Patient education regarding end-stage renal disease (ESRD) has the potential to reduce adverse outcomes and increase the use of in-home renal replacement therapies.This study aimed to investigate whether an online, easily scalable education program can improve patient knowledge and facilitate decision making regarding renal replacement therapy options.We developed a 4-week online, digital educational program that included written information, short videos, and social networking features. Topics included kidney transplant, conservative management, peritoneal dialysis, in-home hemodialysis, and in-center hemodialysis. We recruited patients with advanced chronic kidney disease (stage IV and V) to enroll in the online program, and we evaluated the feasibility and potential impact of the digital program by conducting pre- and postintervention surveys in areas of knowledge, self-efficacy, and choice of ESRD care.2. Before the intervention, 32% of patients (8/25) were unable to make an ESRD treatment choice; after the intervention, all 25 participants made a choice. The proportion of persons who selected kidney transplant as the first choice increased from 48% (12/25) at intake to 84% (21/25) after program completion (P=.01). Among modality options, peritoneal dialysis increased as the first choice for 4/25 (16%) patients at intake to 13/25 (52%) after program completion (P=.004). We also observed significant increases in knowledge score  and self-efficacy score .Of the 98 individuals found to be eligible for the study, 28 enrolled and signed the consent form and 25 completed the study. The average age of participants was 65 (SD 15) years, and the average estimated glomerular filtration rate was 21 (SD 6) ml/min/1.73 mImplementation of a digital ESRD education program is feasible and may facilitate patients’ decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes.ClinicalTrials.gov NCT02976220; https://clinicaltrials.gov/ct2/show/NCT02976220 An important part of care for patients with moderate to advanced chronic kidney disease (CKD) is education about treatment options for end-stage renal disease (ESRD) including in-center or in-home renal replacement therapies as well as nondialysis treatment options including kidney transplant or conservative management with no dialysis. Unfortunately, rather than planning ahead for ESRD, up to 50% of patients have emergent starts or undergo unplanned, urgent starts to dialysis ,2. CircuStudies have shown that predialysis education may increase the likelihood of patients undergoing planned, elective dialysis starts . PredialWe conducted a feasibility and preliminary efficacy study of the Modality Decision Program, a digital online educational program designed by specialty kidney care provider, Cricket Health, to prepare patients with advanced CKD for choosing a plan of care in the event that they reach ESRD . We hypoStudy participants were recruited in person, by mail, and by physician referral from the University of California, San Francisco (UCSF) Nephrology and Hypertension Clinic and the San Francisco Veterans Affairs Medical Center (SFVAMC) Renal Clinic. Patients at these clinics were first screened for eligibility using electronic health records and then mailed a letter explaining the study and providing contact information of the study coordinator. Screening of the medical record was primarily done manually by the study coordinator in the research team; additional efforts to enroll patients were made by enlisting the Clinical Research Services at UCSF to send out letters via their Recruitment Service. Two weeks after the recruitment letter was sent, the study coordinator called to inquire if they would like to join the study and to further evaluate eligibility. Participants were offered US $300 for completing the 2-month study. Flyers were also posted at UCSF and SFVAMC for eligible patients to contact the study team.2 in the 6 months before enrollment, attendance at the renal clinic at least twice within the 18 months before enrollment, and documented discussion between patient and nephrologist about the potential need for dialysis in the future. Any 1 of the following resulted in exclusion: currently on dialysis, eGFR ≥10 ml/min/1.73 m2 over the past 6 months, age greater than 90 years, homelessness, inability to speak English, lack of phone or computer or internet access, lack of email access, dementia, severe cognitive impairment, blindness, deafness, or more than 2 hospitalizations during the last 6 months. All participants gave written informed consent. All procedures were in accordance with the Declaration of Helsinki . The study was approved by the UCSF Human Research Protection Program Institutional Review Board (IRB study #16-19626), including waivers of written consent and Health Insurance Portability and Accountability Act authorization, and was registered on ClinicalTrials.gov (NCT02976220).The study coordinator screened medical records, and the principal investigator confirmed the patient’s eligibility for the study based on the inclusion and exclusion criteria. Eligibility criteria included an estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 mThe main objectives of the educational program were to (1) increase patient knowledge of ESRD treatment options, (2) help patients to prioritize options based on their lifestyle and values, and (3) build patients’ confidence in their treatment choice. The program design was informed by prior successful education programs . The proFollowing the intake visit, participants were asked to engage with the educational program over a period of 4 weeks. During the 4 weeks, the study nurse followed up with the patient via messaging on the website and the participant had the opportunity to read educational materials and interact with the nurse and peer mentor group. For a participant to be considered adequately engaged with the program, the participant had to send at least one message to the nurse, mentors, or discussion board and also view at least one video or FAQ. These metrics of engagement were monitored by Cricket Health, and if a patient’s engagement was less than adequate on the online study platform during the 2 weeks following the intake visit, the study coordinator reminded the patient to engage with the platform. Program completion was marked by the end of the 4-week period or by the achievement of adequate engagement when not achieved by the end of the 4-week period. Upon completion of the educational program, participants discussed their preferred treatment option with the study nurse and addressed any remaining questions or open topics. On the basis of these discussions, the study nurse compiled an insights report summarizing the education the patient had received and any major concerns the patient expressed about their plan of care. After completion of the program, an insights report was sent to the patient and, if requested, their nephrologist.Each participant attended 3 study visits over a period of 2 months at the UCSF Nephrology and Hypertension Clinic. At the first study visit, the study coordinator conducted intake interviews, administered baseline surveys, took a medical history, verified eligibility, and obtained written informed consent. Participants were informed that completion of the study would require 8-14 hours over 2 months . The coordinator helped the participants log on to the website and gave them a tour of the program. The study nurse was present via online video during the intake visit. After participants completed the 4-week education program, they returned for a second study visit during which they repeated the survey administered at baseline. Participants attended a third study visit 1 month after completion of the intervention and were administered the same survey to evaluate whether the educational program had a durable effect. The third study visit occurred 1 month after the second (2 months after intake). During both the second and the third visits, participants were given the opportunity to provide qualitative feedback on the program.The study survey was developed specifically for this pilot study according to the educational content of the instructional materials. Cricket Health gave the research team access to the online subject matter so that we could ensure our surveys covered topics included in the educational program. We conducted a literature review of relevant surveys for patients with CKD to assess the content, vocabulary, and complexity of such surveys. CKD knowledge was assessed by 18 multiple-choice questions about knowledge of dialysis and treatment options modeled on those found in the Kidney Knowledge Survey , the ESRWe contacted each patient’s nephrologist to inform them of the patient’s participation in the study and obtained consent from each nephrologist to contact him or her after the patient completed the study. To evaluate provider perspectives on the usefulness of the educational program for their patients’ individual care, we surveyed study participants’ nephrologists after each patient completed the final visit. The survey included 5 questions assessing whether the program helped the patient and the physician prepare for ESRD care .Initial analyses described the multistep enrollment into the study. For participants who completed the study, we describe engagement with the 4-week educational intervention program and demographic and clinical characteristics at baseline. In this single-group, pretest-posttest study design, patients served as their own control. On the basis of the results of a previous pretest-posttest study of a self-management education program among patients with CKD that evaluated changes in self-efficacy using a survey totaling 250 points , we calcWe designed this study to include 2 posttest surveys to allow the primary evaluation of program effects immediately following program completion as well as a secondary evaluation of the durability of the effects of the educational intervention 4 weeks after program completion. Each participant’s CKD knowledge was scored as the