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Pregnancy and the postnatal period can be a time of increased psychological distress, which can be detrimental to both the mother and the developing child. Digital interventions are cost-effective and accessible tools to support positive mental health in women during the perinatal period. Although studies report efficacy, a key concern regarding web-based interventions is the lack of engagement leading to drop out, lack of participation, or reduced potential intervention benefits.
This systematic review aimed to understand the reporting and levels of engagement in studies of digital psychological mental health or well-being interventions administered during the perinatal period. Specific objectives were to understand how studies report engagement across 4 domains specified in the Connect, Attend, Participate, and Enact (CAPE) model, make recommendations on best practices to report engagement in digital mental health interventions (DMHIs), and understand levels of engagement in intervention studies in this area. To maximize the utility of this systematic review, we intended to develop practical tools for public health use: to develop a logic model to reference the theory of change, evaluate the studies using the CAPE framework, and develop a guide for future data collection to enable consistent reporting in digital interventions.
This systematic review used the Cochrane Synthesis Without Meta-analysis reporting guidelines. This study aimed to identify studies reporting DMHIs delivered during the perinatal period in women with subclinical mood symptoms. A systematic database search was used to identify relevant papers using the Ovid Platform for MEDLINE, PsycINFO, EMBASE, Scopus, Web of Science, and Medical Subject Headings on Demand for all English-language articles published in the past 10 years.
Searches generated a database of 3473 potentially eligible studies, with a final selection of 16 (0.46%) studies grouped by study design. Participant engagement was evaluated using the CAPE framework and comparable variables were described. All studies reported at least one engagement metric. However, the measures used were inconsistent, which may have contributed to the wide-ranging results. There was insufficient reporting for enactment (ie, participants’ real-world use of intervention skills), with only 38% (6/16) of studies clearly recording longer-term practice through postintervention interviews. The logic model proposes ways of conceptualizing and reporting engagement details in DMHIs more consistently in the future.
The perinatal period is the optimal time to intervene with strength-based digital tools to build positive mental health. Despite the growing number of studies on digital interventions, few robustly explore engagement, and there is limited evidence of long-term skill use beyond the intervention period. Our results indicate variability in the reporting of both short- and long-term participant engagement behaviors, and we recommend the adoption of standardized reporting metrics in future digital interventions.
PROSPERO CRD42020162283; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=162283
Pregnancy, delivery, and the postnatal period can be times of increased psychological distress (stress, anxiety, or depression) [
Health promotion strategies aim to enable optimal health and skills to cope with adversity in well subclinical populations. Therefore, it is important that efforts are made not only to deal with illness but also to develop individuals’ emotional skills that can be applied in everyday life [
Although a recent systematic review provided preliminary evidence that web-based interventions can be a promising and advisable form of intervention during the prenatal period [
Dropout from the intervention and loss to follow-up reduces the treatment effect [
It is widely accepted that the full benefit of many effective treatments can be achieved only if the prescribed regime is followed reasonably closely [
One of the frameworks for evaluating engagement in face-to-face programs, which can be adapted to web-based programs, is the Connect, Attend, Participate, and Enact (CAPE) model [
At a time when public resources are strained, policy makers and program administrators are looking to invest in effective, engaging prevention programs supported by scientific evidence and delivering long-term benefits. Intervention engagement must be foremost among these considerations, as this will ultimately determine the degree to which the target population takes up and benefits from the intervention when implemented in the community. Systematic reviews are an influential decision-making tool as they summarize a body of scientific research; identify implications for policy and practice [
This systematic review aimed to understand the reporting and levels of engagement in studies of web-based psychological mental health or well-being interventions administered in the perinatal period to women with subclinical mood symptoms.
Specifically, we aimed to (1) understand how studies report engagement, with engagement defined as containing the 4 steps in the CAPE model; (2) make recommendations on best practices to report engagement in DMHIs based on this; and (3) understand levels of engagement in intervention studies in this area.
To maximize the utility of this systematic review, we intended to develop practical tools for future public health use: to develop a logic model from the literature to reference the theory of change, evaluate the studies using the CAPE framework, and develop a guide for future data collection to enable consistent engagement reporting in web-based (and offline) interventions.
