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Background New smartphone communication technology provides a novel way to provide personalized continuing care support following alcohol treatment. One such system is the Addiction version of the Comprehensive Health Enhancement Support System (A-CHESS), which provides a range of automated functions that support patients. A-CHESS improved drinking outcomes over standard continuing care when provided to patients leaving inpatient treatment. Effective continuing care can also be delivered via telephone calls with a counselor. Telephone Monitoring and Counseling (TMC) has demonstrated efficacy in two randomized trials with alcohol-dependent patients. A-CHESS and TMC have complementary strengths. A-CHESS provides automated 24/7 recovery support services and frequent assessment of symptoms and status, but does not involve regular contact with a counselor. TMC provides regular and sustained contact with the same counselor, but no ongoing support between calls. The future of continuing care for alcohol use disorders is likely to involve automated mobile technology and counselor contact, but little is known about how best to integrate these services. Methods/Design To address this question, the study will feature a 2 × 2 design (A-CHESS for 12 months [yes/no] × TMC for 12 months [yes/no]), in which 280 alcohol-dependent patients in intensive outpatient programs (IOPs) will be randomized to one of the four conditions and followed for 18 months. We will determine whether adding TMC to A-CHESS produces fewer heavy drinking days than TMC or A-CHESS alone and test for TMC and A-CHESS main effects. We will determine the costs of each of the four conditions and the incremental cost-effectiveness of the three active conditions. Analyses will also examine secondary outcomes, including a biological measure of alcohol use, and hypothesized moderation and mediation effects. Discussion The results of the study will yield important information on improving patient alcohol use outcomes by integrating mobile automated recovery support and counselor contact. Trial registration ClinicalTrials.gov, NCT02681406. Registered on 2 September 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2466-1) contains supplementary material, which is available to authorized users.

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.

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 more we as mHealth researchers get involved in dissemination, the more important it becomes to engage the community in that activity not only during needs assessment, solution development, and testing, but also to position that research for later dissemination. Community-based participatory research is desperately needed to maximize the impact of innovations.

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 ).

OBJECTIVES People who grow up with a family member who has a substance use disorder (SUD) are at risk for serious problems, and yet support for family members focuses mainly on the individual with the SUD. Technology may offer a way to make support widely available to family members of those with SUDs. This small randomized trial examined an online system of resources called CHESS (Comprehensive Health Enhancement Support System) for adult children of alcoholics (ACOAs), a population at greater risk for SUDs, depression, and other difficulties than adults whose parents were not alcoholics. METHODS The study randomized 23 self-identified ACOAs to 3 interventions for 8 weeks. The goal was to increase participants' treatment compliance and psychological health. The interventions were therapy only, CHESS only, and CHESS plus therapy. We used 2 measures: compliance with treatment, gauged by attendance in group therapy for the 2 groups assigned to therapy, and aspects of psychological health or distress, measured by a survey with items from 7 scales. RESULTS The CHESS-plus-therapy group had an attendance rate in group therapy of 81.5% compared to 42.8% for the therapy-only group. The CHESS-only intervention had the largest effect size on 5 of the 7 measures of psychological health or distress. In 4 of the 5 cases, the effect size was large; in 1 case, it was moderate. CONCLUSIONS The findings of this pilot study are based on a small sample, but they suggest the need for more research and the potentially important role of technology in behavioral health treatment.

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.

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.

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.

PurposeThis paper seeks to discuss measurement units by comparing the internet use and the traditional media use, and to understand internet use from the traditional media use perspective.Design/methodology/approachBenefits and shortcomings of two log file types will be carefully and exhaustively examined. Client‐side and server‐side log files will be analyzed and compared with proposed units of analysis.FindingsServer‐side session time calculation was remarkably reliable and valid based on the high correlation with the client‐side time calculation. The analysis result revealed that the server‐side log file session time measurement seems more promising than the researchers previously speculated.Practical implicationsAn ability to identify each individual user and low caching problems were strong advantages for the analysis. Those web design implementations and web log data analysis scheme are recommended for future web log analysis research.Originality/valueThis paper examined the validity of the client‐side and the server‐side web log data. As a result of the triangulation of two datasets, research designs and propose analysis schemes could be recommended.