percentage of answers correct out of the 18 CKD knowledge questions from the survey. Confidence in treatment choice and CKD self-efficacy were measured by participants’ responses on individual items according to a 5-point Likert scale. Additionally, scores from all 5 CKD self-efficacy questions were averaged to calculate an overall CKD self-efficacy score. In the main analyses, differences in scores on the survey completed before participating in the online program and after 4 weeks of participating in the program were evaluated by the Wilcoxon signed-rank test. For each measure, we also calculated the number and percentage of patients who improved their score. We described the number and percentage of patients choosing a specific preferred treatment option pre- and postintervention and used McNemar exact test to evaluate differences.Overall, out of 2617 patients screened for eligibility, 156 were potentially eligible after screening the medical chart. After contacting these 156 patients, 98 were deemed eligible after the phone interview. Among 98 eligible patients, 48 were interested in the study and 39 scheduled an intake visit. Of these, 28 attended an intake visit and 25 completed the study .Characteristics of the 25 study participants who completed the study are summarized in According to metrics collected by Cricket Health, each patient engaged with the program for a median of 5 (interquartile range: 2-6) hours over a mean of 32 (SD 14) days. Most participants used their own devices, although 3 participants  accessed the program using a shared or public computer. All participants viewed at least one FAQ, 24  watched at least one video, and 21  chatted with a nurse. Four participants needed more than 4 weeks to demonstrate adequate engagement with the online program and make a modality decision on the month 1 survey. Further details about patient engagement with the videos, FAQs, and discussion are summarized in P=.01). In a post hoc analysis, we determined patients’ preferred treatment choice in the case that a kidney transplant was not available or feasible . At intake, 4  participants chose peritoneal dialysis if transplant was not available, compared with 13  participants after program completion (P=.004). At intake, 2  participants chose in-home hemodialysis if transplant was not available, compared with 4  participants after program completion (P=.50). These proportions remained similar after program completion and 4 weeks later at the month 2 survey  of the participants were unable to make a choice in the treatment plan; after completing the program, 100% (25/25) of the participants made a choice. The most commonly preferred treatment choice was kidney transplant, and the proportion of patients choosing this option increased from 12 12/25, 48%) at intake to 21  after program completion . The mean (SD) of all individual self-efficacy scores also increased significantly after the intervention, from 3.2 (1.4) to 4.1 . Self-efficacy scores on 3 of the 5 individual Likert items improved, specifically: “My treatment would be just as good if I was responsible for my dialysis,” “I understand self-care dialysis,” and “I understand in-center dialysis” . In contrast, there was no statistically significant difference between intake and postintervention scores on the following statements: “I can actively share my experience of managing CKD with other patients” and “I could learn how to do self-care dialysis” . Furthermore, most patients improved their scores between surveys performed at intake for each participant and program completion: 19  on CKD knowledge, 15  on confidence in treatment choice, and 20  on overall CKD self-efficacy. Month 2 scores on assessments of CKD knowledge, confidence in treatment choice, and self-efficacy were similar to those from immediately after program completion  that they would recommend the program to a friend or family member, that the program was valuable in making a treatment choice, and that the website was easy to use. Among 22 nephrologists of program participants, 21  indicated that the program helped their patients prepare for ESRD care, 18  indicated that the program helped the patient choose a care plan for ESRD, and 21  indicated that the program helped the physician learn about the patient’s lifestyle and care preferences and also made it easier for the physician to care for the patient. Only 1  indicated that the program could be improved by including more information on management.In this study, we found that delivering digitally enabled ESRD education to patients in clinical care is feasible using the Modality Decision Program developed by Cricket Health. Patients demonstrated a high level of engagement, and they were able to complete the program and make a choice in the plan of ESRD care. Kidney transplant was the most common first choice for ESRD care. Among choices for dialysis modality, we observed that patients were more likely to choose self-care, in-home dialysis options  after completing the education program. The Cricket Health program increased patients’ knowledge of ESRD treatment options as well as their self-efficacy regarding self-care, in-home dialysis modalities.The importance of predialysis patient education is well established . Prior rThe Modality Decision Program developed by Cricket Health builds on these prior educational programs and also addresses the need for education that can be digitally distributed to a wider audience of CKD patients. The online, digital format increases accessibility, addresses individual lifestyles and preferences, and allows the patient to learn about modality options at his or her own pace. Throughout the educational materials, patients are encouraged to choose a treatment option that fits into his or her own lifestyle. This individualized approach likely contributes to the success we observed in improving patients’ knowledge of ESRD, willingness to choose peritoneal dialysis when transplant is not an option, and to enhance patients’ confidence and self-efficacy regarding treatment choice.In addition to the quantifiable effects on patient knowledge and treatment choice, the Modality Decision Program may have an emotional impact. The educational program incorporates emotional support for patients by integrating peer mentors who already have ESRD and facilitating one-on-one communication with the study nurse. During the program, these sources of emotional support are available through email and chat, which is likely to be more convenient and accessible than conventional in-person support groups. As other researchers have noted, a patient’s effort to learn about CKD can be undermined by uncertainty and fear . AlthougPatients with kidney disease often have other comorbidities that complicate their plan of care. Educational programs should take into account the complex medical condition of many CKD patients and provide educational content addressing the intersections of comorbid diseases, such as diabetes and CKD. Subsequent programs developed by Cricket Health have focused on disease-specific aspects of CKD management, including blood pressure management, congestive heart failure, diet, and nutrition.Enrolling patients with CKD into clinical trials is challenging. Reasons for low enrollment of CKD patients into clinical trials may include their high comorbidity burden, necessitating frequent doctor visits or hospitalizations that make the patient unable to attend study visits, and their high rates of disability . We obseThis study has several limitations. The patient survey we developed to evaluate changes in patient knowledge and self-efficacy used items from validated surveys but was not validated in our population. The study design involved a single group of patients, and the results might be less conclusive than if it were structured as a randomized controlled trial. Specifically, it is possible that the observed improvement may have occurred for reasons unrelated to the program, although there are no other known potential sources of improvement. Our geographical focus in the San Francisco Bay Area and the requirement that participants be screened for eligibility by phone may have selected a higher proportion of affluent, tech-savvy participants that might not be representative of the broader US population. However, our sample of participants was racially diverse and represented a relatively broad socioeconomic spectrum. One of our inclusion criteria was that the patient must have had a documented discussion of dialysis with his or her nephrologist during a clinic visit. We felt it was important for ethical reasons to make sure the patient was not informed for the first time by the study team about the possible need of dialysis in the future; however, these criteria did limit the number of patients in the study and could result in a more informed sample with greater knowledge of ESRD treatment options than the general US population of patients with advanced CKD. We also felt that excluding patients with more than 2 hospitalizations in the past year or no internet access would help expedite timely completion of the study, but these criteria did also limit generalizability as well as our sample size.In conclusion, we have conducted a pretest-posttest study among 25 patients with advanced CKD to evaluate the potential impact of the Modality Decision Program developed by Cricket Health for increasing patients’ CKD knowledge, self-efficacy, ability to make a choice in ESRD treatment modality, and preference for in-home therapies. After completing the Modality Decision Program, patients had improved knowledge, confidence, and self-efficacy; were able to make a choice of treatment modality for ESRD; and were more likely to choose self-care, in-home dialysis therapies as their preferred dialysis modality. In summary, implementation of a digital ESRD education program is feasible and may be effective in facilitating patients’ decisions about renal replacement therapies. Larger studies are necessary to understand whether the program affects clinical outcomes.