The methods used in this systematic review combine standard rigorous and transparent review methods using the Cochrane Synthesis Without Meta-analysis (SWiM) reporting guidelines [
The review question, search strategy, inclusion criteria, and methods were registered in PROSPERO (International Prospective Register of Systematic Reviews; approval number CRD42020162283). The research question was as follows: what is known about engagement in digital mental health and well-being programs for women in the perinatal period? A systematic database search was conducted to identify papers relevant to the aims of this review. The initial search was performed by the first reviewer (JAD), using the Ovid Platform for MEDLINE, PsycINFO, EMBASE on the EBSCO Platform, Scopus, Web of Science, and Medical Subject Headings on Demand for all English-language articles published in the past 10 years (ie, from January 1, 2010, to May 29, 2020). Keywords and index terms identified as relevant in the search strategy were used and individual search criteria were developed for each database. All the database search strategies are provided in
The search strategy aimed to identify studies reporting on engagement and retention in digital mental health and well-being programs for women during and after pregnancy. Clear inclusion and exclusion criteria were developed using the Population, Intervention, Comparison, Outcomes, and Study framework to guide the inclusion criteria for participants, intervention or phenomena of interest, comparators, outcomes, study design, and context (
Participants
Childbearing individuals in the perinatal period (ie, from conception to the first year of the infant’s life)
Studies focusing predominantly on the childbearing individual but can include partners
Studies that include childbearing individuals at moderate risk for psychological distress (ie, with Edinburgh Postnatal Depression Scale score ≤12)
Studies that include women at risk of postnatal depression with a history of depression or anxiety (ie, early intervention)
Intervention
Any minimal contact digital interventions provided in the perinatal period aiming to reduce mild to moderate psychological distress or promote psychological well-being (ie, minimal contact as defined by a maximum of <1 hour of direct contact each week)
Comparators
Studies with any form of comparator were considered
Outcomes
None; although the focus of the review was on engagement outcomes, we included any studies of interventions meeting the above criteria to determine the proportion that reported engagement outcomes
Study design
Quantitative (eg, randomized controlled trials, quasi-experimental studies, cohort studies, descriptive studies), and qualitative studies
Participants
Studies considering programs before conception and those specifically targeting the child
Studies focusing predominantly on the partner or father
Studies that include women at high risk for psychological distress (ie, with Edinburgh Postnatal Depression Scale score ≥13)
Intervention
Interventions with a primary focus other than mental health or well-being (eg, parenting self-efficacy)
Interventions delivered face to face or as telehealth or telephone coaching
All papers that appeared eligible based on their title and abstract were retrieved for screening. The first author (JAD) reviewed the titles and abstracts of all papers, assessed eligibility, and noted any reasons for exclusion. Full-text articles were assessed for eligibility and reviewed independently by both the first author (JAD) and third author (LYG). Once the third author (LYG) had reviewed the papers, any discrepancies were resolved through team discussion. The reference lists of the included studies were examined to identify additional relevant papers.
Key article characteristics were recorded using a Microsoft Excel (version 2020) data extraction table developed for this review. These characteristics included general information about the study, such as the country and author, along with specific information about the study design, comparators, and intervention type. Coding of the study characteristics enabled us to group the studies as part of our synthesis. As our primary aim was to understand the engagement of the study population, we characterized the assessment time points, engagement measures, and reporting of attrition and adherence. Data relevant to engagement were extracted using the CAPE framework; this included variables for recruitment, retention, attrition, and follow-up time points. A framework analysis methodology [
Logic models can help conceptualize a complex review question and specify analytic links to test the plausibility that a program works as intended [
Proposed logic model. GP: general practitioner; DMHI: digital mental health intervention.
