Exposure to traumatic events is extremely common with nearly 75% reported to have experienced one or more traumatic events worldwide. A significant number of those exposed will develop posttraumatic stress disorder (PTSD) along with depression, anxiety, and substance use disorders. Globally, trauma-related mental health disorders are the leading cause of global disability burden, and many of these disorders are caused, or worsened, by exposure to wars, natural and human-caused disasters, and other traumatic events. Significant barriers to treatment exist including logistical, geographical, financial, stigma, and other attitudinal challenges. One opportune approach to overcoming these barriers is the provision of mental health interventions via technology that can be readily standardized for wide dissemination of evidence-based care. However, engagement with technology-based interventions is a concern and limited participation and high attrition rates are common. This may be especially true for trauma survivors who often experience symptoms of avoidance and hyperarousal. Engagement is regarded as an essential component of intervention efficacy and has been demonstrated to be associated with more positive clinical outcomes, yet theoretically based research in this area is sparse. This review focuses on the complex issue of engagement with digital health interventions (DHIs). Specifically, we review the conceptualization and measurement of engagement, predictors of engagement, and importantly, the relationship of engagement with intervention effectiveness. Finally, a theoretically based model of engagement is proposed that considers the unique challenges of trauma recovery. This review is not intended to provide a systematic or exhaustive set of recommendations, rather it is intended to highlight the challenges of engagement research including its definition, measurement, and modeling. Future engagement research that includes valid and reliable measures of engagement will enable consistent exploration of engagement predictors that can then inform methods for increasing engagement and, ultimately, intervention effectiveness.

Background: Although the evidence for the associations among self-efficacy, secondary traumatic stress (STS) and secondary posttraumatic growth (SPTG) is mounting, there is a lack of the experimental evidence for the influence of self-efficacy on positive and negative mental health outcomes among professionals indirectly exposed to trauma.Purpose: This study investigated the effects of an internet-based self-efficacy intervention (the experimental condition), compared to an education (the active control condition) on STS and SPTG among workers exposed to traumatic events indirectly, through their clients. We hypothesized that the group assignment (experimental vs. control) would affect STS and SPTG indirectly, with a mediating role of self-efficacy beliefs.Methods: Participants were 168 health and human services professionals (78% women), exposed indirectly to a traumatic event at work. They were randomly assigned to either a 4-session internet-based self-efficacy intervention (n = 87) or an education control group (n = 81) which received information about coping resources and consequences of stressors at work or at home. STS, SPTG, and self-efficacy were measured at the baseline (Time 1), 1-month follow-up (Time 2) and 2-month follow-up (Time 3).Results: Analysis of covariance showed that the group assignment had a significant effect on STS (Time 2) and self-efficacy (Time 2), with lower STS and higher self-efficacy reported by the self-efficacy intervention participants. Compared to the experimental group, the active control (education) group participants reported higher SPTG at Time 2. Mediation analyses indicated that the group assignment had indirect effects on STS and SPTG at Time 3. Workers who experienced increases in self-efficacy (Time 2) through the intervention were more likely to report lower STS and higher SPTG at Time 3.Conclusion: Elucidating the mediating processes that explain why an intervention for secondary trauma works is essential in order to develop more effective support systems that promote improved mental health outcomes among health and human services professionals. Prevention programs for workers exposed indirectly to traumatic events may target self-efficacy enhancement and education.

Internet and mobile technologies offer potentially critical ways of delivering mental health support in low-resource settings. Much evidence indicates an enormous negative impact of mental health problems in low- and middle-income countries (LMICs), and many of these problems are caused, or worsened, by exposure to wars, conflicts, natural and human-caused disasters, and other traumatic events. Though specific mental health treatments have been found to be efficacious and cost-effective for low-resource settings, most individuals living in these areas do not have access to them. Low-intensity task-sharing interventions will help, but there is a limit to the scalability and sustainability of human resources in these settings. To address the needs of trauma survivors, it will be important to develop and implement Internet and mobile technology resources to help reduce the scarcity, inequity, and inefficiency of current mental health services in LMICs. Mobile and Internet resources are experiencing a rapid growth in LMICs and can help address time, stigma, and cost barriers and connect those who have been socially isolated by traumatic events. This review discusses current research in technological interventions in low-resource settings and outlines key issues and future challenges and opportunities. Though formidable challenges exist for large-scale deployment of mobile and Internet mental health technologies, work to date indicates that these technologies are indeed feasible to develop, evaluate, and deliver to those in need of mental health services, and that they can be effective.