Recent years have seen an increase in Arabic-speaking immigrants in Sweden and other European countries, with research showing this group to suffer from elevated levels of various forms of psychological disorders. There is a lack of treatment options for immigrants with mild to moderate mental health problems, with barriers including lack of accessible services and concerns that problems will not be understood by health care providers.This study aims to describe the process of developing a transdiagnostic internet-based cognitive behavioral therapy self-help program in Arabic for mild to moderate symptoms of common psychological problems such as anxiety, depression, and insomnia.The iterative development process, including feedback from 105 pilot users as well as 2 focus groups, is described.Overall, the modules were rated as acceptable by the pilot users, with overall ratings ranging from 3 to 4 points on average for the respective modules on a 5-point Likert scale. Feedback from the 2 focus groups was overall positive with regard to the content and structure of the program but also included suggestions for improving the Arabic translation as well as the usability of the material.An internet-based self-help program that is deemed acceptable by an Arabic-speaking audience can be successfully developed, thus providing increased access to psychological help for an at-risk population. However, further research regarding the efficacy of this type of intervention is warranted. Recent years have seen a sharp increase in Arabic-speaking immigrants in Sweden, with a majority of these arriving from either Syria or Iraq . ResearcThere is a lack of treatment options for immigrants with mild to moderate mental health problems in Sweden, partly because of an overall low availability of psychotherapy in Swedish primary care , and espInternet-delivered cognitive behavioral therapy (ICBT) could be one way to approach some of the issues mentioned above, as internet-delivered treatment can be translated into different languages and has the potential to reach more people than conventionally delivered psychotherapy, requiring less therapist resources . Moreoveculturally adapted to fit the target audience )The culture and language adaptation consisted of an iterative process, with ongoing feedback from the translator as well as number of pilot users of mixed Arabic origin commenting on the language, content, as well as the overall tone of the modules. The next step involved a total of 105 real-life test users evaluating 133 modules in Arabic through a built-in evaluation function at the end of each module. The users were asked to rate the respective modules on a 5-point Likert scale with regard to whether they found the content understandable, whether it was helpful, and whether they intend to make use of the information and advice in the future. They were also asked to provide an overall rating of the module using the same 5-point Likert scale. It was also possible to provide comments in a free-text format. In addition, 2 focus groups were held, with the aim to provide detailed feedback with regard to how the modules are experienced by the target audience.The focus groups centered around three main questions:How did the participants experience the content and structure of the modules?How did the participants experience the Arabic translation?How did the participants experience the treatment platform?The focus group data were analyzed using qualitative content analysis , focusinImportantly, with regard to cultural adaptation, the initial versions of the program focused mainly on the adaptation of peripheral treatment components including language, semantics, as well as the treatment format itself, which was hypothesized to enhance treatment seeking and engagement by increasing anonymity, given that mental health is still highly stigmatized in Arabic culture . With reThe test users evaluating the Arabic versions of the modules were recruited through advertising through social media platforms and Web search engines. In addition, a number of Web-based seminars aimed at professionals working with recently arrived immigrants were held, aiming to disseminate information about the project. Interested individuals visited the program website where they had to register using an email address and provide a personal password. Once registered, the participants had free access to all the material and were asked to provide ratings as described above at the end of each module. No information was collected about the participants, except for their ratings of the respective modules. The reason for not collecting additional information about the test users was to guarantee their anonymity, as we hypothesized that this would make it significantly easier to recruit test users, given the aforementioned mental health stigma in Arabic culture.The participants in the first focus group consisted of, to our knowledge, the only Arabic-speaking clinical psychologist and the only 2 Arabic-speaking psychology students living in the county of Östergötland where the project took place. All 3 participants were female and were aged between 20 and 40 years. All 3 participants were born in Arabic-speaking countries and had immigrated to Sweden as children together with their families. The participants in the second focus group were recruited at the local branch of the Swedish Red Cross language group for recently arrived immigrants. The 6 participants comprised 5 recently arrived Arabic-speaking immigrants from 4 different countries  with varying professional backgrounds as well as 1 librarian with experience of working with Arab immigrants volunteering for the Swedish Red Cross. All 5 immigrants were male, whereas the librarian was female, with the participants aged between 20 and 60 years.The results from the 105 real-life test users are summarized in Word choices in the Arabic translation, Computer literacy in target population, and Satisfaction with content and structure. With regard to the first theme, all participants agreed that some parts of the Arabic translation needed revision, as some words were overly academic and therefore might be difficult to understand for nonacademics. They also agreed on other words being primarily used in North African countries and therefore making some paragraphs confusing to Arabs originating from countries in the Middle East. In addition, the participants also pointed out a number of spelling and grammatical errors in need of correction.Overall, three main themes emerged from the analysis of the first focus group, which were as follows: The second theme pertained to whether or not Arabs living in Sweden had sufficient computer literacy skills to make use of the program. This was primarily brought up as a concern by 1 participant who gave the suggestion to have a short video clip on the start page, introducing the user to the Web page and material to make the program more user-friendly. With regard to the third theme, all participants agreed that they were satisfied with the content and structure of the material and saw little need for improvements or revisions.Overall satisfaction with program, Enhancing usability, Stigmatization of mental health, and Additional content. With regard to the first theme, all participants in the second focus group agreed that the overall structure and content were satisfactory, although they said that the program could be enhanced by making the material more interactive, for example, by adding free-text fields, which users could use to reflect on their own progress with the exercises. The second theme had to do with several suggestions put forward by the participants on how to improve the usability of the program. Similar to the first focus group, they too pointed out several spelling and grammar errors in need of correction to make the texts easier to understand. One participant also recommended having shorter versions of the material for users with less reading experience, whereas another participant suggested that it would be good to have the possibility to have the text read out loud by the program for users with reading or concentration difficulties. The third theme focused on stigmatization of mental health problems in Arabic culture and ways to address and work around this to get more users to actually make use of the program. Relating to this, 1 participant suggested putting more emphasis on biological explanatory models for mental illness as this might be viewed as less stigmatizing than psychological explanations. Another participant suggested putting even more emphasis on normalizing psychological problems and help seeking to reduce stigmatization. A third suggestion from another participant was to have a person with authority in an Arab population, such as a psychiatrist or psychologist with an Arabic background, introduce the material in a short video clip at the opening page, dispelling common myths and misunderstandings about mental health. Overall, there was a concern among the participants that mental health stigmatization would constitute a barrier for many users accessing the program. Finally, the fourth theme had to do with some participants seeing a need for additional content in the program to meet the needs of Arab immigrants in Sweden. One participant suggested we address problems with concentration, perhaps in a separate module. An additional suggestion concerned having more information with regard to good habits when living in Sweden, such as eating vitamin D supplements and the importance of going outside despite the cold weather. Finally, 1 participant also saw a need among many immigrants to address issues relating to shame and guilt concerning culture-specific practices  that come about when viewing these practices from the lens of Swedish culture.The analysis of the second focus group resulted in four main themes, which were as follows: In response to the feedback received, it was decided that a second translator would be consulted to further review the Arabic translation as this was a theme that was brought up in both focus groups. This translator was herself an immigrant from Syria with an academic background from Damascus, whereas the first translator was born in Sweden and had acquired Arabic as a second language and was currently living in Egypt. With regard to suggestions to increase usability by shortening the material even more, this was decided against, given the potential risk to dilute the content, especially given that the material already consisted of distilled versions of well-researched programs. However, other suggestions relating to this theme, such as having a function that reads the text out loud, were deemed interesting but outside the scope of the current revision process. With regard to the issue of stigmatization as a barrier to accessing the material that was brought forward by the second focus group, we decided to look over the wordings of the program in relation to normalization of mental health problems. However, in most cases, we decided to stick with the original wording as we did not want to blur the important distinction between clinically significant suffering and normal functioning. Moreover, we also decided not to change the emphasis more to biological explanatory models as we felt that this might risk making the CBT conceptualization less conceptually clear and stringent. Regarding some of the other themes that were brought up in the focus groups, such as adding new content, addressing other problem areas, or using video to introduce the material to make it more user-friendly and possibly reduce stigmatization, we felt that these were interesting ideas for future developments of the program, given their more encompassing nature.The final version of the program was equally accessible on computers and mobile devices such as mobile phones and tablets. To make use of the material, the user had to register using an email address and provide a personal password. No personal information was collected about the user except their ratings of the various modules. The program is currently freely available through the Iterapi platform at Linköping University, as described above, and the plan as of now is to continue to host the program through this platform.Overall, it seems that an acceptable internet-based self-help program in Arabic can be successfully developed, based on the results from the focus groups and test user evaluations. With regard to the cultural adaptation of the program, it seems that the relatively modest adaptations made to the material were sufficient to make the program acceptable for the target audience. This might reflect a changing discourse regarding mental health, both in the Middle East and among Arab immigrants, moving from more traditional, religious, or supernatural explanatory models to biological and psychological models more in line with a contemporary Western perspective .The 105 test users gave acceptable ratings for the modules, although the sample size was too small to examine the relative acceptability of the different modules. With regard to the comments left by the users in the free-text section, they can be seen as indicative of the fact that this type of intervention will likely be helpful for some but not all individuals, as reflected by the small effect sizes found in previous research . Other iWith regard to the 2 focus groups, although they both agreed on the overall acceptability of this program, they also had a number of suggestions for improving the program. In the end, we chose to mainly focus on one of these suggestions, namely, consulting a second translator to review the wording of Arabic translation, removing or changing words that were overly academic or that are only used in North African countries. However, the participants in the second focus group also came with a number of interesting suggestions on how to further develop the program, which we have considered below under Future Directions.In retrospect, it would have been a good idea to conduct focus groups earlier in the developmental process before deciding on which problem areas to focus on in the different modules. Had we done this, we might have included additional material aimed at concentration difficulties, as suggested in the second focus group. In line with this, it might also have been beneficial to conduct the focus groups and revise the program before testing the program with a group of test users. The reason that we chose the procedure that we did was to first get a sense of the overall acceptability of the program and then, if the program overall was deemed acceptable, get more specific feedback through the focus groups. However, reversing the order would have enabled us to have the test users try out the final version of the program, which would likely have yielded different feedback and also somewhat higher ratings of acceptability.An additional limitation concerns the lack of information regarding sociodemographic characteristics of the test users. This limits the generalizability of the findings, given that we cannot know for sure whether the test users are representative of the target population. On the other hand, as there was no monetary compensation or other compensation for the test users, it is likely that the individuals who signed up for the program did so because they had some degree of mental health problems that they wanted help with. Furthermore, given that the program will continue to be freely accessible in the same way as during the test period, it is reasonable to assume that the test users are representative of those who might use the program in the future.A final limitation concerns the fact that online programs such as this one necessarily are limited to those individuals with access to the internet, which is probably not always the case for newly arrived immigrants or refugees. However, it is important to underscore that internet-based self-help programs merely constitute 1 potential pathway for accessing psychological help and should not be used as an excuse to not develop other types of services or treatment formats.Future directions include working to disseminate the program further, making it widely known to both service providers and potential users so that it is actually put to use. Other possible future directions include going forward with some of the suggestions put forward by the 2 focus groups, such as having voice recordings of the material, integrating the use of video more in the material, and addressing problems with concentration, as mentioned above. Another interesting possibility would be to test the material in a more formalized way in a randomized controlled trial, to evaluate the efficacy of the program in treating mental health problems among the target population.In conclusion, an acceptable internet-based self-help program in Arabic for mild to moderate symptoms of psychological problems can be successfully developed. However, further research is warranted regarding the efficacy of the program. Future developments of the program should consider making the program more user-friendly by, for example, adding voice recordings of the material as well as adding additional content addressing specific concerns of the target population.