The risk of bias for studies included in this review was based on the Cochrane Collaboration’s tool for assessing the risk of bias for each category of study (ie, randomized controlled trials [RCTs] and non-RCTs), and the risk of bias was adapted for this review and classified as low, uncertain, or high based on the Cochrane risk of bias tool [
As this systematic review synthesized the results from a diverse range of interventions, we used SWiM guidelines [
Summarized the characteristics of each study and reported intervention implementation, recruitment and engagement activities, study findings, reported attrition, and methodological quality
Determined which studies were similar enough to be grouped within each comparison by comparing across studies (eg, types of digital platform and postnatal vs antenatal)
Determined which data were available for synthesis
Synthesized the characteristics of the studies
Performed a statistical synthesis for appropriate quantitative data and comprehensive critical appraisal through a meta-synthesis approach for qualitative data
For each trial included in this systematic review, we recorded counts of trial participants who were assessed for eligibility, those who were recruited, and those who were allocated to the intervention and control arms; rates of recruitment, trial completion, and loss to follow-up were synthesized by evaluating the proportion of recruitment, completeness, and loss to follow-up in base R (R Foundation for Statistical Computing) statistical package [
The electronic searches generated a database of 3473 potentially eligible studies that were assessed using the review eligibility criteria. After duplicates were removed (680/3473, 19.58%), all titles and abstracts were screened for eligibility. In total, of the 3473 studies, 2795 (80.48%) records were screened, and 2654 (76.42%) were excluded based on the inclusion or exclusion criteria (
The literature search and inclusion processes are detailed in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram (
Search flow diagram (PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses]). RCT: randomized controlled trial; SWiM: Synthesis Without Meta-analysis.
The primary aim of this systematic review was to assess the engagement of women participating in digital mental health or well-being interventions; therefore, the standardized metric and transformation method [
In all groups, there was a range of therapeutic approaches, including cognitive behavioral therapy, parenting education, positive psychology, mindfulness, and compassion-based training. Several studies used a psychoeducation approach to build parenting self-efficacy, such as Chan et al [
Group 1: randomized controlled trials (N=6).
Intervention type, format, and duration | Study aims (sample size) | Engagement measures: connect | Engagement measures: attend | Engagement measures: participate | Engagement measures: enact |
Self-guided; iWaWaa; 9 modules [ |
Assess the feasibility and acceptability of iWaWA among postpartum women with anxiety (89 participants) |
Assessed for eligibility (n=147): recruited via social media, posters, and flyers and numbers recruited Reasons for exclusion 89 enrolled and randomized to treatment and control |
Engagement with internet-based components Attrition and attendance Participant CONSORTb flow diagram (access, allocation, and follow-up) |
Module views, module completion, number and duration of support calls |
Treatment feasibility (engagement and usability) and acceptability (usefulness, satisfaction, and helpfulness) were assessed after treatment through semistructured interviews |
Smartphone-based mobile app [ |
Assess the difference in the levels of antenatal and postnatal depression in participants (660 participants) |
Assessed for eligibility (n=803) Reasons for exclusion 660 enrolled and randomized (intervention or treatment as usual) |
Participant CONSORT flow diagram (eligibility, enrollment, randomization, follow-up, and analysis) Retention rates |
The use of the app and other relevant services (eg, antenatal classes and other pregnancy resources: books and websites) documented by self-report |
Postintervention survey included Use of the app |
Web-based compassion-based intervention; |
Assess the effect of the intervention on participants’ well-being (206 participants) |
Assessed for eligibility (n=310) Recruitment methods: social media and snowball sampling Participant vouchers Accessibility Reasons for exclusion 206 enrolled and randomized |
Participant CONSORT flow diagram (enrollment, allocation, follow-up, and analysis) |
Reporting of attrition and engagement (ie, completion of sessions and frequency or program use) |
Acceptability: participants were asked to rate the ease of use and satisfaction after the intervention |