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 article consolidates insights from 15 years of research examining howthe medically underserved use and benefit from an eHealth program, the Comprehensive Health Enhancement Support System (CHESS). The authors outline results from early feasibility tests to determine if the underserved would use CHESS. Distinctive behaviors of underserved populations who have used CHESS are reported with a focus on how online health information and computer-mediated support groups are used. The article then reports on how the underserved benefit from using CHESS. Best practice recommendations for recruitment and training the underserved are offered, and implications for closing the digital divide are discussed.

This article describes how 121 women newly diagnosed with breast cancer used a computer mediated discussion group to cope with their diagnosis. These data are part of a larger data set from a randomized clinical trial assessing the impact of a computer-based system called CHESS (the Comprehensive Health Enhancement Support System) on health outcomes. The larger study found significant improvement in health outcomes for those in the experimental group (those receiving CHESS), especially for women of color. Since discussion group is by far the most heavily used service of CHESS, one might conclude that these benefits (both overall and greater for women of color) should be attributed to amount of discussion group use. This study looks at how women of color and Caucasian women used the CHESS discussion group over the period of the study. Content analysis of messages in the discussion group showed that women of color used the discussion group differently from Caucasian women—they used it less frequently but their messages were more focused on breast cancer, suggesting they used discussion group more instrumentally.

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 Studies that prospectively and simultaneously evaluate, within the first year of diagnosis, the impact of surgery and chemotherapy on quality of life (QOL) of younger women (60 years or younger) with early stage breast carcinoma are limited. METHODS Quality of life of 103 women who had surgery (lumpectomy, 49; mastectomy, 54) approximately 1 month before the start of the study was evaluated at baseline and again after 5 months. Thirty-two women received chemotherapy during the study. RESULTS Over time, subjects reported improvement in body image and physical, emotional, and functional well-being (P < 0.001). They were less bothered by swollen/tender arms and worried less about risk of cancer to family members (P < 0.001). However, satisfaction with sex life, social support, and social/family well-being declined (P < 0.001). In the period closer to surgery, women with mastectomy reported poorer body image (P = 0.001) and worse functional (P = 0.08) and physical well-being (P = 0.10). Women with lumpectomy worried more about the effects of stress on their illness (P < 0.01) and had lower emotional well-being (P = 0.06). By 6 months after surgery, the two groups reported similar QOL scores. Chemotherapy had a negative impact on women's sexual functioning (P = 0.01) and their physical well-being (P = 0.09). Women who received chemotherapy also reported more shortness of breath (P = 0.07). Post hoc analysis showed that women with breast reconstruction had higher emotional well-being at baseline than those with lumpectomy (P = 0.001) and mastectomy alone (P < 0.01). CONCLUSIONS Younger women with breast carcinoma could experience a range of adjustment problems at various points in the treatment cycle. Interventions that would help reduce the negative impact of treatment on QOL need to be designed and integrated into routine clinical practice. Cancer 2001;92:1288–98. © 2001 American Cancer Society.

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.

The Comprehensive Health Enhancement Support System (CHESS) Is an Interactive computer system containing information, social support, and problem-solving tools. It was developed with Intensive input from potential users through needs-assessment surveys and field testing. CHESS had previously been us

This article describes the process of using needs assessment data to develop an interactive information technology specifically designed to support patients in a health-related crisis. The Comprehensive Health Enhancement Support System (CHESS) is an interactive information, social support, and problem-solving system that was developed by a team at the University of Wisconsin. This article looks at the program developed for breast cancer patients and their families.

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.

A computer-based support system was developed to help women cope with the crisis of breast cancer. The system, called Comprehensive Health Enhancement Support System (CHESS)contains integrated information, referral, decision, and social support programs. It was developed with intensive input from potential users through needs-assessment surveys and field testing. This article reports on the results of two pilot studies involving 30 women with breast cancer. The preliminary versions of CHESS were used extensively by older and younger women and by college and high school graduates. Participants in the pilot studies suggested several content enhancements and user-friendly aids for the developing system. User surveys indicated that CHESS was easy to use and would be valuable to other women with breast cancer, their partners, and their adult children. The women reported that they experienced more positive emotions and fewer negative emotions as a result of using the system.