LAC) are often described as a ‘hard to reach' group of young people, and their voices are rarely sought to inform academic research.Looked after children and care leavers (denoted as PPI) group that was set up in the context of an ongoing health service intervention trial with LAC.This paper reports on experiences and reflections of a group of children and young people and academic researchers who developed a Patient and Public Involvement  each approximately 1 hour in length were conducted over an 18‐month period.Eighteen qualitative semi‐structured interviews were conducted with seven The qualitative interviews were transcribed verbatim. Thematic analysis was used to analyse the data, and direct quotes are used within the paper.LAC used the PPI group to produce a 5‐minute video to highlight why they think young people should be involved in research. Overall findings suggested that it was feasible to develop a research‐related PPI group with LAC. Findings from the research were used to co‐develop ‘top tips' of working with vulnerable young people such as looked after children.The PPI with LAC can be done if a co‐production approach to research is taken. It also suggests that assumptions regarding the capabilities of young people as researchers need to be re‐evaluated.This paper has shown that  They are termed as living in Out of Home care in Australia and the United States. There are almost 73 000 children in the UK care system.Looked after children and care leavers (henceforth LAC) are often disadvantaged, and they are more likely than their peers to have experienced Adverse Childhood Experiences.2, p.5 Ideally, a co‐production approach should be taken, in which researchers, the public and professionals work together to share power and responsibility for the whole research project.The National Institute of Health Research (NIHR) defines involvement as ‘research being carried out “with” or “by” members of the public rather than “to,” “about” or “for” them'., p. 21 Much PPI is conducted with adults and often underrepresents, daytime workers, people from lower socio‐economic backgrounds without a university education and ethnic minorities.In research, PPI work has a tendency to focus on specific health conditions, and experiences of attending health services.Guidelines are available to inform the involvement of CYP in PPI groups and research., p. 229 the prospect of engaging a population whom is transient and surrounded by multiple complexities can be daunting. This coupled with researchers having limited time and finite resources to dedicate to engaging this group of young people results in the voices of LAC being underutilized in the research process.This paper aims to make a contribution to filling the gap regarding involving marginalized populations of CYP in research. Dominelli (2005) states that ‘even the most premeditated forms of empirical qualitative research tend to be unpredictable and somewhat “messy”',3Semi‐structured interviews were conducted at two separate time points  with LAC. This method was chosen for its strength in exploring participants' experiences, feelings and perspectives. A semi‐structured approach used a topic guide, but allowed the researchers to remain flexible enough to explore unforeseen areas of discussion. The first semi‐structured interviews took place with seven LAC. Interviews explored LAC's understanding of the term ‘research', how they felt they could contribute to a research project and their expectations and feelings about working with researchers. Interviews were completed by the researchers facilitating the PPI project. LAC volunteered to take part in the interviews conducted within a Children in Care Council (CICC) session; the interview took place in a separate room to ensure confidentiality.The researchers involved in the PPI project were interviewed (n = 3) twice by an independent researcher. The first interviews aimed to capture the researcher's previous experience of being involved in PPI work and their hopes and expectations of the project prior to it commencing.Upon completion of the PPI work, a second qualitative interview took place with participants . The final interview with LAC included participants who were present within the CICC session and had been involved in the PPI work. Four of the original seven involved in the first interview took part . Interviews discussed participants' experience of being involved in the research, if their expectations had been met and whether anything needed to change to facilitate involvement in future research projects. The interviews also aimed to increase our understanding of the practicalities and process of working with LAC.Prior to each interview, written informed assent/consent was obtained from all researchers, the CICC participation officer and LAC, inclusive of consent from the corporate guardian for LAC under 16 years of age. Interviews were carried out by experienced researchers, audio‐recorded and transcribed verbatim. Transcripts were anonymized, and a participant key was stored separately.Looked after children and care leavers were given a £10 voucher for each session they engaged with to demonstrate that their contributions are valued and their expertise respected.Study data have been analysed using thematic analysis.The findings from this project explored pre‐conceptions about the ability to engage and work with this group of young people.3.1This PPI project was set up in the context of an ongoing health service intervention trial called Supporting Looked After Children and Care Leavers In Decreasing Drugs, and alcohol (SOLID). Within the initial set up phase of the SOLID trial, the research team consulted with LAC and received feedback that they would like to have been involved at an earlier stage to more fully influence the research agenda. This drove forward a satellite piece of work, to understand more about how to work closely with LAC to develop an ongoing research programme. We approached an already established CICC to determine whether LAC would like to be involved in a PPI project. In the UK, each local authority has a CICC specifically designed to give children in care and care leavers an opportunity to have a voice and give their opinions on how the council should run its Children's Services. The CICC participation officer acted as a mediator and arranged for researchers to attend a CICC meeting. LAC were asked to register their interest in taking part in the PPI project with the CICC participation officer. Once confirmation of interest was received, a series of sessions were set up in collaboration with all LAC.The CICC participation officers' role was to organize mutually convenient times for LAC and researchers to meet. Sessions were organized to accommodate the requests of the LAC regarding times, duration and venue. LAC requested that researchers attended the already established CICC meetings on dates convenient to them; that is, PPI sessions did not conflict with their other commitments. During sessions, a separate room was provided, so that individuals could either take part in the PPI work or stay within the CICC meeting, exercising their right to be involved in the PPI work and equally their right not to be involved.The LAC were 15‐19 years old, all were white, in keeping with the majority demographic of the local area, and resided in North East England. The LAC  resided in foster placements, residential children's homes and independent living.The project enabled LAC to establish their own project using methods of their own choice. It was established through informal discussions and the initial semi‐structured interview that LAC would like to produce a video. This video could be used to inform other CYP and academics what research is and why they think young people should be involved in research projects. LAC took part in sessions according to their own interests and abilities.Sessions were in two parts: the first involved a facilitated exploratory discussion to consider components of ‘academic research', within which different types of research, that is, qualitative and quantitative methods and types of data collection such as interview/focus groups and surveys were discussed. The second part of the session was used to video record the group taking part in activities and practising skills such as interview techniques and mock focus groups that could be used within the final video production.The last session was used to showcase the final video, produce the top tips and provide certificates of attendance to all LAC.3.2The key contribution and shared learning from the PPI was in the expertise brought by the research team and the lived experience of the LAC involved. A number of themes emerged, and they have provided learning regarding the logistics and the processes of involving LAC in academic research.Learn something new innit? Obviously I've never really done that kind of stuff beforeWhen discussing their motivation for being involved, there was a desire to learn new skills.Having a certificate, you've always got it so you could always be reminded of the good things you've done. Stuff like that's really good to have on CV's.Being involved in new things provided an opportunity to receive a certificate to record their achievement, and there was a definite focus on the future.3.3You could do a mini documentary on like how…..yous could have like a bit that explains why yous are doing the research. Like you could include some of the young people's point in it, it would be really good.The project was fluid, and the idea for the project was led by the LAC and evolved from discussions;Our group are the less engaged and harder to engage, so you've got to make it really flexible for them. People need to remember that actually they're volunteering their time, so they don't have to be there.Due to the voluntary nature of the group, researchers had to be mindful of creating a relaxed environment whilst also progressing towards creating an end product;Whoever wanted to be involved in that session, and take a specific role, they were encouraged to do so– and did.Each session required active facilitation with researchers balancing a goal‐focused approach alongside being responsive to the young people;Do like, activities basically, because sitting round a desk and talking isn't very engaging.There was a strong and repeated request for sessions to be interactive. Researchers needed to be pragmatic when thinking about the structure and content of sessions and what was realistically achievable. A variety of skills were adopted to keep participants engaged;3.4Once they've met you a couple of times, they start to engage a bit more. Building a relationship with them is really, really important.The ability to engage LAC and establish a working relationship was key to the success of the project, and it had to be done face to face to truly engage participants;The group in general, it wasn't too formal, it was just a place where you could talkHaving the opportunity to meet with LAC over an 18‐month period enabled LAC to relax and build up a rapport with researchers;3.5Some people will treat us differently but you have come to us to ask us whether we want to do it. Rather than just going to a group of young people, “Right, do you want to do this?” you've come to children that are in care and given us the opportunity to get our voices heardGenerally, LAC are perceived by society as vulnerable, hard to engage and in need of protection,Sometimes we have these misconceptions of looked after young people. Social workers think they are so vulnerable and they need protecting from this and that and sometimes they haven't got the right skills to communicate with professional and adult people in a way we would want them to but as a researcher I am seeing something totally different.Once LAC were familiar with the researchers, they articulated themselves clearly and CICC members did not stereotypically present in a ‘vulnerable' way;Mel witnessed LAC volunteering to be involved in the study, and they were assertive during activities and confident in articulating themselves when talking to the researchers.