This longitudinal research examined the relationship direction between burnout components (exhaustion and disengagement) within the context of personal resources measured by self-efficacy and social support. In line with the conservation of resources theory we hypothesized that exhaustion may trigger a spiral loss of personal resources where self-efficacy declines and subsequently, social support also declines and in turn predict disengagement. Participants in Study 1 were mental healthcare providers (N = 135) working with U.S. military personnel suffering from trauma. Participants in Study 2 were healthcare providers, social workers, and other human services professionals (N = 193) providing various types of services for civilian trauma survivors in Poland. Baseline and 6-month follow-up measurements included burnout components, burnout self-efficacy and perceived social support. The path analysis showed consistent results for both longitudinal studies; exhaustion measured at Time 1 led to disengagement at Time 2, after controlling for baseline disengagement levels. Across Study 1 and Study 2 these associations were mediated by self-efficacy change: Higher exhaustion led to greater decline in self-efficacy which in turn explained higher disengagement at the follow-up. Social support, however, did not mediate between self-efficacy and disengagement. These mediating effects were invariant across Studies 1 and 2, although the mean levels of burnout and personal resources differed significantly. The results contribute to a discussion on the internal structure of job burnout and a broader understanding of the associations between exhaustion and disengagement that may be explained by the underlying mechanism of change in self-efficacy.

BackgroundThere has been a growing trend in the delivery of mental health treatment via technology (ie, electronic health, eHealth). However, engagement with eHealth interventions is a concern, and theoretically based research in this area is sparse. Factors that influence engagement are poorly understood, especially in trauma survivors with symptoms of posttraumatic stress.ObjectiveThe aim of this study was to examine engagement with a trauma recovery eHealth intervention using the Health Action Process Approach theoretical model. Outcome expectancy, perceived need, pretreatment self-efficacy, and trauma symptoms influence the formation of intentions (motivational phase), followed by planning, which mediates the translation of intentions into engagement (volitional phase). We hypothesized the mediational effect of planning would be moderated by level of treatment self-efficacy.MethodsTrauma survivors from around the United States used the eHealth intervention for 2 weeks. We collected baseline demographic, social cognitive predictors, and distress symptoms and measured engagement subjectively and objectively throughout the intervention.ResultsThe motivational phase model explained 48% of the variance, and outcome expectations (beta=.36), perceived need (beta=.32), pretreatment self-efficacy (beta=.13), and trauma symptoms (beta=.21) were significant predictors of intention (N=440). In the volitional phase, results of the moderated mediation model indicated for low levels of treatment self-efficacy, planning mediated the effects of intention on levels of engagement (B=0.89, 95% CI 0.143-2.605; N=115).ConclusionsThough many factors can affect engagement, these results offer a theoretical framework for understanding engagement with an eHealth intervention. This study highlighted the importance of perceived need, outcome expectations, self-efficacy, and baseline distress symptoms in the formation of intentions to use the intervention. For those low in treatment self-efficacy, planning may play an important role in the translation of intentions into engagement. Results of this study may help bring some clarification to the question of what makes eHealth interventions work.

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BackgroundTechnology offers a unique platform for delivering trauma interventions (ie, eHealth) to support trauma-exposed populations. It is important to evaluate mechanisms of therapeutic change in reducing posttraumatic distress in eHealth for trauma survivors.ObjectiveThis study evaluated a proactive, scalable, and individually responsive eHealth intervention for trauma survivors called My Trauma Recovery. My Trauma Recovery is an eHealth intervention aiming to support trauma survivors and consisting of 6 modules: relaxation, triggers, self-talk, professional help, unhelpful coping, and social support. It was designed to enhance trauma coping self-efficacy (CSE). We tested 3 hypotheses. First, My Trauma Recovery would decrease posttraumatic stress symptoms (PTSS). Second, My Trauma Recovery would increase CSE. And last, changes in CSE would be negatively correlated with changes in PTSS.MethodsA total of 92 individuals exposed to trauma (78/92, 85% females, mean age 34.80 years) participated. Our study was part of a larger investigation and consisted of 3 sessions 1 week apart. Participants completed the baseline online survey assessing PTSS and CSE. Each session included completing assigned modules followed by the online survey assessing CSE. PTSS was remeasured at the end of the last module.ResultsPTSS significantly declined from T1 to T9 (F1,90=23.63, P<.001, η2p=.21) supporting the clinical utility of My Trauma Recovery. Significant increases in CSE for sessions 1 and 2 (F8,83=7.51, P<.001) were found. No significant change in CSE was found during session 3 (N=92). The residualized scores between PTSS T1 and T9 and between CSE T1 and T9 were calculated. The PTSS residualized score and the CSE residualized score were significantly correlated, r=–.26, P=.01. Results for each analysis with a probable PTSD subsample were consistent.ConclusionsThe findings of our study show that participants working through My Trauma Recovery report clinically lower PTSS after 3 weeks. The results also demonstrate that CSE is an important self-appraisal factor that increased during sessions 1 and 2. These improvements are correlated with reductions in PTSS. Thus, changes in CSE may be an important mechanism for reductions in PTSS when working on a self-help trauma recovery website and may be an important target for eHealth interventions for trauma. These findings have important implications for trauma eHealth interventions.