The study also sought to identify the food security definition adopted by the Fund and reviewed available food security indicators. Results and discussion 21 projects, amounting to an investment of $887.2 million, met the criteria. National projects accounted for 17% of the investment, while international projects comprised the remaining $733 million. 7 of the 21 projects (circa 40% of the funds invested) did not provide measurable food security outcomes. The majority of the projects provided some measurable outcome but it is rarely possible to know how this will be measured, as only 3 projects, all from the World Food Program (WFP), declared their MoVs. The GCF seems to not adopt a clear definition of food security. The WFP's indicators, while validated for caloric adequacy, are not consistently validated for micronutrient deficiencies and other health outcomes. Conclusions Insufficient information on monitoring and evaluation may raise further concerns about the GCF's governance. Key messages • Food security is a poliedric concept that requires defintions and indicators to acquire meaning and provide in-field applications, evaluation processes are essential to detect real adaptation. • The Green Climate Fund is the largest public climate fund, it claims to use an innovative approach in climate adaptation actions but it seems to lack robust monitoring and evaluation processes.

Co-producing a culturally sensitive storytelling intervention with Nepalese migrant workers

Abstract Background Labour migration is an increasingly important contributing factor to Nepal's economy; remittance from migrants abroad contribute to quarter of Nepal's gross domestic product. However, this income comes at a great cost; nearly 1,000 Nepalese migrant workers (NMWs) die every year in Gulf States and Malaysia. This interdisciplinary study informs the co-production of a culturally adaptive storytelling intervention to support the mental health and wellbeing of NMWs. Methods We focused on outgoing and returnee adult NMWs in the GCC countries. The study was conducted in Dhading district, Nepal and involved three different but interconnected phases; 1. a systematic review and a mixed methods study exploring health and wellbeing issues of NMWs (both studies already published, available online); 2. exploration, and analysis of Nepalese literature relevant to contemporary migration (n = 49); and 3. co-development of storytelling intervention working together with a co-production group (n = 12). Results Findings from phase one and two showed that NMWs suffer from various health and wellbeing issues (mental health, physical health including workplace hazard, abuse, and exploitation). Themes identified from the Nepalese literature centred around hopelessness, helplessness, and separation. Based on these findings, a culturally sensitive storytelling intervention was co-produced to support the mental health and wellbeing of NMWs in GCC countries. The intervention video includes an animated story centred around the struggles of an archetypal male migrant worker and their use of coping strategies for dealing with adversities. Conclusions Our study suggests that co-production of storytelling intervention provides shared spaces for migrant workers to engage, imagine and participate as communities. The process also helps to redistribute power and redress top-down modes of working that may undermine and devalue the stories of marginalised groups. Key messages • Co-production of storytelling intervention provides shared spaces to engage, imagine and participate as communities. • Co-production helps to redistribute power and redress top-down modes of working that may undermine and devalue the stories of marginalised groups.

A Trauma-Informed, Geospatially Aware, Just-in-Time Adaptive mHealth Intervention to Support Effective Coping Skills Among People Living With HIV in New Orleans: Development and Protocol for a Pilot Randomized Controlled Trial.

In 2020, Greater New Orleans, Louisiana, was home to 7048 people living with HIV-1083 per 100,000 residents, 2.85 times the US national rate. With Louisiana routinely ranked last in indexes of health equity, violent crime rates in Orleans Parish quintupling national averages, and in-care New Orleans people living with HIV surviving twice the US average of adverse childhood experiences, accessible, trauma-focused, evidence-based interventions (EBIs) for violence-affected people living with HIV are urgently needed. To meet this need, we adapted Living in the Face of Trauma, a well-established EBI tailored for people living with HIV, into NOLA GEM, a just-in-time adaptive mobile health (mHealth) intervention. This study aimed to culturally tailor and refine the NOLA GEM app and assess its acceptability; feasibility; and preliminary efficacy on care engagement, medication adherence, viral suppression, and mental well-being among in-care people living with HIV in Greater New Orleans. The development of NOLA GEM entailed identifying real-time tailoring variables via a geographic ecological momentary assessment (GEMA) study (n=49; aim 1) and place-based and user-centered tailoring, responsive to the unique cultural contexts of HIV survivorship in New Orleans, via formative interviews (n=12; aim 2). The iOS- and Android-enabled NOLA GEM app leverages twice-daily GEMA prompts to offer just-in-time, in-app recommendations for effective coping skills practice and app-delivered Living in the Face of Trauma session content. For aim 3, the pilot trial will enroll an analytic sample of 60 New Orleans people living with HIV individually randomized to parallel NOLA GEM (intervention) or GEMA-alone (control) arms at a 1:1 allocation for a 21-day period. Acceptability and feasibility will be assessed via enrollment, attrition, active daily use through paradata metrics, and prevalidated usability measures. At the postassessment time point, primary end points will be assessed via a range of well-validated, domain-specific scales. Care engagement and viral suppression will be assessed via past missed appointments and self-reported viral load at 30 and 90 days, respectively, and through well-demonstrated adherence self-efficacy measures. Aims 1 and 2 have been achieved, NOLA GEM is in Beta, and all aim-3 methods have been reviewed and approved by the institutional review board of Tulane University. Recruitment was launched in July 2023, with a target date for follow-up assessment completion in December 2023. By leveraging user-centered development and embracing principles that elevate the lived expertise of New Orleans people living with HIV, mHealth-adapted EBIs can reflect community wisdom on posttraumatic resilience. Sustainable adoption of the NOLA GEM app and a promising early efficacy profile will support the feasibility of a future fully powered clinical trial and potential translation to new underserved settings in service of holistic survivorship and well-being of people living with HIV. ClinicalTrials.gov NCT05784714; https://clinicaltrials.gov/ct2/show/NCT05784714. PRR1-10.2196/47151.