“Actually I've got a bit of a voice and I've got a bit of power,” a lot of these young people have been through being powerless, really, and had a lot of things done to them.In direct response to LAC's ability to express themselves, researchers had a heightened awareness of maximizing opportunities for LAC to shape the project. This was reinforced when the participation officer stated that LAC wanted to feel;I think there was still the age of the power dynamic. I was sitting in front of a 14‐year‐old girl who was at school who saw me as asking her questions to get the right answer from her and it wasn't like that.Researchers wanted to support LAC to be actively engaged in the project, working towards a common goal. Despite trying to engage LAC on an ‘equal' level, by encouraging discussions led by the LAC and handing control to the group regarding which skills to practice and which elements to video record, some participants still conformed to a more traditional teacher‐student role;3.6“Actually, they've got so much going on that they might have all the will in the world to be involved in this project, but life just takes place.” By keeping turning up, it gave them another opportunity to come back when they were ready.Researchers had to be vigilant of external factors affecting LAC and how they impacted upon individuals and affected group dynamics. The decision to make the PPI group ‘open access' rather than a closed group enabled LAC to attend when possible, without feeling excluded if they missed sessions;I don't want to be on camera so you gave me the opportunity of videoing it instead….so you gave all of us a choice of whether we want to be on camera or notThe research team ensured that there was not any pressure to undertake roles they were not comfortable with and LAC appreciated this level of choice and control over their input;3.7I mean interviewing skills, like life skills, you know, I can take away from that and just the different formats of research that you can doLooked after children and care leavers received a certificate to record their achievement and acknowledged that the skills they had acquired were transferable;It's quite humbling, that… They can bring you to your knees, in a way, by off‐hand comments or not doing what you thought was going to happen. Having to learn, I guess, to improvise.Researchers working on the project were all white British females, in their mid‐30s. All researchers had previous experience of working with young people who accessed drug and alcohol services and young carers support. Despite previous experience, researchers continued to develop their skills;This study reinforced that it is essential for researchers working with this participant group to develop skills such as resilience, patience and tolerance. A commitment to understanding the factors affecting the lives of LAC at the same time as working sensitively and with tact is imperative.It's all very well and good doing a project, but then if you don't know how it turns out, you know…….was it totally useless, sort of thing?At the end of the project, LAC wanted to understand how their input had influenced the research project;Looked after children and care leavers and the participation officer voiced a frustration when external people parachute in and conduct tokenistic consultations with members of the CICC without providing feedback as to how their input had influenced anything.To ensure this did not happen in this project, LAC helped to edit the final video. Once completed, they watched the video and approved use at dissemination events. LAC felt the video they developed could be used in multiple settings to raise awareness of involving CYP in research. This was a positive output for LAC to have been involved in.3.8The group made recommendations of the ‘top tips' for working with LAC and other marginalized CYP in research. The top tips were devised by taking part in a group exercise where LAC individually wrote down tips they thought were important, and they then worked together to co‐produce the ten most important items for consideration. The top tips were divided into suggestions around organizing and running a session.3.8.1Provide transport to sessions—Although transport can be a barrier to any involvement, for LAC and care leavers especially, access to transport can be extremely problematic. Many care leavers live independently with limited finances. They do not have the finances to pay for public transport in order for it to be reimbursed. Therefore, it was pivotal that transport was provided for this particular group of young people or an advanced travel pass issued.Interactive sessions—For the majority of the LAC involved in this project, participating in groups or research implies that it is in addition to school, college or employment. They did not want sessions to feel like an extension of their education by having a ‘teacher‐student' feel to the sessions. Additionally, it is known that many LAC have a reduced level of literacy and behavioural diagnoses of conditions such as attention‐deficit hyperactivity disorder.Keep sessions short—Sessions need to be a maximum of 1 hour, including comfort and refreshment breaks. Researchers need to gauge each session on its own merit and be prepared to make adjustments if LAC are starting to disengage to reduce the likelihood of young people thinking negatively about their experience of involvement.Meetings after school—Timing of sessions was important, and LAC suggested 4‐4:30 pm as an optimum time to start sessions. This allows LAC time to travel to sessions after completion of their daily commitments but would not interfere too significantly with ‘tea time' or other responsibilities they have.Location needs to be familiar—The location was important for LAC whom explained that they are often exposed to numerous different workers and appointments in different locations. This can be anxiety provoking. Therefore, if possible, involvement in PPI/research should take place in a familiar location. This was reinforced by LAC stating that involvement in research could be daunting; if the location was already familiar, it made participating easier.Many of the tips are relevant and important to consider for any PPI group but are even more so for children with care experiences.3.8.2A familiar face—A well‐known face helps LAC to overcome potential insecure attachmentsA researcher who understands—LAC within the group stated that they wanted a researcher that had an understanding of their circumstances and an awareness of the care system and the complexities that they faced. Researchers had to be able to engage with LAC on their terms, be non‐judgemental and sensitive in their approach.Teach us a new skill—PPI should be designed so that participants learn a new skill, as Dunn (2018) also highlights when working with a group of young people experiencing depression.Provide a certificate—A certificate of attendance was important for this group, especially for some LAC who due to disrupted education have limited formal qualifications.Incentives—Incentives are always welcome as a sign of appreciation.4The current paper gives an example of how to develop and engage a group of LAC in a time‐limited PPI project. The findings and top tips reflect the practicalities of working with an under‐represented group, whom often present with a range of competing demands and needs. This project has highlighted that involving LAC in academic research can result in concrete outcomes and has key impacts. It has also highlighted that the involvement process needs to be understood and carefully facilitated, for the desired outputs and impacts to be realized. In line with Dovey‐Pearce's paper, this project suggests that assumptions regarding the capabilities of CYP as researchers need to be re‐evaluated.process of their involvement or its impact.This paper highlights that involving LAC in a PPI group to inform research has considerable potential to be mutually beneficial; however, there is little evidence available regarding successful examples of the With that in mind, this paper highlights important factors to be considered when undertaking PPI with LAC or groups of under‐represented young people. Unsurprisingly, many of the findings are relevant and important to consider for any PPI/research group with young people and the suggested findings are closely aligned with the guidance produced by INVOLVE,why some ideas are important when considering a LAC population.The idea of involvement in research being mutually beneficial and showing respect to CYP is present in the generic PPI guidance, as is the requirement to provide training and support through the researchYoung people can often be viewed as being relatively powerless due to their levels of capacity and competency due to their age.There is a need to understand that tokenism may be experienced by LAC as oppressive as for many LAC the receipt of statutory care is involuntary.Throughout the project, participatory activities improved and LAC's confidence appeared to improve with individuals taking on roles they had previously declined to and asking to be involved in future projects. This is in line with previous findings within which participants involved in PPI have reported, feeling listened to5The opportunity of engaging with an existing group where LAC are represented and the availability of a familiar face (participation officer) helped to overcome some of the barriers to engagement and was undoubtedly paramount to the success of this research project.A limitation of the study is that the number of LAC involved in the research was small and all LAC resided in the same geographical location. The project was extremely resource intensive for a small number of LAC; this limits the potential for generalization and may make the study difficult to replicate.6This paper has described the process of involving LAC in developing and engaging in PPI in academic research. This study has shown that PPI with this group of young people can be done, if researchers have enough time, resources and willingness to work at the pace of the participants. Further work is needed which ensures that LAC have an opportunity to co‐produce research ideas and work on projects and develop an ongoing research strategy for other LAC. Future work needs to accurately assess the impact of PPI work undertaken.The authors declare that they have no conflict of interests.All authors have made an intellectual contribution to this research paper. HA, RL and GDP conceptualized the initial idea of the study. HA wrote the first draft of the paper, and all authors  have input into drafts and have read and approved the final version of the manuscript.This study was undertaken as part of the ongoing PPI element of the SOLID trial, and therefore, the same ethical approval was applied. The SOLID study was granted a favourable ethical opinion by Newcastle and North Tyneside 1 NRES Committee (16/NE/0123). Newcastle University acted as trial sponsor. The SOLID Management Group have been responsible for ensuring the appropriate and timely implementation of the study.Written informed consent was obtained for all participants , inclusive of assent from LAC under 16 years of age and consent from their corporate guardian.The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.


