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      • Record: found
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      Is Open Access

      A Systematic Review of the Impact of Adherence on the Effectiveness of e-Therapies

      research-article
      Author(s): , BSC, MSc 1 , , , PhD 2 , , BA(Hons), Dpsych(Neuro) 1 , , MB ChB, PhD 3 , , MD, FRANZCP 1 , , MBBS, FRANZCP, PhD 1 , 4
      Editor(s):
      Other contributor(s): (Reviewer), (Reviewer)
      Publication date (Electronic):
      Journal: Journal of Medical Internet Research
      Publisher: Gunther Eysenbach
      Keywords: Adherence, persistence, online therapy, e-therapy, systematic review

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          Abstract

          Background

          As the popularity of e-therapies grows, so too has the body of literature supporting their effectiveness. However, these interventions are often plagued by high attrition rates and varying levels of user adherence. Understanding the role of adherence may be crucial to understanding how program usage influences the effectiveness of e-therapy interventions.

          Objective

          The aim of this study was to systematically review the e-therapy literature to (1) describe the methods used to assess adherence and (2) evaluate the association of adherence with outcome of these interventions.

          Methods

          A systematic review of e-therapy interventions was conducted across disease states and behavioral targets. Data were collected on adherence measures, outcomes, and analyses exploring the relationship between adherence measures and outcomes.

          Results

          Of 69 studies that reported an adherence measure, only 33 (48%) examined the relationship between adherence and outcomes. The number of logins was the most commonly reported measure of adherence, followed by the number of modules completed. The heterogeneity of adherence and outcome measures limited analysis. However, logins appeared to be the measure of adherence most consistently related to outcomes in physical health interventions, while module completion was found to be most related to outcomes in psychological health interventions.

          Conclusions

          There is large variation in the reporting of adherence and the association of adherence with outcomes. A lack of agreement about how best to measure adherence is likely to contribute to the variation in findings. Physical and psychological outcomes seem influenced by different types of adherence. A composite measure encompassing time online, activity completion, and active engagements with the intervention may be the best measure of adherence. Further research is required to establish a consensus for measuring adherence and to understand the role of adherence in influencing outcomes.

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          Most cited references71

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          Adherence to long-term therapies: evidence for action.

          Sabina De Geest, Eduardo Sabate (2004)
          Article 0 comments Cited 466 times – based on 0 reviews     Review now
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            Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence.

            Emma Waller, S Gilbody (2009)
            Studies of cognitive behavioural therapy delivered by computer (cCBT) show clinical efficacy for treating anxiety and depression, but have not focused on barriers to uptake. Potential barriers include adverse consequences, accessibility and acceptability. An integrated systematic review was conducted of quantitative and qualitative studies and surveys from multiple electronic databases where computers delivered cCBT for anxiety or depression. Substantial numbers of potential participants are lost prior to trials commencing with little explanation. Among trial participants, drop-outs may be higher in the cCBT groups (odds ratio 2.03, 95% confidence interval 0.81-5.09). Only a median of 56% completed a full course of cCBT and personal circumstance was a more common cause of drop-out than difficulties with the technology or social background. Risk was rarely assessed in the majority of programs. Significant staff time was needed to support clients. Therapists were more negative about cCBT than clients. While cCBT is likely to be an effective and acceptable intervention for some people, there are barriers to its uptake that will substantially limit its impact if not addressed. These included investigating the outcome and attitudes of those who do not make it as far as cCBT trials and why so few finish a full course of cCBT.
            Article 0 comments Cited 176 times – based on 0 reviews     Review now
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              Sample size slippages in randomised trials: exclusions and the lost and wayward.

              Kenneth F Schulz, David A Grimes (2002)
              Proper randomisation means little if investigators cannot include all randomised participants in the primary analysis. Participants might ignore follow-up, leave town, or take aspartame when instructed to take aspirin. Exclusions before randomisation do not bias the treatment comparison, but they can hurt generalisability. Eligibility criteria for a trial should be clear, specific, and applied before randomisation. Readers should assess whether any of the criteria make the trial sample atypical or unrepresentative of the people in which they are interested. In principle, assessment of exclusions after randomisation is simple: none are allowed. For the primary analysis, all participants enrolled should be included and analysed as part of the original group assigned (an intent-to-treat analysis). In reality, however, losses frequently occur. Investigators should, therefore, commit adequate resources to develop and implement procedures to maximise retention of participants. Moreover, researchers should provide clear, explicit information on the progress of all randomised participants through the trial by use of, for instance, a trial profile. Investigators can also do secondary analyses on, for instance, per-protocol or as-treated participants. Such analyses should be described as secondary and non-randomised comparisons. Mishandling of exclusions causes serious methodological difficulties. Unfortunately, some explanations for mishandling exclusions intuitively appeal to readers, disguising the seriousness of the issues. Creative mismanagement of exclusions can undermine trial validity.
              Article 0 comments Cited 167 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                :
                Brain & Mind Research InstituteThe University of Sydney100 Mallet StreetCamperdown, NSW 2050Australia61 29351052061 293510855Liesje.Donkin@sydney.edu.au
                Journal
                Journal ID (nlm-ta): J Med Internet Res
                Journal ID (publisher-id): JMIR
                Title: Journal of Medical Internet Research
                Publisher: Gunther Eysenbach (JMIR Publications Inc., Toronto, Canada )
                ISSN (Electronic): 1438-8871
                Publication date Collection: Jul-Sep 2011
                Publication date (Electronic): 05 August 2011
                Volume: 13
                Issue: 3
                Electronic Location Identifier: e52
                Affiliations
                [1] 1simpleBrain & Mind Research Institute simpleThe University of Sydney CamperdownAustralia
                [2] 2simpleCentre for Mental Health Research simpleAustralian National University CanberraAustralia
                [3] 3simpleThe George Institute for Global Health simpleThe University of Sydney SydneyAustralia
                [4] 4simpleDisciplines of Psychiatry and Sleep Medicine simpleSydney Medical School simpleThe University of Sydney SydneyAustralia
                Article
                Publisher ID: v13i3e52
                DOI: 10.2196/jmir.1772
                PMC ID: 3222162
                PubMed ID: 21821503
                SO-VID: 7843fa41-72f2-4e1a-8545-a90d512700b5
                Copyright © ©Liesje Donkin, Helen Christensen, Sharon L Naismith, Bruce Neal, Ian B Hickie, Nick Glozier. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 05.08.2011.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

                History
                Date received : 14 February 2011
                Date revision requested : 10 March 2011
                Date revision received : 24 May 2011
                Date accepted : 05 May 2011
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Medicine
                Keywords: adherence,persistence,online therapy,e-therapy,systematic review
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: adherence, persistence, online therapy, e-therapy, systematic review

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