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: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.

This study examined what characteristics predict participation in online support groups for women with breast cancer when users are provided free training, computer hardware, and Internet service removing lack of access as a barrier to use. The only significant difference between active and inactive participants was that active users were more likely at pretest to consider themselves active participants in their healthcare. Among active participants, being white and having a higher energy level predicted higher volumes of writing. There were also trends toward the following characteristics predictive of a higher volume of words written, including having a more positive relationship with their doctors, fewer breast cancer concerns, higher perceived health competence, and greater social/family well-being. Implications for improving psychosocial interventions for women with breast cancer are discussed, and future research objectives are suggested.

A fundamental challenge to helping underserved women and their families cope with breast cancer is providing them with easily accessible, reliable health care information and support. This is especially true for low-income families living in rural areas where resources are few and frequently distant as well as low-income families in urban areas where access to information and support can be complex and overwhelming. The Internet is one mechanism that has tremendous potential to help these families cope with breast cancer. This article describes a feasibility test of the potential for the National Cancer Institute's (NCI's) Cancer Information Service (CIS) to provide access to an Internet-based system that has been shown to improve quality of life for underserved breast cancer patients. The test was conducted in rural Wisconsin (low socioeconomic status [SES] Caucasian women) and in Detroit, Michigan (low SES African American women), and compares the effectiveness of several different dissemination strategies. Using these results we propose a model for how CIS telephone and partnership program services could efficiently disseminate such information and support systems. In doing so we believe that important steps can be taken to close the digital divide that separates low-income families from the resources they need to effectively face cancer. This is the first of two articles coming from this study. A companion article reports on an evaluation of the use and impact of this system on the women who were given access to it.

This article is the second of a two-part series reporting on a population-based study intended to use an eHealth system to examine the feasibility of reaching underserved women with breast cancer (Gustafson, McTavish et al., Reducing the digital divide for low-income women with breast cancer, 2004; Madison Center for Health Systems Research and Analysis, University of Wisconsin; Comprehensive Health Enhancement Support System [CHESS]) and determine how they use the system and what impact it had on them. Participants included women recently diagnosed with breast cancer whose income was at or below 250% of poverty level and were living in rural Wisconsin (n = 144; all Caucasian) or Detroit (n = 85; all African American). Because this was a population-based study all 229 participants received CHESS. A comparison group of patients (n = 51) with similar demographics was drawn from a separate recently completed randomized clinical trial. Use rates (e.g., frequency and length of use as well as type of use) as well as impact on several dimensions of quality of life and participation in health care are reported. Low-income subjects in this study logged on and spent more time on CHESS than more affluent women in a previous study. Urban African Americans used information and analysis services more and communication services less than rural Caucasians. When all low-income women from this study are combined and compared with a low-income control group from another study, the CHESS group was superior to that control group in 4 of 8 outcome variables at both statistically and practically significant levels (social support, negative emotions, participation in health care, and information competence). When African Americans and Caucasians are separated the control group's sample size becomes 30 and 21 thus reducing power. Statistical significance is retained, however, in all four outcomes for Caucasians and in two of four for African Americans. Practical significance is retained for all four outcomes. We conclude that an eHealth system like CHESS will be used extensively and have a positive impact on low-income women with breast cancer.

This study examined the relationship between breast cancer patients' experience of barriers to accessing health information and their psychosocial health outcomes and explored the extent to which this relationship was mediated by patient perceptions of competence in dealing with health-related issues. Study sample consisted of 225 women surveyed within 6 months of diagnosis. Regression analyses suggested that patients who reported greater difficulty in accessing needed information experienced lower emotional (P=0.05), functional (P

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

8088 Background: Advanced NSCLC patients continue to have high mortality with median survivals less that one year despite advances in anti-cancer therapies. This high mortality and symptom burden i...