Many university campuses have limited mental health services that cannot cope with the high demand. One alternative is to use internet-delivered cognitive behavioral therapy (iCBT) as a way of tackling barriers such as lack of availability and scheduling issues.This study aimed to assess feasibility, acceptability, effectiveness, and satisfaction of a supported iCBT intervention offering 3 programs on depression, anxiety, and stress to university students. The design was an open or nonrandomized feasibility trial.Space from Depression, Space from Anxiety, or Space from Stress —all comprised 8 modules of media-rich interactive content. Participants were supported throughout the trial by a trained professional. The Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7) questionnaire, and stress subscale of the Depression Anxiety and Stress Scale (DASS-21) were completed at baseline, 8 weeks, and 3-month follow-up. A Satisfaction With Treatment (SAT) questionnaire was completed at 8 weeks, and qualitative interviews were completed by a subsample of participants at 3 months.Participants were recruited from 3 counseling centers at a large midwestern University in the United States. Those agreeing to take part chose 1 of 3 iCBT programs—Space from Anxiety, 31 choosing Space from Depression, and 19 choosing Space from Stress. Mixed-effects models showed a significant decrease in symptoms of depression , anxiety , and stress  over time across all 3 programs. The largest decreases in PHQ-9 scores at 8 weeks were among participants who chose the Space from Depression program (d=0.84); at 3 months, the largest decreases in PHQ-9 scores were among those who chose the Space from Stress program (d=0.74). The largest decreases in GAD-7 scores were among those who chose the Space from Anxiety program (d=0.74 at 8 weeks and d=0.94 at 3 months). The largest decrease in DASS-21 stress subscale scores was among those who chose the Space from Stress program (d=0.49 at 8 weeks and d=1.16 at 3 months). The mean time spent using the platform per session was 27.4 min (SD 33.8), and participants completed 53% (SD 37.6) of the total program content on average. Most  participants found the programs helpful or very helpful and liked the convenience and flexibility of the intervention. Qualitative interviews (n=14) indicated the intervention met students’ expectations, and they saw it as a valuable complement to face-to-face treatment.A total of 102 participants were recruited, with 52 choosing The iCBT programs tested in our study appear to be feasible, acceptable, and effective in a university environment. Participants described the benefits of having a flexible, supported Web-based intervention available on campus. Larger trials should be conducted to further test the effectiveness of supported Web-based interventions that give students a choice of program depending on their symptom profile. For example, the content was perceived to be too generic or not applicable for those who had done CBT before:Some participants reported a Some of the activities were hard or didn’t really apply to my situation.internal factors, including lack of motivation and being busy contributed to participants finding the experience unhelpful:Finally, Not quite as good at holding me accountable for doing it as an actual appointment.Not a ton of motivation to finish a session every week, sometimes I would forget. Maybe reminder emails or an app would be helpful?The structured interviews provided further information regarding how students perceived the SilverCloud programs. Their responses are grouped into 3 categories: accessing SilverCloud, specific aspects of SilverCloud, and satisfaction with the SilverCloud programs.A total of 14 structured interviews were conducted. Those who completed interviews were similar to the overall sample, in that they were mostly female: 71% (10/14) versus 73.5% (75/102) and mostly white: 86% (12/14) versus 79.4% (81/102), although a much larger percentage were graduate students: 71% (10/14) versus 40.2% (41/102). In total, 14% (2/14) were international students, a similar percentage to the overall sample . The mean baseline PHQ-9 score was 10.3 (SD 4.5), and the mean baseline GAD-7 score was 10.6 (SD 4.9), both of which were similar to the baseline scores of the overall sample . The mean baseline DASS-21 stress score was 9.6 (SD 4.2), similar to the overall sample (8.5). Similar to the whole sample, 64% (9/14) completed 8-week follow-up measures (compared with 52.0% (53/102) in full sample), and 50% (7/14) completed 3-month follow-up measures . The mean PHQ-9 scores at 8 weeks and 3 months were 7.8 (5.0) and 7.6 (4.2), respectively (6.5 and 7.1 in the full sample), mean GAD-7 scores were 6.6 (3.7) and 6.7 (2.9), respectively (6.9 and 6.1 in the full sample), and mean DASS-21 stress scores were 7.0 (3.4) and 5.0 (2.6), respectively (6.3 and 5.2 in the full sample).The interviewer asked students how they found out about the program and why they chose to use it. Most students found out about the intervention on the internet , in the process of looking for mental health treatment. All the participants mentioned scheduling and convenience as a reason for using the Web-based programs over in-person therapy. One student, for example, mentioned choosing SilverCloud:...because my schedule is very busy and I wasn’t really sure whether I wanted to do counseling or not, so it felt like a good way to kind of check it out without much commitment.Some also noted that they did not feel comfortable with the idea of in-person counseling, citing worries about confidentiality and intensity . Only 1 had done anything like it before.Students were also asked when they used the program. Their responses were divided: some scheduled specific times for it ; some used it when they were feeling depressed, anxious, or stressed ; and others worked on it when they had free time . For those who used it on more than one of these occasions (n=7), there were mixed results in terms of when it was perceived to be most effective. Some described being able to get more out of it when they were not distressed, as they could approach it with a clear mind:I would say when I actually sat down to do it just to complete it, that actually was more helpful than doing it when I was down, because when I was down I was looking for answers, whereas I was in a more rational and clear mindset when I was just doing it out of my own.Others noted that it was most helpful when they were feeling distressed:It probably felt more helpful when I was coming off of a particularly stressed time, or like when I felt like a serious failure or that sort of thing. So yeah, when I felt worse, it probably helped me a little bit more than doing it on a day when I felt totally fine.One student noted that it was particularly helpful to journal when they were feeling distressed but that they read the informative parts of the modules when they were not feeling distressed.In general, students appreciated having choices about different aspects of the intervention. For example, students were asked what they thought about the ability to complete the intervention in any order. Most enjoyed this about the program  because it allowed them to access the parts they wanted and also allowed them to go back and engage with previous parts of the program that they found helpful. However, 1 was unaware that it could be completed in any order, and others completed it in order anyway . Students generally reported feeling positive about having a choice about whether they used the stress, anxiety, or depression program , although some would have preferred to be assigned one , and some were confused about the process , with 1 student noting:I just kind of chose one at random, I wasn’t really sure which one to choose, and then, I don’t know if they have practically different programs, or if there, if they have some overlap, I’m not sure.One student specifically expressed that they would have liked to access multiple programs.The interview also included questions about having a supporter. Almost all participants appreciated having a supporter , and some noted that they specifically liked receiving feedback :It kind of presented the opportunity to have someone to reach out to and ask some other questions. She gave me some really good guidance on what to do next step.Some participants also said that the supporter helped them feel accountable :Sometimes I feel like I wouldn’t have gone on or I was really lazy and didn’t really do anything, so I felt really guilty when she would take the time, like my supporter would take the time to look over everything and that I didn’t like do anything. So I felt bad sometimes. But I liked having that.A large portion  of the participants would have liked more from the supporter. Participants specifically wanted more detailed and personalized feedback and felt like they lacked a connection with the supporter. Some participants would have liked to be able to speak directly with their supporter over the phone or video chat service:Personally, I think that I was hoping for a little bit more of a personalized approach, and that maybe I would get more feedback about me personally and my issues from the person that was assigned to me. It was a lot more general feedback, like I could tell she [the supporter] had read the things I had done, but she wasn’t there, you know, to talk to me about my problems. So I guess I was expecting it to be a little bit more communication based.When asked how they felt about using SilverCloud, some participants noted that they felt positive about the program and that it met their needs , some expressed more mixed feelings , and others did not find it helpful . Some students with mixed feelings reported that it was helpful to some degree but thought that they would need to seek other treatment to more fully address their concerns. Another student noted that they learned a lot but had not yet noticed a change in symptoms.Those who had experience with in-person therapy  were asked how that experience compared with using SilverCloud. They noted strengths and weaknesses of both. In-person therapy was described as more personalized, specific, and flexible in terms of content. Some specifically noted that SilverCloud could not replace in-person therapy:I think there’s something in-person offers you when it becomes so much more personalized, that