Negative Consequences Of Drug Use Research Articles

The family and substance abuser in the mental health institution environment

Background: South African drug usage demographics are rare. Substance abuse disorder patients and their families have complex interactions. This study examines family members living with drug addict.Aim: The study seeks to investigate the experiences of family members living with a substance use disorder (SUD) individual.Setting: The research took place in a Gqeberha psychiatric facility. Low-income households were interviewed.Methods: This research is qualitative, exploratory, and descriptive study. Recorded and transcribed in-depth patient family interviews were collected. Qualitative thematic analysis was used to analyse data. The data themes were interpreted using family systems theory.Results: Each of the three main themes has subthemes. The first theme concerns family members’ inadequate comprehension of addiction. The subtheme explores family members’ denial and failure to recognize substance use disease symptoms. The second theme concerns variations in behaviour that challenge cultural norms. This subtheme addresses hallucinations, delusions, and fury in SUD patients. The third theme addresses the negative effects of drug use on families, potentially leading to divorce. This subtheme focuses on the family’s lack of awareness of resources that may have supported them and the SUD individual.Conclusion: Immediate family members are crucial to patient recovery. The family seemed to be struggling living with an SUD relative. Experts should help the family to manage the addict’s treatment. Healthcare education can help families cope with substance abusers.Contribution: This study will assist the nursing administration in discovering ways to help families manage a loved one with an SUD.

Understanding the Mechanisms of Action and Effects of Drugs of Abuse.

Drug abuse and addiction are major public health concerns, with millions of people worldwide affected by the negative consequences of drug use. To better understand this complex issue, a review was conducted to examine the mechanisms of action and effects of drugs of abuse, including their acute and chronic effects, the symptoms of abstinence syndrome, as well as their cardiovascular impacts. The analyzed data were obtained after surveying an electronic database, namely PubMed, with no time limit, grey literature sources, and reference lists of relevant articles. The review highlights the different categories of drugs of abuse, such as opioids, stimulants, depressants, hallucinogens, and cannabis, and discusses the specific ways that each drug affects the brain and body. Additionally, the review explores the short-term and long-term effects of drug abuse on the body and mind, including changes in brain structure and function, physical health problems, and mental health issues, such as depression and anxiety. In addition, the review explores the effects of drug abuse on cardiovascular health, focusing on electrocardiogram changes. Moreover, the analysis of relevant literature also highlighted possible genetic susceptibility in various addictions. Furthermore, the review delves into the withdrawal symptoms that occur when someone stops using drugs of abuse after a period of chronic use. Overall, this review provides a comprehensive overview of the current state of knowledge on drug abuse and addiction. The findings of this review can inform the development of evidence-based prevention and intervention strategies to address this critical public health issue.

The Opioid Crisis

The opioid crisis has become one of the most pressing public health issues in recent times, with devastating consequences for individuals, families, and communities. As per the Center for Disease Control and Prevention (CDC), nearly 500,000 people in the United States have died from opioid overdose between 1999 and 2019 [1]. The current opioid epidemic is a multifaceted problem that demands comprehensive and integrated strategies to address it effectively.
 One of the key approaches to address the opioid crisis is harm reduction, which involves reducing the negative consequences of drug use for individuals, families, and communities. Harm reduction strategies include the provision of naloxone to reverse overdoses, access to clean syringes, and testing for infectious diseases such as HIV and hepatitis C. However, harm reduction approaches are often criticized for being permissive and promoting drug use. Still, evidence suggests that harm reduction strategies can be effective in reducing harm and improving health outcomes.
 Another critical strategy to address the opioid crisis is promoting recovery, which involves supporting individuals in their journey towards sobriety and wellness. Recovery-oriented systems of care aim to provide comprehensive, person-centered, and evidence-based interventions to support individuals with substance use disorders. This includes medication-assisted treatment, counseling, peer support, and community-based resources. Promoting recovery requires a long-term commitment and a collaborative effort from healthcare providers, policymakers, and communities to ensure that individuals receive the support they need to achieve their recovery goals [2].
 In conclusion, addressing the opioid crisis requires a multi-pronged approach that integrates harm reduction and recovery-oriented strategies. While preventing opioid misuse and addiction is a key priority, it is equally important to ensure that individuals who are already struggling with substance use disorders receive the necessary support to recover and rebuild their lives. Through collaborative efforts and evidence-based interventions, we can work towards reducing harm, promoting recovery, and improving the overall health and well-being of our communities.

