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This randomized controlled trial evaluated the impact of SurvivorCHESS, an eHealth intervention, on physical activity in colon cancer survivors and to explore the impact of SurvivorCHESS on quality of life and distress. This was a two-arm single-blinded multi-site randomized controlled trial comparing a control group to an intervention group receiving a smartphone with the SurvivorCHESS program. Participants using SurvivorCHESS (n = 144) increased their moderate to vigorous physical activities from 19.4 min at baseline to 50 min compared to the control group (n = 140) increasing from 15.5 to 40.3 min at 6 months (p = .083) but was not sustained 3 months after the study ended. No significant differences were found between groups over time for quality of life or distress items. Reports of physical symptoms were greater than other categories for distress items. Patients who had a higher body mass index and number of comorbid conditions were less likely to increase their physical activity. Self-determination theory including autonomous motivation and relatedness was not associated with the outcomes. Physical activity did increase over time in both groups and was not significantly different with the use of the eHealth intervention, SurvivorCHESS, compared to the control group. The amount of SurvivorCHESS use was not associated with physical activity. Increasing physical activity in colon cancer survivors has the potential to improve quality of life and reduce recurrences. Using smartphone-tracking devices may be useful in helping to change this health behavior.

Background We estimated the efficacy of the Addiction-Comprehensive Health Enhancement Support System (A-CHESS) in increasing the use of services for addiction and examined the extent to which this use of services mediated the effects of A-CHESS on risky drinking days and abstinence from drinking. Methods We conducted secondary data analyses of the A-CHESS randomized controlled trial. Recruitment occurred in five residential treatment programs operated by two addiction treatment organizations. Participants were 349 adults with alcohol use disorders recruited two weeks before discharge from residential treatment. We provided intervention arm participants with a smartphone, the A-CHESS application, and an 8-month service plan. Control arm participants received treatment as usual. Telephone interviews at 4, 8, and 12-month follow-ups assessed past-month risky drinking days, past-month abstinence, and post-discharge service utilization (past-month outpatient addiction treatment and past-week mutual help including Alcoholics Anonymous and Narcotics Anonymous). Using mixed effects latent variable models, we estimated the indirect effects of A-CHESS on drinking outcomes, as mediated by post-discharge service utilization. Results Approximately 50.5% of participants reported outpatient addiction treatment and 75.5% reported mutual help at any follow-up interview in the year following randomization. Assignment to the A-CHESS intervention was associated with an increased odds of outpatient addiction treatment across follow-ups, but not mutual help. This use of outpatient addiction treatment mediated the effect of A-CHESS on risky drinking days, but not abstinence. The effect of A-CHESS through outpatient addiction treatment appeared to reduce the expected number of risky drinking days across follow-ups by 11%. Conclusions The mobile health (mHealth) intervention promoted the use of outpatient addiction treatment, which appeared to contribute to its efficacy in reducing risky drinking. Future research should investigate how mHealth interventions could link patients to needed treatment services and promote the sustained use of these services.

Objective Individuals in recovery for substance use disorders (SUDs) increasingly use online social support forums, necessitating research on how communicating through these forums can affect recovery. This study examines how giving and receiving support within an SUDs recovery forum predict substance use, and considers whether effects vary according to participants’ self-efficacy. Methods We applied content analysis to 3440 messages that were posted by 231 participants in an online SUDs forum. Surveys assessed social support reception and substance use at three timepoints. We assessed relationships between giving and receiving support and substance use (risky drinking days, illicit drug use days), and the interactions between self-efficacy and social support in predicting substance use outcomes. Results Receiving more emotional support was associated with reduced illicit drug use at 6 and 12 months. For those with low self-efficacy, giving more emotional support predicted less risky drinking at month 12, whereas giving more informational support predicted more risky drinking at month 12. Conclusion These results suggest conditional benefits of exchanging support in an online SUDs forum, depending upon type of support (informational versus emotional), the participants’ role (giver or receiver), and their self-efficacy. Practice implications We discuss implications for designing and using peer-to-peer support platforms.

BACKGROUND Online discussion forums allow those in addiction recovery to seek help through text-based messages, including when facing triggers to drink or use drugs. Trained staff (or “moderators”) may participate within these forums to offer guidance and support when participants are struggling but must expend considerable effort to continually review new content. Demands on moderators limit the scalability of evidence-based digital health interventions. OBJECTIVE Automated identification of recovery problems could allow moderators to engage in more timely and efficient ways with participants who are struggling. This paper aimed to investigate whether computational linguistics and supervised machine learning can be applied to successfully flag, in real time, those discussion forum messages that moderators find most concerning. METHODS Training data came from a trial of a mobile phone-based health intervention for individuals in recovery from alcohol use disorder, with human coders labeling discussion forum messages according to whether or not authors mentioned problems in their recovery process. Linguistic features of these messages were extracted via several computational techniques: (1) a Bag-of-Words approach, (2) the dictionary-based Linguistic Inquiry and Word Count program, and (3) a hybrid approach combining the most important features from both Bag-of-Words and Linguistic Inquiry and Word Count. These features were applied within binary classifiers leveraging several methods of supervised machine learning: support vector machines, decision trees, and boosted decision trees. Classifiers were evaluated in data from a later deployment of the recovery support intervention. RESULTS To distinguish recovery problem disclosures, the Bag-of-Words approach relied on domain-specific language, including words explicitly linked to substance use and mental health (“drink,” “relapse,” “depression,” and so on), whereas the Linguistic Inquiry and Word Count approach relied on language characteristics such as tone, affect, insight, and presence of quantifiers and time references, as well as pronouns. A boosted decision tree classifier, utilizing features from both Bag-of-Words and Linguistic Inquiry and Word Count performed best in identifying problems disclosed within the discussion forum, achieving 88% sensitivity and 82% specificity in a separate cohort of patients in recovery. CONCLUSIONS Differences in language use can distinguish messages disclosing recovery problems from other message types. Incorporating machine learning models based on language use allows real-time flagging of concerning content such that trained staff may engage more efficiently and focus their attention on time-sensitive issues.