SilverCloud just can’t reach.One student noted that they felt like the program would have been more helpful for them if they had not already done in-person therapy. Participants generally noted that SilverCloud was more flexible in terms of time and was less intense than in-person therapy, and 1 person specifically noted that they liked SilverCloud better than in-person therapy, explaining that:...while it was nice having the one-on-one time, I think specifically for me, having the information all set there that I could read and kind of understand on my own terms was very very nice.When directly asked, most participants  had positive reactions to the idea of completing SilverCloud in conjunction with in-person therapy, as this would help address the issue of personalization. Some suggested that they would like to see their supporter in person infrequently while using SilverCloud in between sessions:I think that that would be more beneficial than how it is right now. Like with the therapist, if you had an initial in-person session, and then you had like a few, like several online sessions before you went back again, I feel like um that would alleviate a lot of the problems you’re facing. And maybe they could personalize the material that they like sent you between sessions as well.One student noted that, having used SilverCloud, they would be more likely to try in-person therapy. One participant sought additional mental health treatment while they used SilverCloud.The aims of this mixed-methods study were to assess feasibility, acceptability, effectiveness, and satisfaction with iCBT interventions embedded within the care delivery system of a large university. Below, we discuss key findings along with limitations and future directions.The feasibility of offering the iCBT interventions as part of service delivery at the university was evaluated primarily in terms of the number of students who expressed interest and began one of the programs. Approximately 100 students began a program, which was 56% of those who received an invitation and brief overview. Thus, it is feasible to incorporate iCBT into service delivery. It is important to note that most students who were referred to iCBT were seeking in-person counseling; the number recruited might be higher among students who were not already seeking this kind of care. In addition, more students likely would have been recruited if we had launched a larger marketing campaign . It is not clear whether fewer students were recruited from the international student office because of cultural differences related to the acceptability of help seeking or some other reason, although that is something to explore in future research.Space from Anxiety program, even among those who scored above our threshold for moderate symptoms on all 3 measures. They were much less likely to choose the Space from Stress program. This might reflect students’ perception of their own symptoms and which seem most urgent or best addressed through a Web-based program. Other iCBT courses offer patients a choice of programs such as the MindSpot clinic  [why a particular program was chosen over another and the balance between choice and clinical recommendation should be explored further to optimize treatment outcomes. This is especially important given the overlap of depression, anxiety, and stress symptoms.Most students chose the rograms) ; howeverrograms) , but theAcceptability was assessed in terms of the extent to which participants used the program after they began. In total, participants navigated through approximately 50% of the program content during an average of 14 sessions lasting approximately 5 hours in total. One systematic review found similar results, with users completing 50% to 70% of the content in Web-based interventions . A possiSpace from Depression program [Space from Depression and Space from Anxiety programs, whereas Space from Stress users continued to show decreases in PHQ-9 scores from 8 weeks to 3 months. This suggests the latter was best at maintaining low depressive symptoms, although larger trials are needed to replicate these findings.With regard to effectiveness, symptoms of depression, anxiety, and stress decreased over time in users of all 3 programs, with small (0.3) to very large (1.2) within-group effect sizes. The results are in line with previous research on the SilverCloud  program . A recen program  measurind=0.55) [In addition, a recent meta-analysis of 48 studies assessing the effectiveness of universal and indicated prevention approaches to delivering technology-based mental health intervention to college students found that the overall mean between-group effect sizes for indicated interventions (0.37) was larger than the overall mean between-group effect size for universal approaches (0.19) . Althougd=0.55) . OverallThe reliable change analyses indicated that approximately one-third of the users had reliable change on the outcome measures at 8 weeks. Slightly higher percentages of participants achieved reliable change at 3 months (30%-52% across measures). These results positively reflect on the clinical utility of the interventions and their ability to maintain clinical changes beyond the acute treatment period. However, slightly fewer subjects completed the measures at the 3-month follow-up, and it is unclear if those who dropped out maintained their gains. As the RCI analyses excluded participants with missing data, there is a risk of bias in these results. However, the reliable change results are similar to other research on SilverCloud , also usFinally, participants’ responses to the satisfaction questionnaire and the interviews suggested several strengths and limitations of the programs. Students generally found the programs to be helpful, with few saying that they found them unhelpful. Factors mentioned as helpful included flexibility, convenience, and having control over the pace of the intervention. Some students noted that they found the content of the interventions helpful, along with the tools available to learn new skills. In contrast, other students found that the content was not tailored enough to their specific needs. Participants also felt that having a supporter was helpful, although many wanted more contact with and feedback from the supporter. One solution is to offer students the opportunity to complete iCBT interventions along with less frequent  in-person therapy; more research is needed to determine the feasibility and effectiveness of such a delivery format. Finally, despite having a supporter, some found it difficult to stay motivated to complete the program on their own, especially given busy schedules. Taken as a whole, the qualitative results provide a more nuanced and comprehensive understanding of the program, which can be used to guide future research on how to improve Web-based interventions.These results are consistent with another qualitative study of students’ perceptions of Web-based interventions . In bothThis study also has limitations, including the lack of a control group and the lack of follow-up data on a sizable portion of the initial sample. Without a control group, we cannot be sure that decreases in symptoms were because of the intervention rather than the natural course of symptoms over time. As the purpose of this study was to integrate Web-based interventions into natural service delivery, to randomize help-seeking students into a placebo arm would have been difficult. Our conclusions regarding the effectiveness of the interventions would be strengthened by a larger RCT. The lack of follow-up data could be because of several factors. Supporters might not have encouraged the continued use of the program by study participants strongly enough, in some cases. Some study participants might have dropped out because of unmet expectations with regard to their Web-based program, and some might have completed the program early and met all their needs before the 8-week period. The rates of missing data at follow-up are similar to previous studies, and indeed younger persons are more likely to drop out than older participants in studies on self-managed internet interventions . AlthougIn conclusion, we echo the call that Web-based interventions are a useful addition to the list of solutions for addressing growing mental health service needs on campus . Overall


The worldwide increase in type 2 diabetes (T2D) is becoming a major health concern, thus searching for novel preventive and therapeutic strategies has become urgent. In last decade, the paralogous transcription factors MondoA and carbohydrate response element-binding protein (ChREBP) have been revealed to be central mediators of glucose sensing in multiple metabolic organs. Under normal nutrient conditions, MondoA/ChREBP plays vital roles in maintaining glucose homeostasis. However, under chronic nutrient overload, the dysregulation of MondoA/ChREBP contributes to metabolic disorders, such as insulin resistance (IR) and T2D. In this review, we aim to provide an overview of recent advances in the understanding of MondoA/ChREBP and its roles in T2D development. Specifically, we will briefly summarize the functional similarities and differences between MondoA and ChREBP. Then, we will update the roles of MondoA/ChREBP in four T2D-associated metabolic organs  in physiological and pathological conditions. Finally, we will discuss the opportunities and challenges of MondoA/ChREBP as drug targets for anti-diabetes. By doing so, we highlight the potential use of therapies targeting MondoA/ChREBP to counteract T2D and its complications. Type 2 diabetes (T2D) is a chronic metabolic disease which affects more than 370 million people worldwide . It is aAt the cellular and molecular levels, T2D is characterized by relative insulin deficiency caused by pancreatic β-cell dysfunction and insulin resistance (IR) in target organs . AlthougEven though the modification of lifestyle, including weight loss, increasing physical activity and adopting a healthy diet ,9, have Glucose is used almost universally as the preferred carbon and energy source . BreakdoMondoA  -interacting protein, MLXIP) and its paralog ChREBP ) were discovered a decade ago when researchers tried to figure out the molecular mechanisms of intracellular glucose sensing ,23. AlmoL-pk [Acc, Fasn, Scd1, and Elovl6 [Fgf21 and Txnip [These complexes play actions principally