The Impact of Decriminalizing Enhancement Drugs on Society

The decriminalization of enhancement drugs has had a major impact on society. These drugs, which are designed to increase physical and mental performance, have become increasingly popular among athletes and other individuals seeking an edge in their chosen field. Decriminalizing these substances has allowed for more open discussion about their use and potential benefits while also removing the stigma associated with them as well as any legal ramifications that may have been attached previously. This shift in attitude towards enhancement drug use is likely to lead to increased research in the area, leading to a better understanding of how they work and what effects they can produce when used responsibly. In this opinion, I briefly discuss topics related to the criminalization of enhancement drugs. First, I investigate the question, “What is an enhancement drug?” using my own research. Second, I explore how drug use is regulated. Finally, I situate these debates in relation to calls for drug decriminalization. The regulation of drug use is a complex issue that involves legal, social, and health considerations. Decriminalization has been proposed to address the negative consequences of drug use and reduce the harms associated with criminalization. I conclude by exploring the potential implications of decriminalization for society and discuss the need for further research in this field.

Cocaine and stimulants, the challenge of self-regulation in a harm reduction perspective

A significant body of research on cocaine users recruited outside the “captive” populations (i.e. studies from samples of users who have not been enrolled through drug addiction services) has been carried out in many European countries and outside Europe. These studies show a variety of patterns and trajectories of use other than “addictive” use. The reason of most “controlled” use lies in a wide set of self-regulation “rules” users “naturally” apply to keep drug use at bay and prevent the disruption of everyday life. Not only is this perspective at odds with the “pathological” perspective of professionals, focused as this is on “addiction” originated from the chemical properties of drugs and individual psychological deficit; it also challenges the social representation of drugs as intrinsically “out of control” substances and of drug users’ helplessness under the influence of drugs.The paper describes the workstream Innovative cocaine and poly-drug abuse prevention programme, developed in 2013 by the Italian NGO Forum Droghe within the European project New Approaches in Drug Policy &Interventions (NADPI), aimed at linking findings from research on “controls” to operational models in drug addiction services. Through a critical overview of the disease model and taking cues from users’ self regulation strategies, a new “self regulation” operational model has been developed, focused on users’ control abilities; and on social context and setting of use, following the drug/set/setting paradigm. The self regulation model may be seen as a development of the Harm Reduction approach to drug policies, aimed at decreasing the negative consequences of drug use without necessarily reducing the consumption of drugs.

Sex-dependent effects of chronic stress on punished cocaine self-administration and cue-induced relapse to cocaine seeking

We tested the effects of chronic stress on cocaine relapse after drug-reinforced responding was suppressed by punishment, an animal model of human relapse after self-imposed abstinence due to the negative consequences of drug use. Male rats displayed greater resistance to punishment than females, but daily stress decreased this resistance. Only female rats with a history of chronic stress displayed increased responding for cocaine cues from abstinence Day 1 to Day 8. Thus, the effects of chronic stress on punished cocaine self-administration and cue-induced relapse are dependent on biological sex, and may have implications for more targeted treatments for cocaine addiction.

At the Intersection of Harm Reduction and COVID-19: The Role of Anthropologists during and Post-Pandemic

Harm reduction is a public health approach that emphasizes reducing the negative effects of drug use rather than eliminating it. It has been practiced for decades; however, the COVID-19 pandemic poses new challenges for people who use drugs (PWUD) and harm reduction providers. In the United States, public health recommendations to curb the pandemic are complicating harm reduction efforts. Harm reduction programs are rethinking how they engage with PWUD to comply with these recommendations while also providing essential services. In this article, we draw on academic literature, news articles, and information distributed by harm reduction programs to discuss issues currently faced by PWUD and harm reduction providers across the country. This discussion focuses on policy changes and programming adaptations related to three harm reduction interventions—syringe services programs, overdose prevention, and medications for opioid use disorder—that have emerged or gained traction during the pandemic. We argue that anthropologists should play a key role in addressing the obstacles and opportunities for harm reduction in the United States during and post-pandemic. Ethnographic research can generate important knowledge of how pandemic-related service and policy changes are localized by providers and experienced by PWUD and uncover how race, class, and gender may shape access to and experiences with modified harm reduction services. Applied anthropologists also have an important role in collaborating with harm reduction programs to ensure that the voices of marginalized individuals are not ignored as policy and programming changes take place during and after the pandemic.