A Chinese version of the MBSPc program; 10 hours of training with 36 episodes; 6-week internet-based intervention [ |
Assess the effect of the mindful self-compassion intervention on preventing postpartum depression in a group of symptomatic pregnant women (314 participants) |
Assessed for eligibility (n=472) Screening and baseline assessment (n=344) Reasons for exclusion Randomized (n=314) |
Participant CONSORT flow diagram (eligibility, allocation, follow-up, and analysis) Attendance rates Reporting of retention |
Reporting of attrition Feasibility and acceptability After completing each exercise, participants were instructed to exercise the steps during the day; participants provided a graphical overview and a web-based diary book where they registered their reflections |
Reporting of retention and attrition after the intervention |
Condensed web-based version of an 8-week mindfulness course; |
Evaluate the potential of a web-based mindfulness course for expectant participant women (185 participants) |
Assessed for eligibility (n=237) Recruitment methods (email lists, social media advertising, and posters in community settings) Reasons for exclusion Enrolled and randomization methods |
Participant CONSORT flow diagram (recruitment, allocation, follow-up, and analysis) |
Regular reminders to log on or contact the research team via email Reporting of retention and attrition |
Postcourse evaluation 45 days after baseline |
Mobile app for psychoeducation and postnatal depression; “Home-but not Alone” [ |
Examine the effectiveness of the program in improving participant parenting outcomes (250 participants [couples]) |
Assessed for eligibility (n=360 couples) Reasons for exclusion Recruitment methods Randomization methods to intervention or control |
Participant CONSORT flow diagram (eligibility, recruitment, allocation, follow-up, and analysis) |
The research team monitored the use of the app and parents received reminders each week |
Intervention posttest |
aiWaWa: internet-based What Am I Worried About.
bCONSORT: Consolidated Standards of Reporting Trials.
cMBSP: Mindfulness-Based Strengths Practice.
Group 2: non–randomized controlled trials—case series, open trial, and quasi-experimental (N=3).
Intervention type, format, and duration | Study aims (sample size) | Engagement measures: connect | Engagement measures: attend | Engagement measures: participate | Engagement measures: enact |
Positive psychology web-based intervention; 5-week web-based self-applied positive psychology intervention specifically adapted for pregnant women; 4 modules [ |
Examine the effect of a positive psychology web-based intervention on indices of participants’ prenatal well-being (6 participants); case series design |
Eligibility and recruitment method Preassessment on the web |
Weekly emails—reminders for assessments |
Compliance with the intervention measure was developed by the research team No reported attrition |
Exercise preferences were assessed at the posttest time point |
Internet program plus weekly phone coaching sessions, individually or group-wise; MMBa program; 8 weeks [ |
Examine the feasibility, acceptability, and preliminary outcomes of MMB for use with pregnant women at risk for depressive relapse (37 participants); open trial—no control group |
Assessed for eligibility (n=48) Reasons for exclusion Recruitment methods—flyers and via service providers Prescreening by phone Intake interview in person or by phone Participant enrollment and flow (eg, reasons for declining to participate) |
Participant CONSORTb flow diagram (eligibility, enrollment, follow-up, and analysis) |
Session completion and participation in phone coaching calls Home practice completion Participant engagement (eg, completion of sessions, practice per week, and time) |
Self-reported satisfaction (perceived benefits and challenges) via questionnaire and engagement interview (qualitative) at session completion |
Web-based modules: web-based maternity health records, antenatal health education, self-management journals, and infant birth records [ |
Investigate the effectiveness of a web-based antenatal care and education system on pregnancy-related stress, general self-efficacy, and satisfaction with antenatal care (135 participants) quasi-experimental design |
Eligibility—control (n=75) and experimental (n=80) group at pretest Recruitment methods (convenience sampling) Assignment methods to experimental or control groups |
Participant CONSORT flow diagram (enrollment, follow-up, and analysis) Attrition |
Assistance was offered via telephone, email, web conferencing, or face-to-face guidance Follow-up phone calls were made to the participants Attrition |
N/Ac |
aMMB: Mindful Mood Balance.
bCONSORT: Consolidated Standards of Reporting Trials.
cN/A: not applicable.
Group 3: pilot studies (N=7).