Background: Despite the near ubiquity of mobile phones, little research has been conducted on the implementation of mobile health (mHealth) apps to treat patients in primary care. Although primary care clinicians routinely treat chronic conditions such as asthma and diabetes, they rarely treat addiction, a common chronic condition. Instead, addiction is most often treated in the US health care system, if it is treated at all, in a separate behavioral health system. mHealth could help integrate addiction treatment in primary care. Objective: The objective of this paper was to report the effects of implementing an mHealth system for addiction in primary care on both patients and clinicians. Methods: In this implementation research trial, an evidence-based mHealth system named Seva was introduced sequentially over 36 months to a maximum of 100 patients with substance use disorders (SUDs) in each of three federally qualified health centers (FQHCs; primary care clinics that serve patients regardless of their ability to pay). This paper reports on patient and clinician outcomes organized according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results: The outcomes according to the RE-AIM framework are as follows: Reach—Seva reached 8.31% (268/3226) of appropriate patients. Reach was limited by our ability to pay for phones and data plans for a maximum of 100 patients per clinic. Effectiveness—Patients who were given Seva had significant improvements in their risky drinking days (44% reduction, (0.7-1.25)/1.25, P=.04), illicit drug-use days (34% reduction, (2.14-3.22)/3.22, P=.01), quality of life, human immunodeficiency virus screening rates, and number of hospitalizations. Through Seva, patients also provided peer support to one another in ways that are novel in primary care settings. Adoption—Patients sustained high levels of Seva use—between 53% and 60% of the patients at the 3 sites accessed Seva during the last week of the 12-month implementation period. Among clinicians, use of the technology was less robust than use by patients, with only a handful of clinicians using Seva in each clinic and behavioral health providers making most referrals to Seva in 2 of the 3 clinics. Implementation—At 2 sites, implementation plans were realized successfully; they were delayed in the third. Maintenance—Use of Seva dropped when grant funding stopped paying for the mobile phones and data plans. Two of the 3 clinics wanted to maintain the use of Seva, but they struggled to find funding to support this. Conclusions: Implementing an mHealth system can improve care among primary care patients with SUDs, and patients using the system can support one another in their recovery. Among clinicians, however, implementation requires figuring out how information from the mHealth system will be used and making mHealth data available in the electronic health (eHealth) record. In addition, paying for an mHealth system remains a challenge.

This study examined the interplay of depression and different types of e-health interventions on breast cancer patients’ perceived healthcare competence, emotional processing, and social well-being over time. The three e-health interventions - Internet Only as a control condition, CHESS (Comprehensive Health Enhancement Support System) Only, and CHESS with a Human Mentor, a cancer information specialist - provided varying degrees of interactivity and presence. A total of 328 women with breast cancer participated in one of the three interventions for a 6-month period. Women were further split into two groups based on reported levels of depression. For perceived healthcare competence and social well-being, results revealed significant interaction effects for intervention type by depression over time, such that breast cancer patients with higher levels of depression benefited most from the CHESS with Mentor intervention over the 6-month study period. For emotional processing, depressed cancer patients benefited more from the CHESS with Mentor than the other two interventions, regardless of time. These findings have (a) theoretical implications on how mental health factors can intersect with interactivity and presence to influence psychosocial outcomes, (b) conceptual implications for the role of human interaction within e-health systems, and (c) practical implications for the development of e-health interventions for cancer patients with depression.

The chronically relapsing nature of alcoholism leads to substantial personal, family, and societal costs. Addiction-Comprehensive Health Enhancement Support System (A-CHESS) is a smartphone application that aims to reduce relapse. To offer targeted support to patients who are at risk of lapses within the coming week, a Bayesian network model to predict such events was constructed using responses on 2,934 weekly surveys (called the Weekly Check-in) from 152 alcohol-dependent individuals who recently completed residential treatment. The Weekly Check-in is a self-monitoring service, provided in A-CHESS, to track patients’ recovery progress. The model showed good predictability, with the area under receiver operating characteristic curve of 0.829 in the 10-fold cross-validation and 0.912 in the external validation. The sensitivity/specificity table assists the tradeoff decisions necessary to apply the model in practice. This study moves us closer to the goal of providing lapse prediction so that patients might receive more targeted and timely support.

This study attempts to examine the role of social support perception and emotional well-being on online information seeking among cancer patients within the context of CHESS, a well-established Interactive Cancer Communication System ICCS. Factor and regression analyses conducted among 231 breast cancer patients revealed that social support perception and emotional well-being interacted with each other to influence online health information seeking. Patients with low social support perception and high emotional well-being were most likely to seek health information, whereas patients with high social support perception and high emotional well-being sought out the same information least. Practical implications of the study findings are further discussed.