Possessing Drugs, Possessing Rights: Harm Reduction and Drug Policy Reform in Argentina

Argentina’s national drug law, Law 23.737, has been in effect since 1989. Based on prohibitionist drug policy, this law was intended to severely punish drug traffickers and protect the public from drug use-related health concerns. However, it has failed to achieve these goals, and instead targets people who use drugs (PWUD) and brands them “criminals.” In response, the Argentine government announced its intent to reform Law 23.737 in 2008, sparking widespread debate among health, legal, and social service professionals. This article discusses this debate from the perspective of harm reductionists, those who work to reduce the negative effects of drug use rather than eliminate drug use or ensure abstinence. Drawing on archival research and 16 months of ethnographic fieldwork in Argentina, this article examines the positionality of harm reductionists in this drug policy reform, particularly the controversial proposal to decriminalize drug possession for personal use. Demonstrating their contention that Argentina’s legal apparatus is a major contributor to PWUD’s discrimination, stigmatization, and isolation from health and social services, I argue that challenging these problems through policy engagement allows Argentine harm reductionists to draw attention to the broader question of PWUD’s rights and to ultimately recast PWUD as rights-bearing citizens.

Animal Models of Drug Relapse and Craving after Voluntary Abstinence: A Review.

Relapse to drug use during abstinence is a defining feature of addiction. During the last several decades, this clinical scenario has been studied at the preclinical level using classic relapse/reinstatement models in which drug seeking is assessed after experimenter-imposed home-cage forced abstinence or extinction of the drug-reinforced responding in the self-administration chambers. To date, however, results from studies using rat relapse/reinstatement models have yet to result in Food and Drug Administration-approved medications for relapse prevention. The reasons for this state of affairs are complex and multifaceted, but one potential reason is that, in humans, abstinence is often self-imposed or voluntary and occurs either because the negative consequences of drug use outweigh the drug's rewarding effects or because of the availability of nondrug alternative rewards that are chosen over the drug. Based on these considerations, we and others have recently developed rat models of relapse after voluntary abstinence, achieved either by introducing adverse consequences to drug taking (punishment) or seeking (electric barrier) or by providing mutually exclusive choices between the self-administered drug and nondrug rewards (palatable food or social interaction). In this review, we provide an overview of these translationally relevant relapse models and discuss recent neuropharmacological findings from studies using these models. We also discuss sex as a biological variable, future directions, and clinical implications of results from relapse studies using voluntary abstinence models. Our main conclusion is that the neuropharmacological mechanisms controlling relapse to drug seeking after voluntary abstinence are often different from the mechanisms controlling relapse after home-cage forced abstinence or reinstatement after extinction. SIGNIFICANCE STATEMENT: This review describes recently developed rat models of relapse after voluntary abstinence, achieved either by introducing adverse consequences to drug taking or seeking or by providing mutually exclusive choices between the self-administered drug and nondrug rewards. This review discusses recent neuropharmacological findings from studies using these models and discusses future directions and clinical implications.

Illicit Drug Use and Associated Problems in the Nightlife Scene: A Potential Setting for Prevention.

Illicit drug use is prevalent in the nightlife scene, especially at electronic dance music (EDM) events. The aim of the present study was to investigate illicit drug use patterns and consequences of drug use among frequent visitors of EDM events. Young adults (18–34 years old) who had visited at least six EDM events in Sweden during the past year participated in a web-based survey on drug use patterns and its consequences. Fifty-nine percent of participants had used illicit drugs during the past year, most often cannabis followed by ecstasy, cocaine, and amphetamine. Nightlife venues were identified as the main setting for the use of central stimulants, while cannabis was mostly used at home. Frequent alcohol and tobacco use was associated with illicit drug use. The most prevalent negative consequences of drug use were related to mental health, such as impairments in mood, sleep, and memory problems, but physical manifestations were also reported, such as palpitations and collapsing. These findings confirm that drug use is prevalent and associated with negative health effects among EDM nightlife attendees. The nightlife scene is a setting with promising potential to reach a high-risk target group with illicit drug use prevention interventions.