Intervention type, format, and duration | Study aims (sample size) | Engagement measures: connect | Engagement measures: attend | Engagement measures: participate | Engagement measures: enact |
Brief web-based self-help intervention—5 components considered effective in challenging negative beliefs [ |
Assess positive mood in participating mothers of babies and toddlers (80 participants) |
Eligibility Recruitment methods—internet, leaflets, and community postnatal groups Randomization methods |
Only 1 session |
Compliance (missing data) |
Acceptability—an open-response question at the end of the intervention (qualitative) Implications for policy and practice |
Automated self-help internet intervention; 8 lessons—accessible anytime [ |
Assess the efficacy of the intervention to reduce the risk of postnatal depression in participating women (111 participants) |
Assessed for eligibility (n=5071) Consented (n=2966) Recruitment methods—web-based search engine directories, (eg, Google advertisements “sponsored links”) Randomization methods Initial log-ins to the website |
Participant CONSORTa flow diagram (eligibility, consent, allocation, follow-up, and analysis) Adherence |
Automated email messages Automated self-help via website Log-ins, total time spent logged into the website, and the last lesson viewed recorded Module feedback on the materials viewed (eg, usefulness and understandability) Attrition |
Includes discussion on experience and engagement and feedback assessment |
Minimal contact automated SMS text messaging; |
Assess acceptability of an SMS text messaging program to prevent postpartum depression (10 participants [pregnant and postpartum women]) |
Eligibility Recruitment methods—flyers at general public bulletin boards and community agencies; websites and blogs |
Compliance |
Attrition |
Feedback assessment (qualitative) Acceptability assessment |
Intervention—self-guided; 15 steps, each of which takes 45 minutes [ |
Assess feasibility and acceptability; study 1 (n=6): effects of a single teaching and biofeedback session on maternal and fetal biofeedback; study 2 (n=9): effect of consumer satisfaction |
Study 1: eligibility and recruitment methods (flyers at antenatal classes) Study 2: eligibility and recruitment methods (flyers at antenatal classes) |
Study 1: compliance with baseline and 2 conditions (teaching and practice) Study 2: compliance to complete 15 steps |
Attrition Feasibility and acceptability |
Study 1: no postintervention measures Study 2: postintervention assessment and interview Qualitative follow-up |
8-week web-based prevention intervention; website plus initial phone call; 16 core didactic lessons plus 3 postpartum booster sessions and 5 associated tools [ |
Assess a CBTb peer support intervention to prevent postnatal depression in participants (24 participants) |
User-centered-design, recruited via flyers Assessed for eligibility (n=216) Completed baseline assessment (n=30) Enrolled and randomization methods |
Participant CONSORT flow diagram (screened, completed the baseline assessment, and enrolled) Adherence |
Email notifications Total log-ins and completion of tools and lessons Peer support features (likes, comments, nudges, and posts) Reporting of attrition and site use (log-ins); usability and acceptability |
Usability and satisfaction (Usability, Satisfaction, and Ease of Use questionnaire) |
Self-guided, web-based intervention to prevent postpartum depression symptoms; |
Explore the processes underlying therapeutic change for participants in the intervention (194 participants) |
Assessed for eligibility (n=643) Email invitation to participate Recruitment methods—in person and web-based Reasons for exclusion Baseline assessment (n=241) Randomization methods (intervention or waitlist control) |
Participant CONSORT flow diagram (eligibility, enrolled, randomized, and follow-up) Adherence |
Email reminders after 7 days without accessing intervention Attrition |
Postintervention measures included emotion regulation, psychological flexibility, and self-compassion |
Web-based mindfulness and gratitude intervention 4 times a week for 3 weeks [ |
Assess the effect of a novel gratitude and mindfulness-based intervention on prenatal stress, cortisol levels, and well-being in participating women (46 participants) |
Assessed for eligibility (n=362) Recruitment methods—posters, leaflets, and pregnancy forums Reasons for exclusion Randomization methods SMS text message reminders No additional contact with the study team during the study period |
Participant CONSORT flow diagram (enrollment, allocation, follow-up, analysis) |
Participant adherence was evaluated as the total frequency of completion of the web-based diary entries Proxy measure for full intervention use |
Limitations in fidelity evaluation |
aCONSORT: Consolidated Standards of Reporting Trials.
bCBT: cognitive behavioral therapy.