Background Opioid dependence has devastating and increasingly widespread consequences and costs, and the most common outcome of treatment is early relapse. People who inject opioids are also at disproportionate risk for contracting the human immunodeficiency virus (HIV) and hepatitis C virus (HCV). This study tests an approach that has been shown to improve recovery rates: medication along with other supportive services (medication-assisted treatment, or MAT) against MAT combined with a smartphone innovation called A-CHESS (MAT + A-CHESS). Methods/design This unblinded study will randomly assign 440 patients to receive MAT + A-CHESS or MAT alone. Eligible patients will meet criteria for having an opioid use disorder of at least moderate severity and will be taking methadone, injectable naltrexone, or buprenorphine. Patients with A-CHESS will have smartphones for 16 months; all patients will be followed for 24 months. The primary outcome is the difference between patients in the two arms in percentage of days using illicit opioids during the 24-month intervention. Secondary outcomes are differences between patients receiving MAT + A-CHESS versus MAT in other substance use, quality of life, retention in treatment, health service use, and, related to HIV and HCV, screening and testing rates, medication adherence, risk behaviors, and links to care. We will also examine mediators and moderators of the effects of MAT + A-CHESS. We will measure variables at baseline and months 4, 8, 12, 16, 20, and 24. At each point, patients will respond to a 20- to 30-min phone survey; urine screens will be collected at baseline and up to twice a month thereafter. We will use mixed-effects to evaluate the primary and secondary outcomes, with baseline scores functioning as covariates, treatment condition as a between-subject factor, and the outcomes reflecting scores for a given assessment at the six time points. Separate analyses will be conducted for each outcome. Discussion A-CHESS has been shown to improve recovery for people with alcohol dependence. It offers an adaptive and extensive menu of services and can attend to patients nearly as constantly as addiction does. This suggests the possibility of increasing both the effectiveness of, and access to, treatment for opioid dependence. Trial registration ClinicalTrials.gov, NCT02712034. Registered on 14 March 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1726-1) contains supplementary material, which is available to authorized users.

Millions of Americans need but don’t receive treatment for substance use, and evidence suggests that addiction-focused interventions on smart phones could support their recovery. There is little research on implementation of addiction-related interventions in primary care, particularly in Federally Qualified Health Centers (FQHCs) that provide primary care to underserved populations. We used mixed methods to examine three FQHCs’ implementation of Seva, a smart-phone app that offers patients online support/discussion, health-tracking, and tools for coping with cravings, and offers clinicians information about patients’ health tracking and relapses. We examined (a) clinicians’ initial perspectives about implementing Seva, and (b) the first year of implementation at Site 1. Prior to staggered implementation at three FQHCs (Midwest city in WI vs. rural town in MT vs. metropolitan NY), interviews, meetings, and focus groups were conducted with 53 clinicians to identify core themes of initial expectations about implementation. One year into implementation at Site 1, clinicians there were re-interviewed. Their reports were supplemented by quantitative data on clinician and patient use of Seva. Clinicians anticipated that Seva could help patients and make behavioral health appointments more efficient, but they were skeptical that physicians would engage with Seva (given high caseloads), and they were uncertain whether patients would use Seva. They were concerned about legal obligations for monitoring patients’ interactions online, including possible “cries for help” or inappropriate interactions. One year later at Site 1, behavioral health care providers, rather than physicians, had incorporated Seva into patient care, primarily by discussing it during appointments. Given workflow/load concerns, only a few key clinicians monitored health tracking/relapses and prompted outreach when needed; two researchers monitored the discussion board and alerted the clinic as needed. Clinician turnover/leave complicated this approach. Contrary to clinicians’ initial concerns, patients showed sustained, mutually supportive use of Seva, with few instances of misuse. Results suggest the value of (a) focusing implementation on behavioral health care providers rather than physicians, (b) assigning a few individuals (not necessarily clinicians) to monitor health tracking, relapses, and the discussion board, (c) anticipating turnover/leave and having designated replacements. Patients showed sustained, positive use of Seva. ClinicalTrials.gov ( NCT01963234 ).