Rapid evidence review of harm reduction interventions and messaging for people who inject drugs during pandemic events: implications for the ongoing COVID-19 response

BackgroundPeople who inject drugs are at increased health risk in a pandemic due to their greater susceptibility to severe disease and as a consequence of the restrictions put in place to halt the spread of infection. Harm reduction (HR) services, which aim to reduce the negative effects of drug use on health, are likely to be diminished in a pandemic. However, innovative HR interventions and messaging may also develop in response to such a crisis. It is vital to understand the most effective ways to deliver HR in pandemic situations so that guidance can be provided for current and future disruptions to service provision.MethodsA rapid evidence review was conducted with the aim of exploring what HR interventions and messaging are most effective during a pandemic-type situation. Ten health databases were systematically searched using terms relevant to the research aim. A search was also made of grey literature, including a targeted search of HR messaging from key national and service provider websites.ResultsIn the initial search, 121 pieces of evidence were identified which, after screening and de-duplication, resulted in 60 for inclusion. The included evidence consists mainly of non-peer reviewed, pre-publication or expert opinion pieces. The rapid findings suggest that HR services should be deemed essential during a pandemic, with staff supported to work safely and social distancing adaptations implemented. Services should be encouraged to operate more flexibly; for instance, in deciding the amounts of take-home supplies of injecting equipment and medications. The evidence on HR communication was very limited but key messages on infection control, uncertain drug supply and accessing services were identified.ConclusionsThis rapid evidence review identifies implications for national policy makers, commissioners and HR service providers. A person-centred rather than disease-centred approach to HR delivered by collaborating partners, as well as prioritizing tailored HR messaging, is recommended. Further research evaluating the delivery of HR services and messaging, particularly focusing on health inequalities, is urgently needed.

Knowledge, Awareness, And Practices Among Persons Who Use Drugs (Pwuds) In The Community-Based Rehabilitation Program

The purpose of this study is to assess the level of knowledge on illegal drugs and substance awareness on the negative effects of drug use, and practices of the Persons Who Use Drugs (PWUDs) who joined the community - based rehabilitation program in CY 2018-2019. The participants of the study were the 140 “tokhang responders” who voluntarily surrendered and recorded in the PNP and City Health Office of Valencia City for the screening and rehabilitation. Moreover, this covered the ­­­­­31 barangays of Valencia City, Bukidnon. The study utilized the descriptive-correlational and causal research design. Majority of the PWUDs are middle and young adults, male, with 5,000 and below income, and mostly reached high school level. The participants have high knowledge on the harmful effects of illegal drugs to the body. In contrast, they have moderate knowledge on damage to their health if used minimally. The drug increases pleasure to their lives. The participants are moderately aware on the negative effects of illegal drug use. The PWUDs who joined the community - based rehabilitation have primary care physicians since the program was monitored by the City Health Office. They have clear sense of themselves after the program. The least practiced activities are online support groups, no insurance, and active plans for lingering health problems. There is a significant relationship between the knowledge, awareness, and practices of the PWUDs. Knowledge is the single best predictor of practices of PWUDs. Keywords : illegal drugs, tokhang responders, harmful effects, online support groups, active plans

Purpose and mastery as predictors of perceived health and substance use problems.

We explored whether purpose in life and mastery predicted perceived physical health and problematic substance use among a sample of emerging adults who reported ever using alcohol or drugs. We examined perceived stress and coping as potential mediators of these associations and explored whether parental support moderated any of these associations. In a sample of emerging adults from across the United States (N = 2,564; M age = 20.87, standard deviation = 1.75; 49.6% male), purpose in life and mastery were associated with better-perceived health and fewer negative consequences of drug use via lower perceived stress and coping. In addition, parental support modified the relationship between purpose in life and stress and coping. The findings suggest potential health benefits associated with a greater purpose in life and mastery and indicate that parental support may enhance these associations.

Medical multimorbidity and drug use among adults in the United States.