Participant engagement was evaluated using the CAPE model of engagement [
All studies in this review reported enrollment rates in the intervention, which we defined as those who commenced the intervention relative to those who expressed interest in the study. Conversion to commencement was based on multiple factors, not just the participants’ decision to engage, both dependent and independent of the inclusion or exclusion criteria. Most studies in this review reported reasons for exclusion, ranging from lack of contact or completion of baseline surveys to elevated mental distress scores. Enrollment rates varied from a high rate of 82% (Chan et al [
In face-to-face interventions,
The highest reported study retention (groups 1 and 3) was reported by Ayers et al [
In the control arm, Guo et al [
Participant retention in the intervention arm (group 1); 95% CIs determined by test of proportions [
Participant retention in the intervention arm (group 3); 95% CIs determined by test of proportions [
The limited follow-up period restricted our ability to report against measures indicating that participants applied and practiced learning skills [
Through the analysis and reporting of each study, we recorded the types of quantitative and qualitative measures found in the selected studies that could be used to measure engagement. This enabled us to systematically construct a logic model based on our understanding of how interventions are expected to work. This was particularly pertinent for this systematic review as we did not perform a meta-analysis. As indicated, we grouped variables related to the CAPE framework; the logic model includes a range of metrics that could be systematically reported when synthesizing engagement data to visually interpret the underlying theory of change.
The logic model (
As part of this systematic review, we aimed to develop a guide for future data collection to enable consistent engagement reporting in web-based (and offline) interventions.
Proposed reportable metrics: engagement.
CAPEa model of engagement | Measures | Definitions |
Connect | Exposure and enrollment (rates should be reported for each trial arm separately) |
Defined target population (ideally with population size if available) Methods of recruitment and size or proportion of the population exposed to each recruitment method Enrollment rate: proportion of participants who start the intervention relative to those who are exposed to the intervention and those who provide consent for the study Connection rate: proportion of recruited participants electing to enroll relative to those who are eligible |
Attend | Intervention retention |
Proportion of participants who complete the intervention relative to those who enroll in the intervention Mean, SD, and range of the number of modules completed |
Participate | Intervention activity |
Active engagement (depending on the nature of the intervention; this may be module completions, exercise completions, proportion of videos watched, and response to emails) Log-ins (frequency and duration) Time spent logged into the website or app Use of recommended resources (eg, downloads of additional resources and clicks to suggested websites) |
Enact | Sustained practice |
Follow-up reports (eg, questionnaires about the use and application of learned strategies or skills taught from the DMHIb) Postintervention interviews about using skills in everyday life Sustained behavior change |
aCAPE: Connect, Attend, Participate, and Enact.
bDMHI: digital mental health intervention.
In this systematic review, we categorized the selected studies according to study type and assessed their individual and pooled characteristics. We applied the CAPE framework [
Some studies reported strategies to increase
As previously defined,
A key concern in web-based interventions is the lack of
Understanding the barriers to and enablers of real-world utility and practice is crucial if app developers want pragmatic uptake and efficacy of interventions. Sufficient resourcing may be a factor in longitudinal follow-up; however, to leverage the impact and cost-effectiveness of interventions, studies should factor longer-term assessments in the design process from conceptualization. Nevertheless, easier and low-cost measures of enactment are possible and suggested for future research, including questionnaires on the frequency of using skills taught during the intervention.
As part of this review, we developed a logic model to facilitate the process of gathering and integrating studies of complex interventions to better inform our interpretations of cumulative results. The logic model included synthesized data capture and engagement methods used in each study. Theoretically, logic models need moderating or mediating factors to understand how the pathway develops. In these studies, there was a common strength-based approach, such as skill development, confidence, satisfaction, and self-efficacy. Overall, the heterogeneous nature of the data collection meant that we were unable to undertake a meta-analysis; however, the range of methods and types of data collection is useful in guiding future web-based interventions targeting this population group and helping decision-makers understand the rationale for how interventions are expected to work and what enablers keep participants engaged to ultimately achieve the intended outcomes.