in two steps, including glucose metabolites-induced nuclear translocation and activation of target gene transcription by coordination with cofactors . A detaiL-pk ), lipoged Elovl6 ) and othnd Txnip ,35) geneO-linked N-acetylglucosamine (O-GlcNAc) transferase (OGT) [So far, several types of regulators have been identified to be involved in the activation or inhibition of MondoA/ChREBP-Mlx complexe formation or activities . They inse (OGT) ), nuclease (OGT) ,42, chrose (OGT) , and impse (OGT) ), nuclease (OGT)  and farnse (OGT) ), transcse (OGT) ), epigense (OGT)  and PHD se (OGT) ), accessse (OGT)  and cyclse (OGT) ), and evse (OGT) ). These se (OGT) ,53.Despite the overall structural and functional similarities between MondoA and ChREBP , theSkeletal muscle represents about 40% of body mass, but accounts for 80% of glucose uptake in the body, therefore it plays a fundamental role in the regulation of whole-body glucose homeostasis . AccordiAs mentioned previously, MondoA is predominantly expressed in skeletal muscle, but its specific roles in skeletal muscle were not clear until recently. By adapting human skeletal myotube as an in vitro model, Ahn et al. have found very recently that MondoA activity in skeletal muscle is physiologically regulated by glucose or fructose level . SpecifiHowever, under conditions of chronic nutrient overload, the MondoA-mediated negative feedback mechanism is crashed, leading to persistently activated MondoA, which results in a vicious cycle of muscle lipid accumulation and IR. In this setting, MondoA actually acts as a molecular driver for the pathogenesis of IR. In support, selective loss of MondoA in mice muscle improves high-fat diet (HFD)-induced glucose tolerance and IR through reducing muscle lipid accumulation, and improving muscle insulin signaling as well as glucose uptake . BesidesThe liver plays a central role in the maintenance of systemic glucose homeostasis in response to different energy status. . Under fChREBP is most highly expressed in the liver and has emerged as a principal insulin-independent hepatic lipogenic determinant during the last decade ,55. A grob/ob mice [Hepatic ChREBP expression is highly regulated by nutritional states. Under physiological conditions, the hepatic expression of both ChREBP-α and ChREBP-β is low in fasting state, but it can be significantly induced  when refeeding with carbohydrate-rich diet . However/ob mice . These rob/ob mouse model, where globally or liver-selectively deficiency of ChREBP decreases hepatic lipogenesis and restores hepatic and peripheral insulin sensitivity [In support of this speculation, so far, the most direct evidence is derived from two early studies performed in the sitivity ,65. Conssitivity . Furthersitivity ,83. TherInterestingly, recent studies have indicated that ChREBP is beneficial for hepatic insulin sensitivity and whole-body glucose homeostasis. Benhamed et al. have found that mice with liver-specific ChREBP overexpression develop obvious hepatic steatosis, but surprisingly protect against the systemic IR regardless of feeding with normal diet or HFD . ConsistOverall, the role of hepatic ChREBP in IR development seems to be context-dependent, but under most conditions, ChREBP is more likely protective rather than detrimental in maintaining insulin sensitivity. However, given the fact that overexpression of ChREBP also causes hepatic steatosis, which impairs the insulin sensitivity, thus activation of ChREBP may be not a good choice for the improvement of hepatic insulin sensitivity.Adipose tissues (ATs) play an important role in regulating whole-body energy and glucose homeostasis . There aob/ob mice as young as seven-weeks old [Opposite with that in the liver, ChREBP expression in ATs is often impaired under various detrimental conditions. Specifically, the short-term HFD, which causes IR, reduces DNL and ChREBP expression in both WAT and BAT ,94. Thateeks old . Besideseeks old . Intereseeks old . Moreoveeeks old . TherebyConsistent with the ChREBP expression during the pathogenesis of IR, the gain/loss-of-function studies in animals have further demonstrated that WAT ChREBP preserves the systemic insulin sensitivity. Specifically, mice with fat-specific loss of ChREBP show whole-body IR and WAT inflammation regardless of the lean or obese state . ConsistConsistent with the beneficial effects of ChREBP on systemic insulin sensitivity, genetic manipulations of ChREBP upstream factors or binding partners in ATs also regulate mice insulin sensitivity. Glucose transporter 4 (GLUT4) is responsible for the glucose entering into the adipocytes, while glucose metabolites can activate ChREBP, therefore, alterations in adipose GLUT4 expression have profound effects on systemic insulin sensitivity through regulation of ChREBP-α-mediated expression of ChREBP-β . BesidesAlthough there are no documents directly depicting BAT ChREBP function in the regulation of systemic insulin sensitivity to date, it is already known that BAT DNL seemingly has limited effects on whole-body insulin sensitivity. Abolition of BAT DNL by the specific loss of fatty acid synthase  in brown adipocytes do not alter mice glucose tolerance regardless of feeding with normal chow or HFD . In partCollectively, ChREBP in ATs, particularly in WATs, plays an important role in the maintenance of systemic insulin sensitivity. Since the expression of ChREBP, especially the ChREBP-β isoform, is often downregulated in conditions predisposing to diabetes, therefore, restoration of ChREBP expression or activity in WATs might be an important therapeutic strategy to treat T2D and its complications.Pancreatic β-cells play an important role in maintaining levels of circulating glucose constant through the production of insulin in response to nutritional states . The proBoth ChREBP-α and ChREBP-β are expressed in pancreatic β-cells, and their levels/activities are induced by high glucose concentration ,104. Addob/ob mice , the ChREBP-β mRNA level is dramatically induced compared with the lean mice or non-diabetic controls [Strikingly, ChREBP has also been revealed to be a key contributor to pancreatic β-cell dysfunction under conditions of chronic caloric excess. Firstly, the pancreatic ChREBP is activated in conditions susceptible to T2D. Specifically, the total protein levels of ChREBP, particularly the nucleus-localized ChREBP, are significantly increased in human diabetic pancreatic islets compared with non-diabetic controls ,107. Simcontrols . But intcontrols .Secondly, the activation of pancreatic ChREBP is more likely the cause for the development of T2D. As happened in prolonged hyperglycemia in diabetes, overexpression of ChREBP-CA via viral vectors for too much or too long, causes β-cell apoptosis in vitro . ConsistCollectively, pancreatic ChREBP plays dual roles in the pathogenesis of T2D. In response to the acute high glucose stimulation, pancreatic ChREBP protects against hyperglycemia through promoting β-cell proliferation. However, under conditions of chronic nutrient overload, the continuously activated ChREBP results in β-cell apoptosis, which exacerbates T2D development. Thereby, developing strategies to precise regulation of ChREBP expression and/or activity in pancreatic β-cells may represent a therapeutic approach in the treatment of T2D.In summary, recent studies have revealed that glucose-sensing transcription factor MondoA/ChREBP plays a fundamental role in the control of systemic glucose metabolism and insulin sensitivity via a context- and tissue-dependent manner. Under normal physiological conditions, MondoA/ChREBP acts as a key player in each metabolic tissue to synergistically maintain the whole-body glucose homeostasis and energy metabolism. However, under conditions of chronic energy surplus, the dysregulated expression and/or activity of MondoA/ChREBP in metabolic tissues often results in a common consequence, namely IR, a prerequisite for the development of T2D. Therefore, targeting MondoA/ChREBP might offer new approaches to combat T2D and its complications in humans.Based on the functional characteristic of MondoA/ChREBP, so far, at least two strategies can be adopted to develop drugs to prevent T2D. One aim is to develop MondoA/ChREBP-specific inhibitors. This strategy is supported by one recent study in which SBI-993, an inhibitor of MondoA and probably also ChREBP, was given to mice and alleviated HFD-induced mice IR . HoweverTo avoid the shortcomings of the first strategy, the second strategy focuses on the tissue-specific MondoA/ChREBP targets or effectors which have potentials to serve as the drug leads. One such example is that the insulin-sensitizing fatty acids PAHSAs, which are synthesized by ChREBP-mediated DNL in ATs, have been recently shown with great therapeutic potentials to treating T2D . Thus, t


Psychosocial interventions have the potential to offer substantial benefit to people with dementia and their family caregivers. The Buddy Program is an experiential learning program that pairs students with persons with dementia for activities and relationship-building. Previous studies have demonstrated the program’s positive impact on student knowledge and attitudes. New York University’s (NYU) Alzheimer’s Family Support Program began replicating the Buddy Program in 2017 and has enrolled 80 students. Northwestern University’s (NU) Buddy Program, in its 22nd year, has enrolled 260. This presentation describes the impact of the program on the mentors (NU) and the caregivers (NYU). Post program focus groups with mentors and student journals describing interactions with the caregiver were thematically analyzed. Mentors describe feelings of pride in the mentorship role, enjoyment being with student, and the opportunity to develop a new friendship. Caregivers enjoyed the respite provided by the buddies, knowing that their relatives with dementia were enjoying themselves and seeing their relatives with dementia in the role of valued companion. Qualitative data from caregivers and mentors participating in the buddy programs at NU and NYU underscore the possibility that people with dementia can still make contributions to society. The buddy program has a positive impact on quality of life for persons living with dementia and their family members, while providing a valuable educational experience for students. Further research on the buddy program’s benefits is warranted.