Adults with medical multimorbidity (≥2 chronic conditions) present challenges for health care systems to provide coordinated care. Substance use can complicate the management of chronic medical conditions, but little research has focused on the intersection of medical multimorbidity and substance use. This study uses cross-sectional analysis of 115,335 adult respondents of the 2012–2014 administrations of the National Survey on Drug Use and Health to estimate the prevalence and correlates of past-year drug use among adults with multimorbidity. The prevalence of past-year drug use was compared between individuals reporting 0, 1, and ≥2 chronic medical conditions. We used multivariable logistic regression to determine correlates of past-year drug use among adults with ≥2 chronic medical conditions. 53.1% reported no chronic conditions, 29.5% reported one chronic condition, and 17.4% reported ≥2 chronic conditions. Past-year drug use was reported by 18.3% of those with no chronic conditions, 14.8% with 1 chronic condition, and 11.6% with ≥2 chronic conditions. Cannabis and opioid analgesics (nonmedical use) were the most common drugs used across all three groups. In the adjusted model, among adults with medical multimorbidity, adults with past-year drug use were more likely to be younger, male, have lower income, and report current tobacco use, alcohol dependence, past-year depression, and having received mental health treatment in the past year. In this national cohort, fewer adults with multimorbidity reported substance use compared to adults with no or one chronic condition, however, this population with high multimorbidity may be particularly vulnerable to the negative effects of drug use.

Estimation of Intravenous Drug Users' Population in Kermanshah City, West of Iran in 2016 using Capture-recapture Method.

Drug abuse, particularly intravenous drug use, is one of the most common challenges in human communities so that its negative impact on economic and cultural conditions of society and physical as well as mental health of individuals is evident. We aimed to estimate the IDUs' population in Kermanshah City, West of Iran using Capture-recapture method. A Cross-sectional study. The data in this study were collected from three different sources: Drop in Centers (DICs), Out Reach Teams (ORTs) and Methadone Maintenance Treatment centers (MMTs) in Kermanshah City from Mar 2015 until Mar 2016, and then indirect Capture-recapture was used to estimate the IDUs' population. The number of IDUs registered in DICs, ORTs, and MMTs were 694, 731, and 156 cases, respectively. Having determined the commonalities and removing duplicates, the number of drug users registered were 1,375 cases, after analysis of data, the number of drug users not registered in any center was estimated as 2,042 (95% CI: 1708, 2444). By counting 1,375 cases recorded in these sources, the total number of injection drug users in the Kermanshah City was about 3,417 people, (95% CI: (3083, 3819). The prevalence of IDUs in Kermanshah City is high, which could cause severe economic and social problems in the society. To reduce the negative effects of drug use, awareness and measuring of the drug users population, seem to be necessary overtime.

Diagnostic accuracy of a two-item Drug Abuse Screening Test (DAST-2)

ObjectiveDrug use is prevalent and costly to society, but individuals with drug use disorders (DUDs) are under-diagnosed and under-treated, particularly in primary care (PC) settings. Drug screening instruments have been developed to identify patients with DUDs and facilitate treatment. The Drug Abuse Screening Test (DAST) is one of the most well-known drug screening instruments. However, similar to many such instruments, it is too long for routine use in busy PC settings. This study developed and validated a briefer and more practical DAST for busy PC settings. MethodWe recruited 1300 PC patients in two Department of Veterans Affairs (VA) clinics. Participants responded to a structured diagnostic interview. We randomly selected half of the sample to develop and the other half to validate the new instrument. We employed signal detection techniques to select the best DAST items to identify DUDs (based on the MINI) and negative consequences of drug use (measured by the Inventory of Drug Use Consequences). Performance indicators were calculated. ResultsThe two-item DAST (DAST-2) was 97% sensitive and 91% specific for DUDs in the development sample and 95% sensitive and 89% specific in the validation sample. It was highly sensitive and specific for DUD and negative consequences of drug use in subgroups of patients, including gender, age, race/ethnicity, marital status, educational level, and posttraumatic stress disorder status. ConclusionsThe DAST-2 is an appropriate drug screening instrument for routine use in PC settings in the VA and may be applicable in broader range of PC clinics.