Being diagnosed with breast cancer and undergoing various treatments is a traumatic event for cancer patients [1]. They often experience many anxieties and uncertainties about the prognosis of their illness, thus their needs for support are likely to be high and vary during the course of their cancer experience. For breast cancer patients, one common way to cope with these problems is to engage in social support groups. Indeed, many scholars argue that social support exchange could function as a effective means to empower patients, enhancing their control over their illness, and managing uncertainty about their situation, which, in turn, leads to improved physical and emotional well-being [2–4]. Similar to the beneficial effects of traditional face-to-face social support, computer-mediated social support can be offered as a functional alternative for people with chronic illness [5–8]. In recent years, this phenomenon has increased because the growth and prevalence of the Internet has increased the accessibility and use of information and support for people with serious illnesses. Such trends are consistent with the growing recognition that, rather than being passive recipients, patients actively engage in mediated information and support seeking to help them effectively cope and make informed decisions during the course of their illness [9]. Recent studies found that participating in computer-mediated social support (CMSS) groups has emerged as an important source to seek and receive social support during social interaction, which ultimately yields positive effects on health outcomes [10–16]. A review of literature also suggests that it is important to differentiate the two behavioral exchanges of giving and receiving social support in order to uncover how supportive messages are exchanged [14, 17, 18]. For example, one recent study found that those who have more resources at pretest are more likely to provide emotional support to others, while those who lack resources are more likely to seek and receive emotional support from peer patients to compensate for deficits in their social network [19]. Unfortunately, little is known about how different modes of engaging in supportive exchanges - the reception and provision of emotional support - might matter for breast cancer patients’ psychosocial health outcomes. Accordingly, this study will simultaneously take these two supportive behaviors of giving and receiving into account in explaining their relative effects on psychosocial adjustments for breast cancer patients in the context of online support groups. In addition, this study will further examine the dynamic interplay of support giving and receiving among breast cancer patients within CMSS groups. Our aim here is to provide insights into the underlying mechanisms of what makes CMSS groups effective and how patients facing life-threatening illnesses interact and obtain benefits from such systems.

Past studies on the efficacy of participation in online cancer support groups have primarily focused on the role of expression in the accrual of health benefits for participants. Unfortunately, few steps have been taken to determine whether this observed effect arises solely from the internal mental processes underlying the act of expressing or, perhaps, owes something to a nuanced, multidimensional understanding of expression that includes reception of responses to what is expressed. To test for the multilayered effect, we attend to one of the key concepts in the online support community scholarship: empathy. Our findings suggest that it is a combination of empathy expression and reception that is crucial to attaining optimal benefits for cancer patients. Further, our finding supports the buffering hypothesis that empathic expression provides a salutary effect for patients who experienced a higher degree of concern associated with their cancer diagnosis and follow-up treatments.

Little is known about the effective elements of Interactive Cancer Communication Systems (ICCSs). A randomized trial explored which types of services of a multifaceted ICCS benefited patients and the nature of the benefit. Women with breast cancer (N = 450) were randomized to different types of ICCS services or to a control condition that provided internet access. The Comprehensive Health Enhancement Support System (CHESS), served as the ICCS. ICCS services providing information and support, but not coaching such as cognitive behavior therapy, produced significant benefits in health information competence and emotional processing. Provision of Information and Support ICCS services significantly benefited women with breast cancer. More complex and interactive services designed to train the user had negligible effects.

In order to provide insights about cancer patients' online information seeking behaviors, the present study analyzes individuals' transaction log data and reports on how demographics, disease-related factors, and psychosocial needs predict patterns of service use within a particular Interactive Cancer Communication System (ICCS). Study sample included 294 recently diagnosed breast cancer patients. Data included pretest survey scores of demographic, disease-related, and psychosocial factors and automatically collected ICCS use data over the 4-month intervention. Statistical analyses correlated pre-test survey scores with subsequent, specific types of ICCS service usage. Patterns of online cancer information seeking differed according to the patients' characteristics, suggesting that lower income, less educated women and those lacking in information-seeking competence use the computer and online services to the same or a greater degree if those services are made available to them. Results of this study can inform more effective resource development for future eHealth applications.

Research suggests communicating too much about one's self within an online support group may amplify breast cancer patients' focus on their own problems and exacerbate negative emotions while focusing on others may have the opposite effects. This study explored how pronoun usage within an online support group was associated with subsequent mental health outcomes. There were 286 patients recruited into the study who filled out the pre-test and 231 completed post-tests four months later with survey measures including breast cancer-related concerns and negative emotions. Messages were analyzed using a program counting first person and relational pronouns. A positive relationship was found between use of first person pronouns and negative emotions.

To compare the benefits of the Internet generally versus a focused system of services, 257 breast cancer patients were randomly assigned to a control group, access to the Internet with links to high-quality breast cancer sites, or access to an eHealth system (Comprehensive Health Enhancement Support System, CHESS) that integrated information, support, and decision and analysis tools. The intervention lasted 5 months, and self-report data on quality of life, health-care competence, and social support were collected at pretest and at 2-, 4-, and 9-month posttests. CHESS subjects logged on more overall than Internet subjects and accessed more health resources, but the latter used non health-related sites more. Subjects with access to the Internet alone experienced no better outcomes than controls at any of the 3 time points, compared to pretest levels. Subjects with CHESS experienced greater social support during the intervention period and had higher scores on all 3 outcomes at 9 months, 4 months after the intervention ended. CHESS subjects also scored higher than those with Internet access during the intervention period but not significantly after the intervention ended. Thus, CHESS (with one simple interface and integrated information, communication, and skills services) helped newly diagnosed breast cancer patients even after computers were removed. In contrast, patients received little benefit from Internet access, despite having links to a variety of high-quality sites.

To determine the effects of online narrative and didactic information on breast cancer patients' healthcare participation and the interaction effects of race.353 breast cancer patients (111 African Americans) using an eHealth program with narratives (audiovisual and text) and didactic information (text only).healthcare participation scale (0, 4 months), online information use.hierarchical regression.Narrative (beta=0.123, p0.01) and didactic (beta=0.104, p0.05) information use had independent and positive effects on healthcare participation. Effects of both were significantly greater for African Americans.Findings are consistent with and advance prior research on online learning processes and outcomes for breast cancer patients: (1) benefits accrue with using a variety of online learning tools; (2) African Americans use and benefit more from online narrative and didactic information than do Caucasians.eHealth programs should provide both didactic and narrative information-especially for African Americans and might consider making greater use of interactive and audiovisual formats. As patients increasingly use of the web for cancer information, clinicians should provide lists of web high quality resources that provide both narrative and didactic information.