Identifying Design Opportunities for Adaptive mHealth Interventions That Target General Well-Being: Interview Study With Informal Care Partners.

Mobile health (mHealth) interventions can deliver personalized behavioral support to users in daily contexts. These interventions have been increasingly adopted to support individuals who require low-cost and low-burden support. Prior research has demonstrated the feasibility and acceptability of an mHealth intervention app (CareQOL) designed for use with informal care partners. To further optimize the intervention delivery, we need to investigate how care partners, many of whom lack the time for self-care, react and act in response to different behavioral messages. The goal of this study was to understand the factors that impact care partners' decision-making and actions in response to different behavioral messages. Insights from this study will help optimize future tailored and personalized behavioral interventions. We conducted semistructured interviews with participants who had recently completed a 3-month randomized controlled feasibility trial of the CareQOL mHealth intervention app. Of the 36 participants from the treatment group of the randomized controlled trial, 23 (64%) participated in these interviews. To prepare for each interview, the team first selected representative behavioral messages (eg, targeting different health dimensions) and presented them to participants during the interview to probe their influence on participants' thoughts and actions. The time of delivery, self-reported perceptions of the day, and user ratings of a message were presented to the participants during the interviews to assist with recall. The interview data showed that after receiving a message, participants took various actions in response to different messages. Participants performed suggested behaviors or adjusted them either immediately or in a delayed manner (eg, sometimes up to a month later). We identified 4 factors that shape the variations in user actions in response to different behavioral messages: uncertainties about the workload required to perform suggested behaviors, concerns about one's ability to routinize suggested behaviors, in-the-moment willingness and ability to plan for suggested behaviors, and overall capability to engage with the intervention. Our study showed that care partners use mHealth behavioral messages differently regarding the immediacy of actions and the adaptation to suggested behaviors. Multiple factors influence people's perceptions and decisions regarding when and how to take actions. Future systems should consider these factors to tailor behavioral support for individuals and design system features to support the delay or adaptation of the suggested behaviors. The findings also suggest extending the assessment of user adherence by considering the variations in user actions on behavioral support (ie, performing suggested or adjusted behaviors immediately or in a delayed manner). RR2-10.2196/32842.

Small Steps over time: A longitudinal usability test of an automated interactive text messaging intervention to support self-management of depression and anxiety symptoms

BackgroundDigital mental health interventions (DMHIs) offer potential solutions for addressing mental health care gaps, but often suffer from low engagement. Text messaging is one promising medium for increasing access and sustaining user engagement with DMHIs. This paper examines the Small Steps SMS program, an 8-week, automated, adaptive text message-based intervention for depression and anxiety. MethodsWe conducted an 8-week longitudinal usability test of the Small Steps SMS program, recruiting 20 participants who met criteria for major depressive disorder and/or generalized anxiety disorder. Participants used the automated intervention for 8 weeks and completed symptom severity and usability self-report surveys after 4 and 8 weeks of intervention use. Participants also completed individual interviews to provide feedback on the intervention. ResultsParticipants responded to automated messages on 70 % of study days and with 85 % of participants sending responses to messages in the 8th week of use. Usability surpassed established cutoffs for software that is considered acceptable. Depression symptom severity decreased significantly over the usability test, but reductions in anxiety symptoms were not significant. Participants noted key areas for improvement including addressing message volume, aligning message scheduling to individuals' availability, and increasing the customizability of content. LimitationsThis study does not contain a control group. ConclusionsAn 8-week automated interactive text messaging intervention, Small Steps SMS, demonstrates promise with regard to being a feasible, usable, and engaging method to deliver daily mental health support to individuals with symptoms of anxiety and depression.