No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone

IntroductionSome fear that distribution of naloxone to persons at risk of experiencing an opioid overdose may reduce the perceived negative consequences of drug use, leading to riskier patterns of use. This study assessed whether participation in naloxone/overdose training altered drug use frequency, quantity or severity among heroin users in and out of treatment. MethodsClinical interviews were performed assessing patterns of heroin and other drug use prior to, and at multiple timepoints after overdose education and naloxone training. This study compared baseline drug use to that at 1 and 3months post training. ResultsBoth current heroin users (n=61) and former users in agonist maintenance (n=69) typically showed decreases in heroin and polydrug use at both 1 and 3months after training. The Addiction Severity Index drug composite score also decreased at follow up. ConclusionsThis analysis found no evidence of compensatory drug use following naloxone/overdose training among two groups of heroin users. These findings support the acceptance and expansion of naloxone distribution to at-risk populations and may assist in allaying concerns about the potential for unintended negative consequences on drug use.

A Brief High School Prevention Program to Decrease Alcohol Usage and Change Social Norms

This study assessed the effectiveness of Refuse, Remove, Reasons (RRR), a universal classroom-based substance abuse prevention program for urban and suburban high school students. A total of 1,352 adolescents were part of either a treatment (n = 678) or a comparison group (n = 674). The study evaluated the influence of implementing RRR in decreasing alcohol use, increasing perceived risk of drug use, decreasing social norms drug use, and increasing perceptions about negative consequences of drug use. Participants were assessed at baseline and treatment exit. One-way between-groups analyses of covariances were used to detect significant differences between treatment and comparison groups, using the pretest as a covariate. Findings indicated that RRR significantly reduced getting drunk from alcohol, decreased social norms and acceptance of alcohol and cigarettes, and increased perceptions about negative consequences of drug use for the treatment group compared with the comparison group. Results support school-based prevention models for reducing alcohol use and changing social norms for high school youths.

Regulation of cocaine craving by cognitive strategies in an online sample of cocaine users.

Emphasis on the negative consequences of drug use is a critical component of cognitive-behavioral therapy (CBT) skills to regulate craving. Despite the relative success of CBT for treating substance use disorders, effective human laboratory models of CBT are lacking. Recent reports have indicated that the regulation of craving (ROC) task provides a valid model of craving regulation for nicotine, alcohol, and methamphetamine use. The present study examined ROC in an online sample of regular cocaine users (n = 44) recruited from Amazon.com's Mechanical Turk. In the ROC task, cognitive regulation strategies were manipulated by instructing participants to think about either the positive or negative consequences of consuming cocaine. Participants were then presented with cocaine images while engaging in each cognitive regulation strategy and asked to report current craving that was then compared to neutral look conditions. Food images served as a control. A cocaine purchase task was also completed to assess economic demand for cocaine and its relationship with cocaine craving. The use of negative appraisal strategies that model those used in CBT significantly attenuated craving for cocaine. Cocaine craving was also stimulus-specific, with greater smoked cocaine craving reported by individuals with a history of smoked cocaine use. This online extension of the ROC task provides converging evidence for its use as a model of CBT cocaine-craving regulation. Futures studies can use this model to examine the mechanisms underlying the effectiveness of CBT for cocaine use and the relationship between craving regulation and drug-use behavior. (PsycINFO Database Record

Process evaluation of a technology-delivered screening and brief intervention for substance use in primary care

Psychotherapy process research examines the content of treatment sessions and their association with outcomes in an attempt to better understand the interactions between therapists and clients, and to elucidate mechanisms of behavior change. A similar approach is possible in technology-delivered interventions, which have an interaction process that is always perfectly preserved and rigorously definable. The present study sought to examine the process of participants' interactions with a computer-delivered brief intervention for drug use, from a study comparing computer- and therapist-delivered brief interventions among adults at two primary health care centers in New Mexico. Specifically, we sought to describe the pattern of participants' (N=178) choices and reactions throughout the computer-delivered brief intervention, and to examine associations between that process and intervention response at 3-month follow-up. Participants were most likely to choose marijuana as the first substance they wished to discuss (n=114, 64.0%). Most participants indicated that they had not experienced any problems as a result of their drug use (n=108, 60.7%), but nearly a third of these (n=32, 29.6%) nevertheless indicated a desire to stop or reduce its use; participants who did report negative consequences were most likely to endorse financial or relationship concerns. However, participant ratings of the importance of change or of the helpfulness of personalized normed feedback were unrelated to changes in substance use frequency. Design of future e-interventions should consider emphasizing possible benefits of quitting rather than the negative consequences of drug use, and—when addressing consequences—should consider focusing on the impacts of substance use on relationship and financial aspects. These findings are an early but important step toward using process evaluation to optimize e-intervention content.