Objective To examine how the pre-existing doctor–patient relationship predicts conceptually distinct service use within an Interactive Cancer Communication System (ICCS) for underserved women with breast cancer and in turn how service utilization influences the doctor–patient relationship. Methods Study sample included 231 recently diagnosed, lower income breast cancer patients. Participants were provided a free computer, Internet access and training in how to use an ICCS called the Comprehensive Health Enhancement Support System (CHESS) “Living with Breast Cancer” program. Survey data was collected at pre-test and 4-months after using the system, and use data about how women used the system was also collected. Results The only statistically significant predictor of service use was that patients with a more negative appraisal about the doctor–patient relationship used the Ask an Expert service more frequently, and there were trends toward a more negative appraisal of the doctor–patient relationship being associated with higher use of Information and Interactive services. Conversely, there was a trend toward a more positive appraisal predicting higher use of the Discussion Group service. In terms of statistically significant effects, more frequent utilization of Information services was associated with a more positive appraisal of the doctor relationship. Conclusion While a more negative perception of the doctor–patient relationships at pre-test was associated with higher use of most of the conceptually distinct services within this ICCS, use of the Information services was associated with having a more positive appraisal of the doctor–patient relationship at post-test suggesting that high-quality information on the Internet can serve to improve patients’ satisfaction with their doctor.

Background This study investigates the use of an information and communication technology (Elder Tree) designed for older adults and their informal caregivers to improve older adult quality of life and address challenges older adults face in maintaining their independence (for example, loneliness and isolation, falling, managing medications, driving and transportation). Methods/Design This study, an unblinded randomized controlled trial, will evaluate the effectiveness and cost of Elder Tree. Older adults who are at risk for losing their independence - along with their informal caregivers, if they name them - are randomized to two groups. The intervention group has access to their usual sources of information and communication as well as to Elder Tree for 18 months while the control group uses only their usual sources of information and communication. The primary outcome of the study is older adult quality of life. Secondary outcomes are cost per Quality-Adjusted Life Year and the impact of the technology on independence, loneliness, falls, medication management, driving and transportation, and caregiver appraisal and mastery. We will also examine the mediating effect of self-determination theory. We will evaluate the effectiveness of Elder Tree by comparing intervention- and control-group participants at baseline and months 6, 12, and 18. We will use mixed-effect models to evaluate the primary and secondary outcomes, where pretest score functions as a covariate, treatment condition is a between-subjects factor, and the multivariate outcome reflects scores for a given assessment at the three time points. Separate analyses will be conducted for each outcome. Cost per Quality-Adjusted Life Year will be compared between the intervention and control groups. Additional analyses will examine the mediating effect of self-determination theory on each outcome. Discussion Elder Tree is a multifaceted intervention, making it a challenge to assess which services or combinations of services account for outcomes in which subsets of older adults. If Elder Tree can improve quality of life and reduce healthcare costs among older adults, it could suggest a promising way to ease the burden that advancing age can place on older adults, their families, and the healthcare system. Trial registration ClinicalTrials.govNCT02128789. Registered on 26 March 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0713-2) contains supplementary material, which is available to authorized users.

To provide insights about how women with breast cancer learn from interactive cancer communication systems (ICCSs), this study examined how use of different types of services that employ conceptually distinct pedagogical methods relates to learning outcomes. The study sample included 231 recently diagnosed, lower income breast cancer patients. Participants were provided a free computer, Internet access and training in how to use an ICCS called the Comprehensive Health Enhancement Support System 'Living with Breast Cancer' program. Data comprised survey information collected at pre-test and 4 months after using the system and computer records of how women used the system (use data). The findings suggest that use of the information and interactive services independently contributed to perceived information competence, though the communication services, including both discussion group and ask an expert, did not. Consistent with expectations, use of discussion group and interactive services amplified the learning effects of using the information services. However, use of the ask an expert service did not amplify the learning effects of using the information services as predicted. Some constructivist pedagogical methods-specifically online support groups and intelligently designed, computer-driven interactive services-may supplement and extend the learning potential of information services delivered via a transmission-oriented pedagogical approach.

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review places particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups.

Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary-care practices to integrate treatment for addiction and other behavioral health conditions into their practices. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these settings is substantial but largely untested. This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones, called Seva, into primary-care settings. Seva is an evidence-based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians. Our implementation strategy uses three models of organizational change: the Program Planning Model to promote acceptance and sustainability, the NIATx quality improvement model to create a welcoming environment for change, and Rogers’s diffusion of innovations research, which facilitates adaptations of innovations to maximize their adoption potential. We will implement Seva and conduct an intensive, mixed-methods assessment at three diverse Federally Qualified Healthcare Centers in the United States. Our non-concurrent multiple-baseline design includes three periods — pretest (ending in four months of implementation preparation), active Seva implementation, and maintenance — with implementation staggered at six-month intervals across sites. The first site will serve as a pilot clinic. We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework, including effects on clinicians, patients, and practices. Our mixed-methods approach will include quantitative (e.g., interrupted time-series analysis of treatment attendance, with clinics as the unit of analysis) and qualitative (e.g., staff interviews regarding adaptations to implementation protocol) methods, and assessment of implementation costs. If implementation is successful, the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support, as well as a proven strategy for implementing the technology. Seva also has the potential to improve core elements of addiction treatment, such as referral and treatment processes. A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems. ClinicalTrials.gov ( NCT01963234 ).

