Acceptability and feasibility of Community-based mHealth Motivational Interviewing Tool for Depression (COMMIT-D) to improve adherence to treatment

项目摘要 治疗依从性差是抑郁症护理中的一个全球性问题，三分之一的患者停止治疗 抗抑郁药在治疗的第一个月。社区医护人员(CHW)已成功使用 激励性访谈(MI)，以提高美国和全球各种疾病的治疗依从性。 然而，持续的挑战包括：1)缺乏对沟通技能(如MI)的实时支持，例如 CHW正在与病人交谈；以及2)CHW的MI技能在没有 持续的监督，因为社区卫生工作者远离医疗机构，从一个病人的家到另一个病人的家。 移动医疗(MHealth)工具有可能通过以下方式应对这些挑战：1)提供MI决策- 社区中的支持；以及2)创建患者-CHW音频记录，然后可供 主管帮助CHW保持MI技能，防止技能衰退。在我们过去十年工作的基础上 在尼泊尔农村多年，我们将为CHW开发一款mHealth应用程序-基于社区的mHealth激励 抑郁访谈工具(Commit-D)-将为MI和捕获提供决策支持 经同意的患者互动录音，供基于设施的MI专家审查和反馈。 科学的前提是基于三个公认的行为原则：五步设计思维 (迭代的利益相关者投入提高了可接受性和可行性)，社会心理学(内在的，而不是 外在动机与积极行为相关)，以及MI因果链模型 (CHW做出的不一致的声明改善了患者的预后)。我们已经开发了设施- 以及尼泊尔语中针对抑郁症和其他慢性病的基于移动的数字决策支持工具。 虽然我们现有的工具侧重于基于知识的技能，但拟议的干预措施将侧重于 沟通技巧(例如，评估患者的变化阶段并在一致的MI中做出响应 方式)。使用以人为中心的五步设计思想，我们将迭代地开发和测试Commit-D 以及来自利益相关者的频繁、结构化的意见。然后，我们将进行为期6个月的试点试验，以研究其 患者、社区卫生工作者及其主管的可接受性和可行性。我们将评估影响的途径 通过测量CHW对MI原则的保真度(使用标准工具MITI)，治疗依从性 (抗抑郁药物和临床预约)，以及对抑郁结果的总体影响(患者健康 问卷--9分)。我们的团队组成了研究团队之间长达十年的合作， 尼泊尔非营利性医疗保健提供者的可能性，以及尼泊尔政府。这项研究将得到发展和持续 尼泊尔的研究能力建设，通过面对面研讨会、在线讲座和 指导研究mHealth、MI、抑郁症、手稿写作和研究的伦理行为。如果 成功，这项研究的结果将成为评估有效性和相关性的有力试验 服务不足的全球人口，包括美国的人口。

Project Summary Poor adherence to treatment is a global problem in depression care, with one-third of patients discontinuing antidepressants in the first month of treatment. Community healthcare workers (CHWs) have successfully used Motivational Interviewing (MI) to improve treatment adherence for various illnesses in the US and globally. However, persistent challenges include: 1) lack of real-time support for communication skills (such as MI) as the CHWs are talking to the patients; and 2) decay of MI skills among CHWs through time in the absence of ongoing supervision because CHWs work away from facilities, traveling from one patient's home to another. Mobile health (mHealth) tools have the potential to address these challenges by: 1) providing MI decision- support in the community; and 2) creating patient-CHW audio recordings, which can then be used by supervisors to help CHWs maintain MI skills, preventing skill decay. Building on our work over the last ten years in rural Nepal, we will develop an mHealth app for CHWs—Community-based mHealth Motivational Interviewing Tool for Depression (COMMIT-D)—that will provide decision-support for MI and capture consented audio recordings of patient interactions for review and feedback by facility-based MI specialists. The scientific premise is based on three well-established behavioral principles: five-step design thinking (iterative stakeholder inputs enhance acceptability and feasibility), social psychology (intrinsic, rather than extrinsic, motivation correlate with positive behaviors), and the MI causal chain model (MI-consistent statements made by CHWs improve patient outcomes). We have already developed facility- and mobile-based digital decision-support tools for depression and other chronic conditions in Nepali. Whereas our existing tools focus on knowledge-based skills, the proposed intervention will focus on communication skills (e.g., assessing the patient’s stage of change and responding in an MI-consistent manner). Using the five-step human-centered design thinking, we will iteratively develop and test COMMIT-D with frequent, structured input from stakeholders. We will then conduct a 6-month pilot trial to study its acceptability and feasibility among patients, CHWs, and their supervisors. We will assess pathways to impact by measuring CHW fidelity to MI principles (using the standard tool MITI), treatment adherence (antidepressants and clinic appointments), and the overall impact on depression outcomes (Patient Health Questionnaire-9 scores). Our team constitutes a ten-year-long collaboration between the research team, the Nepali non-profit healthcare provider Possible, and the Nepal Government. This study will develop and sustain research capacity-building in Nepal by supporting researchers via in-person workshops, online lectures, and mentored research in mHealth, MI, depression, manuscript writing, and ethical conduct of research. If successful, the results from this study will inform a well-powered trial to assess effectiveness and relevance to underserved global populations, including those in the United States.