There is a need for a greater understanding of the individual-level, real-world factors affecting engagement in home and minimal contact practice interventions to ascertain how participants experience interventions and how this relates to their outcomes [
As the studies in this review were diverse in terms of study design, therapeutic intervention approach and delivery, length of follow-up, and outcome measures, we summarized the engagement data using the CAPE framework but were unable to perform a meta-analysis of the data. Attrition rates were high in many studies, and the number of participants was small, particularly in some pilot studies. We were unable to report this in terms of increasing our understanding of sustained practice as there was limited follow-up in most studies. There are inconsistent reports and terminology regarding engagement behavior. Inconsistencies in language between studies and interchangeability of terms, for example, attrition, withdrawal, dropout, and loss to follow-up, make direct comparison and systematic analysis challenging. Another potential limitation of this review is the lack of inclusion of studies in languages other than English. In addition, the protracted nature of systematic reviews means that the original search was concluded in 2020 and was affected by delays because of the COVID-19 pandemic. Since then, additional studies may have been published and not included in this review but would not necessarily affect our general conclusions or implications for using the logic model or reporting matrix.
The ability to leverage several frameworks enhanced this systematic review. The SWiM guidelines, part of the Cochrane methods, directed our synthesis and reporting. In addition, the CAPE framework provided an evidence-based approach to reporting on intervention engagement; using this framework, we were able to propose clear metrics for future reporting. It is recommended that future research provide engagement analytics to more clearly delineate between study and intervention compliance, particularly longer-term enactment or sustained practice to reflect pragmatic efficacy. The research team has a strong focus on research translation; therefore, the incorporation of a logic model provides a clear pathway for decision-makers, such as policy makers and commissioners, to interpret and guide the key constructs and evaluation metrics in future digital interventions in this field of research.
There is substantial evidence that psychological programs delivered on the web can be effective in treating and preventing mental health problems; however, the uptake of these programs can be suboptimal, and there remains a lack of evidence on how to increase engagement with evidence-based programs [
Advances in technology, particularly the internet, have proven to be an effective tool for building individual skills as it is inexpensive and accessible, both geographically and temporally. Despite promising results, internet interventions are still not widely disseminated or well-integrated into health services; successfully doing so will, in part, depend on engagement. As mental health apps have proliferated, choosing among them has become increasingly challenging for not only patients but also clinicians [
To invest in accessible, long-term, sustainable health solutions, researchers, policy makers, and clinicians must identify optimal interventions that can be targeted to help specific risk groups or in specific contexts. Advances in technology, particularly the internet, have proven to be an effective tool for building individual skills as it is inexpensive and widely accessible. Pregnancy and the postnatal period can be times of increased psychological distress; therefore, it is an optimal time to intervene with strength-based tools to build affirmative self-efficacy. Although several studies in this field demonstrate efficacy, few robustly explore the construct of engagement, and in particular, there is limited evidence of the long-term enactment of the strategies learned. Our results indicate a disparity in the reporting of short- and long-term participant engagement behaviors, and we recommend the adoption of standardized metrics for reporting DMHI engagement in both research and real-world settings. This systematic review provides a framework for understanding the pathways for enhancing the mental well-being of mothers and their infants. With the world experiencing an endemic escalation in poor mental health across the life course, both in low- and high-income countries [
Search strategy and study selection.
Detailed study characteristics.
Consolidated Standards of Reporting Trials
Connect, Attend, Participate, and Enact
digital mental health intervention
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
International Prospective Register of Systematic Reviews
randomized controlled trial
Synthesis Without Meta-analysis
This study was funded by the University of Western Australia, Telethon Kids Institute, the 100 Women Grant.
The authors would like to thank the University of Western Australia, Telethon Kids Institute, and the ORIGINS Project, which is funded by the Paul Ramsay Foundation and the Commonwealth Government of Australia through the Channel 7 Telethon Trust.
Data presented in this study are available on reasonable request from the corresponding authors.
JAD, JLO, and ALF-J were involved in the conceptualization of the study. JAD and LYG performed the analysis. JAD wrote the original draft. Review and approval of the manuscript were conducted by JAD, LYG, ALF-J, JLO, and SLP. Funding support was acquired by ALF-J, JLO, and SLP.
None declared.