Importance Patients leaving residential treatment for alcohol use disorders are not typically offered evidence-based continuing care, although research suggests that continuing care is associated with better outcomes. A smartphone-based application could provide effective continuing care. Objective To determine whether patients leaving residential treatment for alcohol use disorders with a smartphone application to support recovery have fewer risky drinking days than control patients. Design, Setting, and Participants An unmasked randomized clinical trial involving 3 residential programs operated by 1 nonprofit treatment organization in the Midwestern United States and 2 residential programs operated by 1 nonprofit organization in the Northeastern United States. In total, 349 patients who met the criteria for DSM-IV alcohol dependence when they entered residential treatment were randomized to treatment as usual (n = 179) or treatment as usual plus a smartphone (n = 170) with the Addiction–Comprehensive Health Enhancement Support System (A-CHESS), an application designed to improve continuing care for alcohol use disorders. Interventions Treatment as usual varied across programs; none offered patients coordinated continuing care after discharge. A-CHESS provides monitoring, information, communication, and support services to patients, including ways for patients and counselors to stay in contact. The intervention and follow-up period lasted 8 and 4 months, respectively. Main Outcomes and Measures Risky drinking days—the number of days during which a patient’s drinking in a 2-hour period exceeded 4 standard drinks for men and 3 standard drinks for women, with standard drink defined as one that contains roughly 14 g of pure alcohol (12 oz of regular beer, 5 oz of wine, or 1.5 oz of distilled spirits). Patients were asked to report their risky drinking days in the previous 30 days on surveys taken 4, 8, and 12 months after discharge from residential treatment. Results For the 8 months of the intervention and 4 months of follow-up, patients in the A-CHESS group reported significantly fewer risky drinking days than did patients in the control group, with a mean of 1.39 vs 2.75 days (mean difference, 1.37; 95% CI, 0.46-2.27; P = .003). Conclusions and Relevance The findings suggest that a multifeatured smartphone application may have significant benefit to patients in continuing care for alcohol use disorders. Trial Registration clinicaltrials.gov Identifier:NCT01003119

Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved.Randomized controlled trial conducted between 1995 and 1998.Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago), and a cancer resource center (Indianapolis, Ill). The latter three sites treat many underserved patients.Newly diagnosed breast cancer patients (N = 246) under age 60.Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support.Pretest and two post-test surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group.Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations.

Background Emotional support has traditionally been conceived as something a breast cancer patient receives. However, this framework may obscure a more complex process, facilitated by the emerging social media environment, which includes the effects of composing and sending messages to others. Accordingly, this study explores the effects of expression and reception of emotional support messages in online groups and the importance of bonding as a mediator influencing the coping strategies of breast cancer patients. Methods Data were collected as part of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of diagnosis of primary breast cancer or recurrence. Expression and reception of emotionally supportive messages were tracked and coded for 237 breast cancer patients. Analysis resulted from merging 1) computer-aided content analysis of discussion posts, 2) action log analysis of system use, and 3) longitudinal survey data. Results As expected, perceived bonding was positively related to all four coping strategies (active coping: β = 0.251, P = .000; positive reframing: β = 0.288, P = .000; planning: β = 0.213, P = .006; humor: β = 0.159, P = .009). More importantly, expression (γ = 0.138, P = .027), but not reception (γ = -0.018, P = .741), of emotional support increases perceived bonding, which in turn mediates the effects on patients' positive coping strategies. Conclusions There is increasing importance for scholars to distinguish the effects of expression from reception to understand the processes involved in producing psychosocial benefits. This study shows that emotional support is more than something cancer patients receive; it is part of an active, complex process that can be facilitated by social media.

Informal caregivers (family and friends) of people with cancer are often unprepared for their caregiving role, leading to increased burden or distress. Comprehensive Health Enhancement Support System (CHESS) is a Web-based lung cancer information, communication, and coaching system for caregivers. This randomized trial reports the impact on caregiver burden, disruptiveness, and mood of providing caregivers access to CHESS versus the Internet with a list of recommended lung cancer websites.A total of 285 informal caregivers of patients with advanced nonsmall cell lung cancer were randomly assigned to a comparison group that received Internet or a treatment group that received Internet and CHESS. Caregivers were provided a computer and Internet service if needed. Written surveys were completed at pretest and during the intervention period bimonthly for up to 24 months. Analyses of covariance (ANCOVAs) compared the intervention's effect on caregivers' disruptiveness and burden (CQOLI-C), and negative mood (combined Anxiety, Depression, and Anger scales of the POMS) at 6 months, controlling for blocking variables (site, caregiver's race, and relationship to patient) and the given outcome at pretest.Caregivers randomized to CHESS reported lower burden, t(84) = 2.36, p = .021, d = .39, and negative mood, t(86) = 2.82, p = .006, d = .44, than those in the Internet group. The effect on disruptiveness was not significant.Although caring for someone with a terminal illness will always exact a toll on caregivers, eHealth interventions like CHESS may improve caregivers' understanding and coping skills and, as a result, ease their burden and mood.

OBJECTIVE: Mobile technology has the potential to radically improve addiction treatment and continuing care by offering emotional and instrumental support anywhere and just in time. This is particularly important in addiction because timing is critical to preventing relapse. Although most experts consider alcoholism to be a chronic disease, providers do not typically offer ongoing support for relapse prevention after patients complete treatment, even though a central characteristic of alcoholism and other addictive behaviors is their chronically relapsing nature. A-CHESS is a smartphone-based system for preventing relapse to heavy drinking among people leaving active alcohol dependence treatment. A-CHESS is designed to improve competence, social relatedness, and motivation, the three tenets of Self-Determination Theory. This paper reports on the relative impact and use of A-CHESS four months after patients entered the study and discusses implications of the results on treating addiction and chronic diseases generally. METHODS: A total of 349 individuals with alcohol dependence leaving residential treatment were randomly assigned to either receive A-CHESS+Treatment as Usual or Treatment as Usual (standard aftercare). Patients came from two treatment agencies, one in the Midwest and one in the Northeast. Patients assigned to A-CHESS received a smartphone for 8 months and were followed for 12. The authors analyzed use patterns during the first 4 months of use by those receiving A-CHESS. RESULTS: Participants used A-CHESS heavily and sustained their use over time. Ninety-four percent of A-CHESS participants used the application during the first week after residential treatment. At week 16, almost 80% continued to access A-CHESS. Participants with alcohol and drug-dependence showed higher levels of system use than those with alcohol dependence only. Participants with a mental health diagnosis had slightly lower levels of use at the end of the intervention period (week 16), although more than 70% still accessed the system. CONCLUSIONS: These findings illustrate that patients with alcohol dependence, alcohol and drug dependence, and mental health issues will use smartphone applications such as A-CHESS for ongoing support, resources and information, thus extending patient care if given the opportunity. Further analysis is needed to determine if sustained A-CHESS use improves outcomes.

Despite the benefits and growing availability of online cancer support groups, many breast cancer patients still do not actively participate in the support groups. To better understand cancer patients’ online information and support seeking behaviors, this study explores how various social and psychological characteristics predict different levels of engagement with an online breast cancer support group: posters, lurkers, and non-users. The study sample included 231 recently diagnosed breast cancer patients. Data included baseline survey scores of demographic, disease-related, and psychosocial factors and automatically collected discussion group use data over the 4-month intervention. Patterns of engagement with the cancer support group differed according to the patients’ characteristics, suggesting that (1) cancer patients have very different orientations to and engagement with an online support group, and (2) ‘deficits’ in social and psychological resources may not be barriers to participation in a cancer support group, but rather motivators to interact with other patients. Theoretical and practical implications of the findings are discussed.

Social support in computer-mediated settings is an important variable in health communication research, yet little is known about the factors that influence the amount of social support one gives and receives in online support groups. To shed some light on this issue, the authors examined demographics, disease-related factors, psychosocial factors, and strategies for coping with breast cancer as potential determinants of which patients provide support to others and which ones consume it. Data collected from 177 participants in the Comprehensive Health Enhancement Support System "Living With Breast Cancer" program revealed that individuals who are younger, have higher levels of positive reframing, and lower levels of self-blame are more likely to provide emotional support in online settings. In contrast, individuals who are more educated, have less perceived availability of social support, and have lower levels of religious coping are more likely to receive emotional support from others. The authors discuss the theoretical and practical implications for providing effective psychosocial support for women with breast cancer.

Numerous studies have investigated the effect of Interactive Cancer Communication Systems (ICCSs) on system users' improvements in psychosocial status. Research in this area, however, has focused mostly on cancer patients, rather than on caregivers, and on the direct effects of ICCSs on improved outcomes, rather than on the psychological mechanisms of ICCS effects. To understand the underlying mechanisms, this study examines the mediating role of perceived caregiver bonding in the relation between one ICCS (the Comprehensive Health Enhancement Support System [CHESS]) use and caregivers' coping strategies. To test the hypotheses, a secondary analysis of data was conducted on 246 caregivers of lung cancer patients. These caregivers were randomly assigned to (a) the Internet, with links to high-quality lung cancer websites, or (b) access to CHESS, which integrated information, communication, and interactive coaching tools. Findings suggest that perceived bonding has positive effects on caregivers' appraisal and problem-focused coping strategies, and it mediates the effect of ICCS on the coping strategies 6 months after the intervention has begun.

Following demonstrations of success of interactive cancer communication systems (ICCS) for patients, the challenge and opportunity are to integrate such systems with human resources. A randomized trial explored relative benefits of an ICCS, a human cancer information mentor, and a condition combining both. Women with breast cancer (N = 434) were randomized to have access to a tested ICCS (CHESS, the Comprehensive Health Enhancement Support System), a human cancer information mentor, both interventions, or a control condition providing a computer, training, and Internet access. Both a human mentor and an ICCS version improved health information competence and emotional processing over the Internet control, and the combined condition exceeded either alone. Integrating human and computer-based resources for breast cancer patients benefits them more than either alone.

To understand the underlying psychosocial reactions against the unfolding of medical events that announce the disease progression, the objective of this analysis was to identify the patterns of online discussion group message themes in relation to the medical timeline of one woman's breast cancer trajectory. 202 messages posted by Darlene (our studied case) were analyzed by 2 independent coders using a grounded theory approach. The findings suggest that the pattern of messages was clearly correlated with distress-inducing events. The most frequent interaction theme was about building friendship with peers through communication of encouragement, validation, appreciation, and life sharing. Narratives of medical progression were constantly updated to identify similarities with peers. Family issues were increasingly raised at the end of life.

The goal of the current study was to examine how social support and coping strategies are related in predicting emotional well-being of women with breast cancer. In achieving this goal, we examined two hypothesized models: (1) a moderation model where social support and coping strategies interact with each other in affecting psychological well-being; and (2) a mediation model where the level of social support influences choices of coping strategies between self-blame and positive reframing. In general, the data from the current study were more consistent with the mediation model than the moderation model.

Parents of pediatric hematopoietic stem cell transplant (HSCT) play a pivotal role in the care of their child during and after transplant. In addition to the child's comforter, parents also serve as care coordinators and conduits of communication between various health care providers, family and community members. The stress on the parent and family is enormous during this process, which for many is compounded by geographic dislocation to accompany their child during the rigorous treatment and recovery process. For many parents, their own recovery spans months to years.Parental activation, a process of becoming informed to participate in decisions, collaborate with health care providers, and manage care provided the conceptual framework to develop an eHealth approach for this population. HSCT-CHESS was developed, based on previous success with an existing eHealth system of integrated services, the Comprehensive Health Enhancement Support System (CHESS). CHESS(TM) is designed to help individuals and families cope with a health crisis or medical concern. The iterative user-centered development process for HSCT-CHESS included parents of HSCT recipients, representatives from an HSCT Advocacy Group, and members of the clinical, research, development and design teams. This rigorous process, including online focus groups and surveys, utilization of a parental user group, and an editorial and development process are described.As the population of cancer survivors and caregivers increase and as the oncology workforce becomes more stretched; developing eHealth applications may be an approach to address many of caregivers unmet needs. The purpose in describing this process is to help others when considering such an endeavor. HSCT-CHESS is now being tested in a randomized controlled trial versus standard care to evaluate its impact on the quality of life of both the parent and child HSCT recipient.

Objectives: To examine the effects of exchanging treatment information within computer-mediated breast cancer support groups on emotional well-being, and to explore whether this relationship is moderated by health self-efficacy. Methods: Sample: 177 breast cancer patients using an electronic Health (eHealth) program with discussion group. Measure: expression and reception of treatment information; emotional well-being scale (0, 4 months). Analyses: hierarchical regression. Results: Effects of expression and reception of treatment information on emotional well-being were significantly greater for those who have higher health self-efficacy. Conclusions: Results conditionally support prior research finding positive effects of treatment information exchanges among breast cancer patients. Such exchanges had a positive impact on emotional well-being for those with higher health self-efficacy, but they had a negative influence for those with lower health self-efficacy. Practice implications: Given that the association between emotional well-being and exchanging treatment information was moderated by health self-efficacy, clinicians should explain the role of health self-efficacy before encouraging patients to use eHealth systems for treatment exchanges.

Objectives:Familial caregivers are providing increasing amounts of care to advanced cancer patients. Increased understanding of caregivers’ needs is vital in providing necessary support to lessen caregiver burden and morbidity. Current literature has identified caregiver and patient needs at broad stages of the cancer trajectory; however, such broad stages may be too general to inform a practice of targeting specific interventions when they have the greatest utility. This study examines a variety of particular needs across a number of more discrete illness-related transition experiences specifically in the advanced cancer disease trajectory.Methods:One hundred fifty-nine female informal caregivers of people with advanced cancer completed a needs assessment survey.Results:Analyses of these cross-sectional retrospective-report data reveal that cancer caregiver needs vary across specific key experiences occurring within the broader stages of illness identified by current literature. Furthermore, caregivers have unique needs during bereavement.Significance of results:Although the sample characteristics are demographically limited, this study provides preliminary evidence that the broad stages are not specific enough increments for effectively examining caregiver needs and supports the need for more precise distribution of cancer-related information at more discrete times in the illness course.

With the increased pressure to contain healthcare costs, it is critical to find more eVective ways of providing information, emotional support, decision making, and behaviour change assistance for patients. In the United States, a doctor spends approximately 18 minutes in face to face contact with the patient during each clinic appointment. 1 During morning hospital rounds, physicians spend on average just over four minutes in the patient’s room. 2 It has been proposed that ideal physician communication with patients with breast cancer should be tailored to patients’ needs or coping styles to reduce their distress. 3 However, in an environment of continued pressure to reduce healthcare costs, it is virtually impossible for doctors to give patients adequate information or even direct them to appropriate support resources. If costs are to be reduced while at the same time improving patient support we must find new ways to help patients to cope with their disease, make necessary decisions, and gain emotional support. Computer systems can help to fill this void. A key problem encountered by people facing a health crisis is that they are often given information when they are least able to take it in, such as at the time of diagnosis. SiminoV and others have concluded that nearly all studies point to serious gaps in patient recall and understanding of the information they are given. 34